The Palms Nursing & Rehabilitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) of fifteen residents reviewed for abuse.<BR/>The facility failed to protect Resident #1 from being verbally abused by SA on April 29th 2024. <BR/>The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/29/2024 and ended on 04/29/2024. The facility corrected the non-compliance before the investigation began.<BR/>This failure placed all residents at the facility at risk of severe psychosocial harm by being forced to interact with an employee that verbally abuses residents.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet reflected a [AGE] year-old female with an admission date of 01/12/2023. Pertinent diagnoses included depression unspecified (patient is primarily depressive but does not meet the full criteria for any specific depressive disorder) and type 2 diabetes mellitus.<BR/>Record review of Resident #1's quarterly MDS assessment section C, cognitive patterns, dated 05/29/2024 reflected a BIMS score of 15 (cognition intact). <BR/>Record Review of Resident #5's face sheet reflected a [AGE] year-old male with an admission date of 03/10/2024. Pertinent diagnoses included depression unspecified, generalized anxiety disorder, and alcohol-induced persisting dementia (damage to the brain caused by regularly drinking alcohol over many years resulting in memory loss and difficulty thinking things through).<BR/>Record review of Resident #5's quarterly MDS assessment section C, cognitive patterns, dated 06/06/2024 reflected a BIMS score of 13 (cognition intact).<BR/>Record review of Resident #6's face sheet reflected a [AGE] year-old female with an admission date of 06/04/2024. Pertinent diagnoses included vascular dementia (general term for problems with reasoning, planning, judgement, memory and other thought processes), anxiety disorder, unspecified depression, and bipolar disorder (mental illness causing unusual shifts in a person's mood, energy, activity levels, and concentration).<BR/>Record review of Resident #6's MDS assessment section C, cognitive patterns, dated 06/10/2024 reflected a BIMS score of 13 (cognition intact).<BR/>Record review of the provider investigation report dated 05/01/2024 revealed that on 04/29/2024 The alleged perpetrator (SA) was in the patio washing the concrete area. This is when the alleged victim (Resident #1) started confronting the alleged perpetrator about washing the concrete during smoke break. According to witness' the alleged perpetrator became upset with the alleged victim and cussed at her. Once the facility was advised of the incident at about 2:15 PM., the Administrator suspended the alleged victim pending the outcome of the investigation. The provider investigation report found the results of the investigation to be inconclusive. <BR/>Record review of the provider investigation report dated 05/01/2024 revealed a signed statement from Resident #1 stating I went outside to have a cigarette after lunch. SA was wetting down the patio (smoke area) with the water hose, I asked why he was doing that, he said they asked him to. So I went inside to find his boss (HR) to tell her he was not passing cigarettes because he was cleaning the patio. She asked why I was telling her. I said because you are his boss and I went outside to where he was then pouring liquid soap. Then HR came out and asked if he was giving cigarettes out, he said in a few minutes, but he was on the first part of the patio. At this point I told him his head was a little big with his job, and I was tired of him being so controlling. He said fuck you, I said what did you say to me? He said it a little louder. I am not defending my behavior, but I did not deserve that. I went and to SSD, then administrator and my witnesses came forward and corroborated my complaint. The DON came and talked to me, and again before she left for the night.<BR/>Record review of the provider investigation report dated 05/01/2024 revealed a signed statement from Resident #7 stating I heard SA, the smoke monitor, tell Resident #1 'Fuck you.' 4/29/24<BR/>Record review of the provider investigation report dated 05/01/2024 revealed a signed statement from FT stating On April 29th I was outside SA was scrubbing the patio and Resident #1 came outside and asked for a cigarette. He told her she had to wait she questioned why they had to wait and his reply was after she asked what did you say and he said 'fuck you.'<BR/>Record review of 1:1 in-service titled, Abuse Prevention, Abuse & Neglect Facility Policy, specifically verbal abuse was conducted by the Administrator with the SA on 04/28/24 and signed in ink by both.<BR/>In an interview with SM on 08/06/2024 at 10:41 AM, SM stated that the patio was open to residents that wish to smoke from 7 AM to 7 PM. SM stated there was a lunch break from 12 PM to 1 PM where the patio was closed for smoking. SM stated that he was familiar with SA and he had heard from residents that SA would frequently yell and cuss at all of them. SM stated he was not familiar with any specific incident involving Resident #1, and that he had not started working yet at the facility on 04/29/2024.<BR/>In an interview with Resident #5 on 08/06/2024 at 1:07 AM, Resident #5 stated that SA would cuss and yell at all the residents in the smoking area. Resident #5 stated that he was aware of the incident involving Resident #1 when SA said Fuck you to her on 04/29/2024, but could not elaborate further on other incidents. <BR/>In an interview with Resident #6 on 08/06/2024 at 2:49 PM, Resident #6 stated that SA told one of the ladies in the smoking area to Fuck off. Resident #6 stated that she was not there at the time of the incident, but that she heard it from everyone that goes out to the patio to smoke. <BR/>In an interview with Resident #1 on 08/07/2024 at 9:50 AM, Resident #1 stated that SA said fuck you to her. Resident #1 stated that a lot of other residents were out there and heard it as well. Resident #1 stated that she immediately reported the incident to the Administrator. Resident #1 stated that SA was suspended, but that he came back to work as a maintenance person and that she had seen him walking around the building. <BR/>In an interview with HR on 08/07/2024 at 11:09 AM, HR stated that the last day SA worked was on 07/10/2024. HR stated that SA was not fired after the verbal abuse incident. HR stated the reason SA no longer works at the facility was because he stopped showing up for work after 07/10/2024. <BR/>In an interview with the Administrator on 08/07/2024 at 11:33 AM, the Administrator stated that, during the initial incident on 04/29/2024, Resident #1 was upset because SA was washing the patio and not handing out cigarettes. The Administrator stated that SA allegedly told Resident #1 to fuck off when she told him to stop cleaning the patio. The Administrator stated they reported the incident to Texas Department of Health and Human Services for verbal abuse and suspended SA. The Administrator stated that SA was suspended for a few days before returning to work, but he could not remember exactly how long the suspension lasted. <BR/>In a follow-up interview with Resident #1 on 08/08/2024 at 9:41 AM, Resident #1 stated that when the incident first occurred, she felt embarrassed and anxious because she did not like being talked to that way in front of other residents. Resident #1 stated that after the incident, when she saw SA working in the facility, she felt fearful that he might confront her because she made him change job roles at the facility. Resident #1 stated that there was one incident once SA returned to work at the facility where he was painting other resident's doors outside her room in the 300 hall. Resident #1 stated that a lot of her fear and anxiety returned when she saw him so close to her room. Resident #1 stated that she felt like the facility did not care to protect her from him, or future aggressors if a similar event happened again. <BR/>In a follow-up interview with the Administrator on 08/08/2024 at 10:53 AM, the Administrator stated that the findings of the provider investigation were inconclusive because SA never admitted to saying fuck you. The Administrator refused to answer if he had reasonable suspicion on whether SA said fuck you to Resident #1. The Administrator stated that verbal abuse of this nature does not reach the threshold of needing to call the police. The Administrator stated that the resident never voiced any concerns about SA still working at the facility. The Administrator stated that this incident did not violate Resident #1's rights because she could have waited a few minutes for her cigarette. The Administrator stated that he did not know if SSD did wellness checks on Resident #1 after the incident. <BR/>In an interview with the SSD on 08/08/2024 at 1:20 PM, the SSD stated approximately two weeks after SA was suspended where Resident #1 saw SA painting the doors near Resident #1's room. SSD stated that Resident #1 was upset at that time, but SSD calmed Resident #1 down and let Resident #1 know that SA would finish his work soon. SSD stated that was the only incident she was aware of involving Resident #1 and SA after the incident on 04/29/2024.<BR/>In an interview with the DON on 08/08/2024 at 1:25 PM, the DON stated that she talked with Resident #1 a few weeks after the incident and Resident #1 expressed concerns about SA still working in the facility. The DON stated that she reported this to the Administrator and SSD. <BR/>Record review of the Time Card Report for SA revealed that on the day of the incident, 04/29/2024, SA clocked out at 2:44 PM. The Time Card report revealed that on the day after the incident, 04/30/2024, SA worked from 7:01 AM to 7:16 PM with a break from 11:57 AM to 12:37 PM.<BR/>Record Review of the facility's undated policy titled Abuse Prevention defined Verbal Abuse as The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Following that, in the section titled PROCEDURE: STEPS TO PREVENT, DETECT AND REPORT: SCREENING: #3 stated It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. <BR/>Record review of the facility's policy titled Statement of Resident Rights dated 07/20/2015 stated under the DIGNITIY AND RESPECT section You have the right to: Be free from abuse, neglect, and exploitation. Be treated with dignity, courtesy, consideration, and respect.<BR/>Record review of the facility's abuse and neglect in-service dated 08/08/2024, 08/09/2024 reflected all staff in attendance.<BR/>Record review of the facility's customer service, resident rights, respecting resident wishes in-service dated 08/10/2024 reflect all staff in attendance. <BR/>Record review of the facility's Abuse Prevention policy and procedure undated. <BR/>Record review of the facility's resident safe surveys, including Resident #1, dated 08/09/2024 were reviewed and reflected residents felt safe in the facility environment.

Based on interviews and record review, the facility failed to report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures by one staff member (the SW) of five staff members reviewed for reporting of abuse allegations. The facility failed to ensure the SW reported all suspected abuse or mistreatment when a handful of residents informed her RN F and RN G were being mean to them approximately between March and April of 2025. This failure could place residents at risk for physical, mental, and psychosocial harm. The findings include: In an anonymous interview, it was stated, night nurses RN F and RN G would yell at residents to go to bed and would yell at the residents to hurry up. RN F would yell at the residents saying, the call light is not a toy'. RN F made the residents feel scared to ask for help or use the call light. RN F would tell residents If I am investigated by HHS, they will believe me and not you because you have dementia. LVN E and SW were told about the mistreatment by RN F and RN G but unsure of what came about the complaint. RN F and RN G no longer work at the facility and the residents feel safe. Residents felt like nothing was being done when they made complaints about the mistreatment by RN F and RN G. In an anonymous interview, it was stated, RN G would poke residents when she would go in to give them medicine, yelling at residents to get up and would make them feel beneath her. RN F would yell at residents stating, I am tired of cleaning up your shit and both RN F and RN G would make the residents feel like they were alone and could not ask for help, especially since it was nighttime and no administration was around. In an interview on 07/29/25 at 9:10am, LVN E stated the residents would complain to her about their medicine being administered late but never expressed to her they were being mistreated or yelled at by any staff member, including RN F and RN G. LVN E stated she would have reported any suspected abuse to the ADM. In an interview on 07/29/25 at 3:29pm, the SW stated a resident (who was no longer at the facility) informed her that they (night nurses, SW did not get names of who) were rude to them and would not give them their medicine. The SW stated she thought she reported it to the DON and was not sure what happened after that. The SW stated she did not follow up on the grievance and was not sure if anything was investigated. The SW stated the allegation was reported to her several months ago but could not recall when. The SW stated she would hear from a handful of residents that the night nurses were mean to them. The SW stated when the residents informed her of this, they told her not to say anything. The SW stated she did not ask why they felt they should not report anything and did not think it was abuse even though the residents used the word mean. The SW stated she never asked what the residents meant by mean and left it at that. The SW stated she did not write up grievances because the residents told her not to. The SW stated she was aware of what verbal abuse was and that all suspected abuse should be reported to the abuse coordinator. The SW stated in-service on ANE was held every month and the SW was the one who conducted the monthly in-service. The SW stated all suspected abuse should be reported and could not give a reason why she did not report the allegations of the night nurses being mean to the residents other than the resident did not want me to. In an interview on 07/30/25, the DON stated the SW should have reported any and all suspected mistreatment or possible abuse. The DON stated resident safety was important to the facility and any allegations of abuse were taken seriously and needed to be investigated. The DON stated if suspected abuse was not reported, it could cause the residents to become fearful or allow the alleged perpetrator/s to continue or escalate the abuse. In an interview on 7/30/25 at 11:10 am, ADON B if a resident went to her and stated that a nurse was being mean or mistreating them, she would ask the resident for details, remove the nurse from the area and go tell the DON and ADM. ADON B stated a staff member yelling at a resident or cursing at a resident was verbal abuse and should be reported to the DON and ADM immediately. In an interview on 07/30/25 at 11:54pm, the ADM stated the SW should have reported any suspected abuse and the facility takes all allegations of abuse or neglect seriously. The ADM stated he was going to in-service the SW on ANE as well as all staff. The ADM stated the facility staff, including administration, conduct Angel Rounds every morning and residents have not expressed they were being mistreated by any staff. Record review of the facility's Abuse Investigation and Reporting policy not dated reflected: 'Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Record review of the facility's policy on Abuse Prevention not dated reflected: POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. b) Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. 3. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatment shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed. CORRECTIVE ACTION: Any instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and measures were taken to prevent further potential abuse, neglect, exploitation or mistreatment in accordance with State law, and if the alleged violation was verified appropriate, corrective action must have been taken for 1 (Resident #1) of 5 residents reviewed for abuse, neglect, and/or misappropriation. <BR/>The facility failed to do a thorough investigation to include interviewing the victim (Resident #1) in the incident, the victim ' s RP, as well as other residents which may have been involved in the incident. <BR/>This failure placed residents at risk of not having their allegations investigated thoroughly or timely. <BR/>The findings included: <BR/>Record review of Resident #1 ' s face sheet dated 11/29/2024 revealed a [AGE] year-old female with an admission date of 07/16/2024. Diagnoses included End Stage Renal Disease (last stage of kidney failure), Anxiety, Type 2 Diabetes (chronic condition which occurs when the body cannot use insulin effectively), and Depression. <BR/>Record Review of Resident #1's annual MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15, which revealed intact cognition. <BR/>Record Review of the PIR completed on 11/21/2024 revealed an incorrect narcotic count of Resident #1 ' s Clonazepam 0.125 MG (a medication used to treat seizure disorders and panic disorder) on 11/21/2024 at 8:30 AM. The controlled medication count revealed 11 missing tablets. Incorrect count was identified when oncoming LVN-B counted with off-going LVN-A. Both LVN-A and LVN-B were interviewed and denied taking the pills. ADON-A recounted and determined 11 tablets were missing. According to the PIR, both LVN-A and LVN-B stated the count was correct the previous night when oncoming LVN-A counted with off-going LVN B. Both nurses were suspended pending investigation, with LVN-B ultimately being fired for other reasons. <BR/>Record review of Resident #1 ' s physician orders revised 02/05/2025 revealed Clonazepam 0.125 MG, give 1 tablet twice per day. <BR/>In an observation on 06/25/2025 at 6:25 AM revealed off-going LVN-A and on-coming MA-F counted controlled medications whereas MA-F would actually count the medications, but LVN-A just looked to verify the count on the controlled medication sheet was correct. LVN-A was not actually watching MA-F count the medications, and MA-F was not actually looking at the sheet to verify it was correct. <BR/>In an interview with ADON-A on 06/24/2025 at 2:25 PM she stated she was informed of the drug discrepancy on the morning 0f 11/21/2024 and recounted the medications herself. She stated there were 11 missing Clonazepam when she counted, and they were never recovered. She stated in house drug screens were completed, and both nurses were suspended pending investigation results with LVN-B ultimately being fired for other issues. She stated both nurses were interviewed at the time of the investigation, but no one else was interviewed at that time. She stated neither Resident #1 nor her RP was notified interviewed for this investigation. <BR/>In an interview with the Administrator on 06/24/2025 at 3:16 PM he stated the count was wrong with 11 controlled medications missing on the morning of 11/21/2024, so an investigation was started. He stated the nurses involved were drug tested and suspended pending investigation. He also stated the nurses were interviewed, but no one else was interviewed at the time of the investigation because he did not see any need to involve anyone else. <BR/>In an interview with LVN-A on 06/24/2025 at 4:23 PM she stated she was the off-going nurse the morning the controlled medication count was off. She stated she was interviewed, a drug screen was done, and she was suspended pending investigation. <BR/>In an interview with Resident #1 on 06/24/25 at 4:50 PM she stated she remembered when her medication went missing in November of 2024 because she heard the nurses talking about it, but she stated she was never interviewed or questioned about the missing medication or if she had received or missed any of her medication. She denied ever missing any doses of her medication or any increased anxiety. <BR/>In an interview with LVN-A on 6/25/25 at 6:35 AM stated she was usually here until 7:00 AM, but sometimes the nurses or medication aides came in early, so they went ahead and counted early. LVN-A stated if she was the one off-going she looked at the count sheet to make sure it was correct, and the one who was on-coming actually counted the controlled medication, and they did not typically double check if the other was correct or telling the truth. LVN-A stated she had never been told to do the count any other way, but she saw how not verifying the count was correct could be a cause for concern because medications could be missing or stolen if the count was not correct. She also stated she gave the medication during her shift, she did not technically perform a count after the medication was given but waited until the end of her shift to count. She denied taking any of the controlled medications. <BR/>In an interview with the DON on 06/25/2025 at 9:00 AM she stated on the morning of 11/21/2024 she, along with the ADONs, did a re-count of the controlled substances and found Resident #1 ' s Clonazepam 0.125 MG was missing 11 tablets. She stated both LVN-A and LVN-B were interviewed, drug tested and suspended pending investigation. She stated no residents or RPs were contacted or interviewed for this investigation. <BR/>In an interview with ADON-A on 06/26/2025 at 4:55 PM she stated the facility could have and should have done more with the investigation of the missing controlled medications. She stated no resident or RP interviews were done until yesterday (06/25/2025). She stated they interviewed Resident #1 as well as other residents with high BIMS scores to determine if they were getting their medications as ordered and scheduled, and all residents stated they were. She also stated they did not notify Resident #1 ' s RP until two days ago (06/24/2025). She stated they should have interviewed Resident #1 when the controlled medication went missing, as well as interviewed residents which were on the same type of medication as the one that went missing. <BR/>Record review of Resident Rights, date unknown, revealed (c) the facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident ' s property. (3) The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. <BR/>Record review of the facility ' s How to Conduct an Investigation policy, dated 04/2012, revealed 6. Interview all potential witnesses. Statements will be taken in anticipation of litigation. 8. Identify who the alleged victim is, who witnessed the incident, who may have information related to the incident.

Based on interviews and record review, the facility failed to report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures by one staff member (the SW) of five staff members reviewed for reporting of abuse allegations. The facility failed to ensure the SW reported all suspected abuse or mistreatment when a handful of residents informed her RN F and RN G were being mean to them approximately between March and April of 2025. This failure could place residents at risk for physical, mental, and psychosocial harm. The findings include: In an anonymous interview, it was stated, night nurses RN F and RN G would yell at residents to go to bed and would yell at the residents to hurry up. RN F would yell at the residents saying, the call light is not a toy'. RN F made the residents feel scared to ask for help or use the call light. RN F would tell residents If I am investigated by HHS, they will believe me and not you because you have dementia. LVN E and SW were told about the mistreatment by RN F and RN G but unsure of what came about the complaint. RN F and RN G no longer work at the facility and the residents feel safe. Residents felt like nothing was being done when they made complaints about the mistreatment by RN F and RN G. In an anonymous interview, it was stated, RN G would poke residents when she would go in to give them medicine, yelling at residents to get up and would make them feel beneath her. RN F would yell at residents stating, I am tired of cleaning up your shit and both RN F and RN G would make the residents feel like they were alone and could not ask for help, especially since it was nighttime and no administration was around. In an interview on 07/29/25 at 9:10am, LVN E stated the residents would complain to her about their medicine being administered late but never expressed to her they were being mistreated or yelled at by any staff member, including RN F and RN G. LVN E stated she would have reported any suspected abuse to the ADM. In an interview on 07/29/25 at 3:29pm, the SW stated a resident (who was no longer at the facility) informed her that they (night nurses, SW did not get names of who) were rude to them and would not give them their medicine. The SW stated she thought she reported it to the DON and was not sure what happened after that. The SW stated she did not follow up on the grievance and was not sure if anything was investigated. The SW stated the allegation was reported to her several months ago but could not recall when. The SW stated she would hear from a handful of residents that the night nurses were mean to them. The SW stated when the residents informed her of this, they told her not to say anything. The SW stated she did not ask why they felt they should not report anything and did not think it was abuse even though the residents used the word mean. The SW stated she never asked what the residents meant by mean and left it at that. The SW stated she did not write up grievances because the residents told her not to. The SW stated she was aware of what verbal abuse was and that all suspected abuse should be reported to the abuse coordinator. The SW stated in-service on ANE was held every month and the SW was the one who conducted the monthly in-service. The SW stated all suspected abuse should be reported and could not give a reason why she did not report the allegations of the night nurses being mean to the residents other than the resident did not want me to. In an interview on 07/30/25, the DON stated the SW should have reported any and all suspected mistreatment or possible abuse. The DON stated resident safety was important to the facility and any allegations of abuse were taken seriously and needed to be investigated. The DON stated if suspected abuse was not reported, it could cause the residents to become fearful or allow the alleged perpetrator/s to continue or escalate the abuse. In an interview on 7/30/25 at 11:10 am, ADON B if a resident went to her and stated that a nurse was being mean or mistreating them, she would ask the resident for details, remove the nurse from the area and go tell the DON and ADM. ADON B stated a staff member yelling at a resident or cursing at a resident was verbal abuse and should be reported to the DON and ADM immediately. In an interview on 07/30/25 at 11:54pm, the ADM stated the SW should have reported any suspected abuse and the facility takes all allegations of abuse or neglect seriously. The ADM stated he was going to in-service the SW on ANE as well as all staff. The ADM stated the facility staff, including administration, conduct Angel Rounds every morning and residents have not expressed they were being mistreated by any staff. Record review of the facility's Abuse Investigation and Reporting policy not dated reflected: 'Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Record review of the facility's policy on Abuse Prevention not dated reflected: POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. b) Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. 3. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatment shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed. CORRECTIVE ACTION: Any instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one of four residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to ensure CNA A used a gait belt to transfer Resident #1 from the bed to the wheelchair . <BR/>This failure could place residents at risk for falls, injuries and a decline in health.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 03/30/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 with diagnoses which included muscle wasting and atrophy , abnormalities of gait and mobility, lack of coordination, cerebral infarction (stroke) affecting left non-dominant side, and hemiplegia (paralysis of one side of body) and hemiparesis (weakness on one side of the body). <BR/>Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 14, which meant mild cognitive impairment. Resident #1 needed partial to moderate assistance for chair/bed-to-chair transfer. Resident #1 was coded to have neurological deficits of cerebrovascular accident, transient ischemic attack or stroke and hemiplegia or hemiparesis. Resident #1 was coded for having functional limitation of range of motion with both impairment on one side for both upper and lower extremities. <BR/>Record review of Resident #1's care plan problem start date 10/17/2024 edited on 10/28/2024 revealed ADLs Functional Stat/Rehabilitation Resident requires assistance/supervision for ADL and mobility tasks status post CVA with residual left hemiplegia weakness, impaired balance poor endurance activity tolerance. He has reduced ROM to left upper extremity. He attempts ADLs per self, does not use call light or assist at times, is at risk for falls/injuries. Approach (Interventions): Assist resident with shower three times per week per schedule and PRN. Resident Requires physical x1 staff assistance. Encourage resident to participate to the fullest extent possible with each interaction, task. Encourage resident to turn and reposition Q2 hours and PRN while in bed and up in wheelchair. He is independent for bed mobility and turning and repositioning tasks. Encourage/remind resident to use bell to call for assistance. Check on resident at routine intervals and to assess needs, monitor safety issues and offer/provide assistance as needed. He requires extensive assist x1 staff for dressing and clothing changes daily and PRN. Monitor for changes in functional status and independence for ADLs, strength, balance, safety. Make appropriate referrals PRN. Resident is mobile using wheelchair. He requires supervision and set-up assistance for locomotion on and off of the unit. He is only able to walk very short distances with extensive assistance. Resident requires limited x 1 staff assistance for personal hygiene tasks. The care plan had a revision date of 03/30/2025 to include He is independent for transfer tasks. <BR/>Record review of Resident #1's care plan problem start date 10/17/2024 edited on 03/30/2025, revealed potential for falls due to history of falling, history of CVA with resident left hemiplegia, weakness, impaired balance, unsteady gait, impaired cognitive functioning/ safety awareness/ problem solving with dementia (cognitive impairment) neuropathy (nerve deficit), seizure disorder (brain disorder), arthritis (joint disorder), muscle spasm and cardiovascular, psychotropic, and neuroleptic medication administration. Approach (approach) bed in lowest position, call light in easy reach. Remind resident to call for staff assist when needed and answer call promptly. Check on resident at routine intervals to assess needs, monitor safety issues and offer assist as needed. Intervene with resident to minimize or reduce fall occurrences. Provide adequate staff assistance and support for tasks. <BR/>During an observation on 03/29/2025 at 4:42 PM revealed Resident #1 engaged the call light system in his room and began to situate himself on the side of his bed. CNA A entered Resident #1's room and turned off the call light and asked Resident #1 what he needed. Resident #1 stated he needed to utilize the restroom. Upon initial observation there was observable left sided deficit on both Resident #1's left leg and left arm. CNA A proceeded to retrieve Resident #1's wheelchair and secured it on Resident #1's left side. CNA A then proceeded to assist Resident #1 to stand while she simultaneously grabbed Resident #1's left arm and with strength assisted him into the wheelchair. During Resident #1's transfer, Resident #1 pivoted to the wheelchair, and was observed to struggle while he staggered when pivoting from bed to wheelchair. Resident #1 was observed to have compromising balance as he was observed to be struggling while transferring to the wheelchair. Resident #1 was successful in transferring to the wheelchair while CNA A utilized his left arm to assist him. Throughout the transfer CNA A did not utilize a gait belt . <BR/>During an interview on 03/29/2025 at 5:17 PM, CNA A stated she should have used a gait belt to assist Resident #1 to transfer onto his wheelchair. CNA A stated she should not have used Resident #1's left arm to transfer and should have used a gait belt . CNA A stated she was unaware Resident #1 had a left arm deficit however during this bed to wheelchair transfer, Resident #1 struggled to transfer into the wheelchair. CNA A was asked if she utilized a gait belt when transferring Resident #1, CNA A gave no definitive answer. CNA A stated she left her gait belt in her locker and did usually keep it on her person. CNA A stated she did not use a gait belt because she had left the gait belt in her locker. CNA A stated she was supposed to use a gait belt for transfers but did not have access to it as it was in a destination that was not near Resident #1's room. CNA A stated by not using a gait belt Resident #1 could have fallen and was fortunate that he did not fall. CNA A stated going forward she would ensure to always keep a gait belt with her and would utilize the gait belt when she transferred any resident. CNA A stated she could not recall when she was last in-serviced about resident transfers. <BR/>During an interview on 03/29/2025 at 5:43 PM, the DON stated she was made aware of the observation by CNA A. The DON stated CNA A should have used a gait belt when transferring Resident #1 from the bed to the wheelchair as not only a safety precaution but also to maintain Resident #1's wellbeing. The DON stated CNA A may have compromised Resident #1's well-being as Resident #1 may have fallen. The DON stated all CNAs were supposed to keep a gait belt on their persons. The DON stated going forward she would conduct an impromptu in-service regarding gait belt transfers. <BR/>During an interview on 03/30/2025 at 11:47 AM, ADON B stated Resident #1 was independent during transfers. ADON B stated as she pointed out while reviewing Resident #1's care plan, Resident #1 was independent with transfers, however when asked about the edited date of 03/30/2025, ADON B did not give a definitive answer. ADON B while reviewing Resident #1's MDS stated it appeared Resident #1 was coded for needing assistance with transfer from bed to chair. ADON B stated CNA A could have compromised Resident #1's well-being by not using a gait belt as he could have fallen. ADON B stated CNA A should have used a gait belt while transferring Resident #1 given he was coded for hemiparesis (paralysis) and hemiplegia (weakness). ADON B stated she facilitated an impromptu in-service regarding transfer with gait belts on 03/29/2025. <BR/>Record review of CNA A's 03/08/2025 Lifting, Moving, Positioning, and Transferring competency revealed CNA A completed Transfer Resident from Bed to Chair/Wheelchair or Chair/Wheelchair to bed: <BR/>A. <BR/>(1) Person *Use of Gait Belt.<BR/>B. <BR/>(2) Person *Use of Gait Belt. <BR/>Record review of the facility's gait belt usage in-service, dated 03/29/2025, documented CNA A in attendance.<BR/>Record review of the facility's, undated, One Person Transfer with Gait Belt-Check Off reflected ,<BR/> .4. Position and secure belt properly.<BR/>5. Grasp belt on either side of resident, assist resident to move toward edge of bed. <BR/>6. Place feet firmly on floor under resident. <BR/>8. Face resident, squat with knees bent and your waist at resident's waist level, with back straight use leg muscles to lift to standing position.<BR/>Record review of the facility's, undated, Safe Lifting and Movement of Residents reflected, <BR/>1.Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of resident. <BR/>2.Manual lifting of resident shall be eliminated when feasible.<BR/>4.Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. All manual lifting devices will be made available for use, when necessary, in resident transfer with staff training on usage implement. <BR/>5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving resident when necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and measures were taken to prevent further potential abuse, neglect, exploitation or mistreatment in accordance with State law, and if the alleged violation was verified appropriate, corrective action must have been taken for 1 (Resident #1) of 5 residents reviewed for abuse, neglect, and/or misappropriation. <BR/>The facility failed to do a thorough investigation to include interviewing the victim (Resident #1) in the incident, the victim ' s RP, as well as other residents which may have been involved in the incident. <BR/>This failure placed residents at risk of not having their allegations investigated thoroughly or timely. <BR/>The findings included: <BR/>Record review of Resident #1 ' s face sheet dated 11/29/2024 revealed a [AGE] year-old female with an admission date of 07/16/2024. Diagnoses included End Stage Renal Disease (last stage of kidney failure), Anxiety, Type 2 Diabetes (chronic condition which occurs when the body cannot use insulin effectively), and Depression. <BR/>Record Review of Resident #1's annual MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15, which revealed intact cognition. <BR/>Record Review of the PIR completed on 11/21/2024 revealed an incorrect narcotic count of Resident #1 ' s Clonazepam 0.125 MG (a medication used to treat seizure disorders and panic disorder) on 11/21/2024 at 8:30 AM. The controlled medication count revealed 11 missing tablets. Incorrect count was identified when oncoming LVN-B counted with off-going LVN-A. Both LVN-A and LVN-B were interviewed and denied taking the pills. ADON-A recounted and determined 11 tablets were missing. According to the PIR, both LVN-A and LVN-B stated the count was correct the previous night when oncoming LVN-A counted with off-going LVN B. Both nurses were suspended pending investigation, with LVN-B ultimately being fired for other reasons. <BR/>Record review of Resident #1 ' s physician orders revised 02/05/2025 revealed Clonazepam 0.125 MG, give 1 tablet twice per day. <BR/>In an observation on 06/25/2025 at 6:25 AM revealed off-going LVN-A and on-coming MA-F counted controlled medications whereas MA-F would actually count the medications, but LVN-A just looked to verify the count on the controlled medication sheet was correct. LVN-A was not actually watching MA-F count the medications, and MA-F was not actually looking at the sheet to verify it was correct. <BR/>In an interview with ADON-A on 06/24/2025 at 2:25 PM she stated she was informed of the drug discrepancy on the morning 0f 11/21/2024 and recounted the medications herself. She stated there were 11 missing Clonazepam when she counted, and they were never recovered. She stated in house drug screens were completed, and both nurses were suspended pending investigation results with LVN-B ultimately being fired for other issues. She stated both nurses were interviewed at the time of the investigation, but no one else was interviewed at that time. She stated neither Resident #1 nor her RP was notified interviewed for this investigation. <BR/>In an interview with the Administrator on 06/24/2025 at 3:16 PM he stated the count was wrong with 11 controlled medications missing on the morning of 11/21/2024, so an investigation was started. He stated the nurses involved were drug tested and suspended pending investigation. He also stated the nurses were interviewed, but no one else was interviewed at the time of the investigation because he did not see any need to involve anyone else. <BR/>In an interview with LVN-A on 06/24/2025 at 4:23 PM she stated she was the off-going nurse the morning the controlled medication count was off. She stated she was interviewed, a drug screen was done, and she was suspended pending investigation. <BR/>In an interview with Resident #1 on 06/24/25 at 4:50 PM she stated she remembered when her medication went missing in November of 2024 because she heard the nurses talking about it, but she stated she was never interviewed or questioned about the missing medication or if she had received or missed any of her medication. She denied ever missing any doses of her medication or any increased anxiety. <BR/>In an interview with LVN-A on 6/25/25 at 6:35 AM stated she was usually here until 7:00 AM, but sometimes the nurses or medication aides came in early, so they went ahead and counted early. LVN-A stated if she was the one off-going she looked at the count sheet to make sure it was correct, and the one who was on-coming actually counted the controlled medication, and they did not typically double check if the other was correct or telling the truth. LVN-A stated she had never been told to do the count any other way, but she saw how not verifying the count was correct could be a cause for concern because medications could be missing or stolen if the count was not correct. She also stated she gave the medication during her shift, she did not technically perform a count after the medication was given but waited until the end of her shift to count. She denied taking any of the controlled medications. <BR/>In an interview with the DON on 06/25/2025 at 9:00 AM she stated on the morning of 11/21/2024 she, along with the ADONs, did a re-count of the controlled substances and found Resident #1 ' s Clonazepam 0.125 MG was missing 11 tablets. She stated both LVN-A and LVN-B were interviewed, drug tested and suspended pending investigation. She stated no residents or RPs were contacted or interviewed for this investigation. <BR/>In an interview with ADON-A on 06/26/2025 at 4:55 PM she stated the facility could have and should have done more with the investigation of the missing controlled medications. She stated no resident or RP interviews were done until yesterday (06/25/2025). She stated they interviewed Resident #1 as well as other residents with high BIMS scores to determine if they were getting their medications as ordered and scheduled, and all residents stated they were. She also stated they did not notify Resident #1 ' s RP until two days ago (06/24/2025). She stated they should have interviewed Resident #1 when the controlled medication went missing, as well as interviewed residents which were on the same type of medication as the one that went missing. <BR/>Record review of Resident Rights, date unknown, revealed (c) the facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident ' s property. (3) The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. <BR/>Record review of the facility ' s How to Conduct an Investigation policy, dated 04/2012, revealed 6. Interview all potential witnesses. Statements will be taken in anticipation of litigation. 8. Identify who the alleged victim is, who witnessed the incident, who may have information related to the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #3) of 6 residents reviewed for quality of care.<BR/>The facility failed to enforce the post-fall assessment policy leading to Resident #3 being moved after a fall prior to checking her vital signs and neurological status on 05/21/25. <BR/>The failure could affect residents currently residing in the facility, resulting in not receiving needed care to maintain optimal health and placing them at risk for injury or deterioration in their condition. <BR/>The findings included:<BR/>Record review of Resident #3's face sheet dated 06/25/25 revealed a [AGE] year-old female with an initial admission date of 04/18/25 and a discharge date of 06/19/25. Pertinent diagnosis included Depression and Muscle Wasting and Atrophy, <BR/>Record review of Resident #3's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 13 (cognition intact).<BR/>Record review of Resident #3's comprehensive care plan dated 05/12/25 revealed the resident posed a risk for potential injuries from falls. Interventions listed to prevent injuries from falls were to place articles I need within my reach, remind/encourage me to use call light for assistance, Provide me with a low bed. Keep the bed in low position whenever I'm in bed, Place fall mats on floor at my bedside, and Refer me to therapy so they can re-screen me.<BR/>During an observation of a surveillance video at 8:45 AM on 06/25/25 from Resident #3's room with a timestamp dated 05/21/25, Resident #3 was observed falling in her room with no staff around. LVN E was observed on video entering the room and briefly checking on the resident for 45 seconds before supervising her movement from the floor too her bed. LVN E was observed not performing vital signs checks or neurological status checks on Resident #3 before moving her into her bed.<BR/>In an interview with ADON-A at 5:38 PM on 06/25/25, ADON-A stated when a resident had an unwitnessed fall, it was important to follow the proper post-fall procedure to ensure the resident was not harmed further. ADON-A stated the resident's vitals (blood pressure, oxygen saturation, temperature, and pulse) and neurological status should be checked prior to moving the resident. The ADON-A stated LVN E did not assess Resident #3's vitals or neurological status before moving Resident #3 back to her bed after her fall on 05/21/25. ADON-A stated the facility policy was not followed in this instance. <BR/>In an interview with LVN E at 6:31 PM on 06/25/25, LVN E stated when responding to an unwitnessed fall of a resident, she would check their vital signs, ask them questions, check for trauma, check their range of motion, look for bleeding. LVN E stated she would determine if the resident was safe to move after performing her examination. LVN E stated she did not check the vital signs or neurological status of Resident #3 before moving her into her bed. LVN C stated Resident #3 was not on her hall the evening 05/21/25, so she was helping the other nurse because she was busy. LVN E stated she should have checked Resident #3's vital signs and neurological status before moving Resident #3 to her bed. LVN E stated it was important to check a resident's vitals and neurological status before moving them because they could be harmed further if they were moved prematurely. <BR/>In an interview with the DON at 5:06 PM on 06/26/25, the DON stated when a resident had an unwitnessed fall, the nurse responding to the incident should perform a physical assessment on the resident before determining it was safe to move them. The DON stated a physical assessment included checking the resident's vital signs and neurological status. The DON stated it was important to check on the resident before moving them because they may be harmed further when moving them prematurely. <BR/>Record review of the facility policy titled Falls - Evaluation and Prevention last revised 09/2014 revealed the following:<BR/> .Evaluate the resident promptly in order to identify and treat injuries. The resident should not be moved until the licensed nurse has evaluated their condition, unless absolutely necessary. The evaluation should include vital signs and neurological status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 5 residents reviewed for pharmacy services.<BR/>The facility failed to ensure LVN-A's medication cart on hall 300 contained an accurate count and record for Resident #1's Clonazepam 0.125 MG (a medication used to treat seizure disorders and panic disorder).<BR/>This failure could place residents at risk for drug diversion and/or a delay in medication administration, as well as risk of not having allegations investigated throoughly or timely.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 11/29/2024 revealed a [AGE] year-old female with an admission date of 07/16/2024. Diagnoses included End Stage Renal Disease (last stage of kidney failure), Anxiety, Type 2 Diabetes (chronic condition which occurs when the body cannot use insulin effectively), and Depression.<BR/>Record Review of Resident #1's annual MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15, which revealed intact cognition.<BR/>Record Review of the PIR completed on 11/21/2024 revealed an incorrect narcotic count of Resident #1's Clonazepam 0.125 MG on 11/21/2024 at 8:30 AM. The controlled medication count revealed 11 missing tablets. The incorrect count was identified when oncoming LVN-B counted with off-going LVN-A. Both LVN-A and LVN-B were interviewed and denied taking the pills. ADON-A recounted and determined 11 tablets were missing. According to the PIR, both LVN-A and LVN-B stated the count was correct the previous night when oncoming LVN-A counted with off-going LVN B. Both nurses were suspended pending investigation, with LVN-B ultimately being fired for other reasons.<BR/>Record review of Resident #1's physician orders revealed a revised active order for Clonazepam 0.125 MG revised on 02/05/2025.<BR/>Record review of Resident #1's Individual Drug Administration Record revealed the Clonazepam 0.125 MG count at 9:00 PM on 11/20/2024 was 29, and on 11/21/2024 at 10:15 AM the count was 18.<BR/>In an observation on 06/25/2025 at 6:25 AM revealed off-going LVN-A and on-coming MA-F counting controlled medications whereas MA-F would actually count the medications, but LVN-A just looked to verify the count on the controlled medication sheet was correct. LVN-A was not actually watching MA-F count the medications, and MA-F was not actually looking at the sheet to verify it was correct.<BR/>In an interview with ADON-A on 06/24/2025 at 2:25 PM she stated she was informed of the drug discrepancy on the morning 0f 11/21/2024 and recounted the medications herself. She stated there were 11 missing Clonazepam when she counted, and they were never recovered. She stated in house drug screens were completed and both nurses were suspended pending investigation results with LVN-B ultimately being fired for other issues. She stated both nurses were interviewed at the time of the investigation, but no one else was interviewed at that time. She stated neither Resident #1 nor her RP were interviewed for this investigation. She denied anyone alleging abuse, neglect or misappropriation at that time.<BR/>In an interview with the Administrator on 06/24/2025 at 3:16 PM he stated on the morning of 11/21/2024 the count was wrong with 11 controlled medications missing, so an investigation was started. He stated the nurses involved were drug tested and suspended pending investigation. He stated the nurses were interviewed, but no one else was interviewed at the time of the investigation because he did not see any need to involve anyone else in the investigation. He denied anyone alleging abuse, neglect or misappropriation at that time.<BR/>In an interview with LVN-A on 06/24/2025 at 4:23 PM she stated she was the off-going nurse the morning the controlled medication count was off, but she stated the count was correct when she had come on shift the night before on 11/20/2024 and counted with LVN-B. She stated she was interviewed, a drug screen was done, and she was suspended pending investigation. <BR/>Interview with Resident #1 on 06/24/25 at 4:50 PM she stated she remembered when her medication went missing in November of 2024 because she heard the nurses talking about it, but she stated she was never interviewed or questioned about the missing medication or if she had received or missed any of her medications. She denied ever missing any doses of her medication or any increased anxiety.<BR/>In an interview LVN-A on 6/25/25 at 6:35 AM she stated she was usually here until 7:00 AM, but sometimes the nurses or medication aides came in early, so they went ahead and counted early. LVN-A stated if she was the one off-going she looked at the count sheet to make sure it was correct, and the one who was on-coming actually counted the controlled medication, and they did not typically double check the other was correct or telling the truth. LVN-A stated she had never been told to do the count any other way, but she saw how not verifying the count was correct could be a cause for concern because medications could be missing or stolen if the count was not correct. She also stated if she gave the medication during her shift, she did not technically perform a count after the medication was given but waited until the end of her shift to count. She denied taking any of the controlled medications.<BR/>In an interview with LVN-B on 6/25/25 at 8:30 AM she stated she was the on-coming nurse on 11/21/2024 and counted around 7am. She stated she was the one who noticed the controlled medications were missing. LVN-B stated she was drug tested by the DON, and as far as she knew they were both fired because of the missing medication. She refused to accept the keys to the medication cart because the count was incorrect. <BR/>In an interview with the DON on 06/25/2025 and 9:00 AM she stated on the morning of 11/21/2024 she, along with the ADONs, did a re-count of the controlled medications and found Resident #1's Clonazepam 0.125 MG was missing 11 tablets. She stated both LVN-A and LVN-B were interviewed, drug tested and suspended pending investigation. She stated no residents or RPs were contacted or interviewed for this investigation. She denied anyone alleging abuse, neglect or misappropriation at that time.<BR/>In an interview with ADON-A on 06/26/2025 at 4:55 PM she stated the facility could have and should have done more with the investigation of the missing controlled medications. She stated no resident or RP interviews were done until yesterday (06/25/2025) when they interviewed Resident #1 as well as other residents with high BIMS scores to determine if they were getting their medications as ordered and scheduled, and all residents stated they were. She also stated they did not notify Resident #1's RP until two days ago (06/24/2025). She stated they should have interviewed Resident #1 and her RP when the controlled medication went missing, as well as interviewed residents who were on the same type of medication as the one that went missing. She denied anyone alleging abuse, neglect or misappropriation at that time.<BR/>Record review of the facility's Administering Medications policy, date unknown, revealed 13. During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide.<BR/>Record review of the facility's Medication Storage policy, date unknown, revealed 7. Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the safe and orderly discharge for one (Resident #1) of four residents.<BR/>Based on interviews and record review, the facility failed to ensure the safe and orderly discharge for one (Resident #1) of four residents.<BR/>The facility (Facility A) failed to plan a coordinated discharge and returned Resident #1 back to the discharging facility (Facility B) on the same day.<BR/>This failure placed Resident #1 in the hospital due to the original discharging facility not accepting the resident. <BR/>Findings included:<BR/>Record review of Resident #1's Face sheet dated 4/10/2025 indicated Resident #1 was a [AGE] year old who was admitted with diagnosis of Autistic Disorder (a neurodevelopmental disorder characterized by repetitive, restricted, and inflexible patterns of behavior, interests, and activities, as well as difficulties in social interaction and social communication), Epilepsy (a brain disorder characterized by recurrent seizures, which are episodes of abnormal electrical activity in the brain), Dysphasia (difficulty with swallowing foods or liquids), and Cognitive Communication Deficit Disorder (a type of communication impairment where difficulties arise due to problems with cognitive processes, rather than speech or language production itself).<BR/>A quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS (Brief Interview for Mental Status) of 99 which indicated severe cognitive impairment and also indicated the resident could not complete the interview. The section GG (Functional Abilities) indicated Resident #1 independently walked and transferred himself but needed assistance with toileting and showering himself. <BR/>Record review of Resident #1's care plan, undated, revealed, Resident #1 had behavior problems. The care plan indicated Resident #1 was sexually inappropriate with female staff and continually tries to reach for female staff as they passed by the resident.<BR/>A record review of Resident #1's progress note dated 3/19/2025 indicated Resident #1 had an increase in dosage of his medication. The progress note indicated the medication Provera was increased from 10 mg to 15 mg by mouth 1 time per day for the diagnosis of Paraphilia (an intense or recurring sexual arousal from atypical situations).<BR/>During an interview on 4/12/2025 at 3:51 p.m., the DON stated Resident #1 was admitted to Facility A on 4/11/2025. The DON stated upon admission Resident #1 did not have any of his medications, he did not have any paperwork to include a medication list, the resident was soiled and brought no personal clothing items with him upon admission. The DON stated after setting the resident up in his room Resident #1 started trying to sexually grope the female staff. The DON stated the facility in which the resident was discharged from did not communicate Resident #1's behavior issues of sexual inappropriateness (this diagnosis was not in the list on the face sheet). The DON stated this was when Facility A became unable to care for the resident or to meet the needs of the resident. The DON stated she was informed Administrator A called the facility where Resident #1 was discharged and made them aware Facility A would be returning the resident to their facility (Facility B). The DON was informed that the Administrator at Facility B was not going to readmit Resident #1, but after contacting the local Ombudsman, Facility A was told Facility B would have to readmit Resident #1.<BR/>During an interview on 4/12/2025 at 4:03 p.m., Administrator A at Facility A stated after finding out Resident #1 was sexually deviant and grabbed private parts of the staff he contacted the local Ombudsman. Administrator A stated he was informed Facility A could return Resident #1 back to the facility he originated. Administrator A stated the Ombudsman informed him the admitting facility had three to five days to make this transfer back to the other facility due to Facility B not communicating the behaviors of Resident #1 and the condition the resident was in when admitting to Facility A (no medications, no medication list, and no clothing). Administrator A stated he called the other facility and made them aware they would be transporting Resident #1 back to their facility. Administrator A stated staff at Facility B informed him they would not be accepting Resident #1 back at their facility and they would call the police. Administrator A informed the staff at Facility B they lied to Facility A and put their staff in danger and informed Facility B Resident #1 was already in route to Facility B.<BR/>During an interview on 4/17/2025 at 12:38p.m., LVN A stated Resident #1 was admitted to Facility A on 4/11/2025 during her shift. LVN A stated she was calling for report from Facility B when Resident #1 arrived at the facility with no medications, no medication list, no personal items, and was soiled. LVN A stated, Resident #1 reached out and grabbed my bottom while bent over the medication cart and Resident #1 was also making sexual gestures towards other people in the area.<BR/>During a review of email correspondence on 4/15/2025, the local Ombudsman stated, I do not represent the facility but the resident. The Ombudsman also communicated that he (Administrator A) should have consulted with his legal team regarding the discharge of Resident #1.<BR/>During an interview on 4/16/2025 at 1pm, Resident #1's family member stated she was aware the discharge occurred on Friday (4/11/25), but the discharge was very rushed from Facility B to Facility A. She also stated the discharge from Facility A to Facility B was rushed as it occurred the same day, which caused her family member to be placed in the hospital because he had nowhere to go.<BR/>During an interview on 4/12/25 at 2:40p.m., Administrator B from Facility B stated, Facility A did transfer Resident #1 back to the facility, but due to informing Administrator A that Resident #1 would not be readmitted to the facility, the police and Adult Protective Services (APS) were contacted. Administrator B stated APS instructed Facility B to take the resident to the hospital due to not having placement for Resident #1.<BR/>Record review of facility's Transfer and Discharge policy dated 3/2012 stated, written notice will be given to Resident/Responsible Party for all planned discharges and transfers. Exceptions to the 30-day requirement apply when the transfer or discharge is effected because: the residents welfare and needs cannot be met in the facility, resident no longer needs services provided by the facility, the resident is endangering the safety of other persons in the facility, the resident is endangering the health of other individuals in the facility, the resident fails to pay for goods and services provided by the facility after reasonable and appropriate notices have been provided, the facility ceases to participate in the program that pays for the resident's care, or a resident has not resided in the facility for 30 days. The facility's Transfer and Discharge policy also included verbiage stating, documentation of the reason for transfer or discharge and the necessity for the resident's welfare and the needs that cannot be met in the facility, and the service available to meet the needs will be documented in the resident's medical record. And in exceptional cases a notice must be provided to the resident, the resident's representative if appropriate, and the Long-Term Care Ombudsman as soon as practicable before the transfer or discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one of four residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to ensure CNA A used a gait belt to transfer Resident #1 from the bed to the wheelchair . <BR/>This failure could place residents at risk for falls, injuries and a decline in health.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 03/30/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 with diagnoses which included muscle wasting and atrophy , abnormalities of gait and mobility, lack of coordination, cerebral infarction (stroke) affecting left non-dominant side, and hemiplegia (paralysis of one side of body) and hemiparesis (weakness on one side of the body). <BR/>Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 14, which meant mild cognitive impairment. Resident #1 needed partial to moderate assistance for chair/bed-to-chair transfer. Resident #1 was coded to have neurological deficits of cerebrovascular accident, transient ischemic attack or stroke and hemiplegia or hemiparesis. Resident #1 was coded for having functional limitation of range of motion with both impairment on one side for both upper and lower extremities. <BR/>Record review of Resident #1's care plan problem start date 10/17/2024 edited on 10/28/2024 revealed ADLs Functional Stat/Rehabilitation Resident requires assistance/supervision for ADL and mobility tasks status post CVA with residual left hemiplegia weakness, impaired balance poor endurance activity tolerance. He has reduced ROM to left upper extremity. He attempts ADLs per self, does not use call light or assist at times, is at risk for falls/injuries. Approach (Interventions): Assist resident with shower three times per week per schedule and PRN. Resident Requires physical x1 staff assistance. Encourage resident to participate to the fullest extent possible with each interaction, task. Encourage resident to turn and reposition Q2 hours and PRN while in bed and up in wheelchair. He is independent for bed mobility and turning and repositioning tasks. Encourage/remind resident to use bell to call for assistance. Check on resident at routine intervals and to assess needs, monitor safety issues and offer/provide assistance as needed. He requires extensive assist x1 staff for dressing and clothing changes daily and PRN. Monitor for changes in functional status and independence for ADLs, strength, balance, safety. Make appropriate referrals PRN. Resident is mobile using wheelchair. He requires supervision and set-up assistance for locomotion on and off of the unit. He is only able to walk very short distances with extensive assistance. Resident requires limited x 1 staff assistance for personal hygiene tasks. The care plan had a revision date of 03/30/2025 to include He is independent for transfer tasks. <BR/>Record review of Resident #1's care plan problem start date 10/17/2024 edited on 03/30/2025, revealed potential for falls due to history of falling, history of CVA with resident left hemiplegia, weakness, impaired balance, unsteady gait, impaired cognitive functioning/ safety awareness/ problem solving with dementia (cognitive impairment) neuropathy (nerve deficit), seizure disorder (brain disorder), arthritis (joint disorder), muscle spasm and cardiovascular, psychotropic, and neuroleptic medication administration. Approach (approach) bed in lowest position, call light in easy reach. Remind resident to call for staff assist when needed and answer call promptly. Check on resident at routine intervals to assess needs, monitor safety issues and offer assist as needed. Intervene with resident to minimize or reduce fall occurrences. Provide adequate staff assistance and support for tasks. <BR/>During an observation on 03/29/2025 at 4:42 PM revealed Resident #1 engaged the call light system in his room and began to situate himself on the side of his bed. CNA A entered Resident #1's room and turned off the call light and asked Resident #1 what he needed. Resident #1 stated he needed to utilize the restroom. Upon initial observation there was observable left sided deficit on both Resident #1's left leg and left arm. CNA A proceeded to retrieve Resident #1's wheelchair and secured it on Resident #1's left side. CNA A then proceeded to assist Resident #1 to stand while she simultaneously grabbed Resident #1's left arm and with strength assisted him into the wheelchair. During Resident #1's transfer, Resident #1 pivoted to the wheelchair, and was observed to struggle while he staggered when pivoting from bed to wheelchair. Resident #1 was observed to have compromising balance as he was observed to be struggling while transferring to the wheelchair. Resident #1 was successful in transferring to the wheelchair while CNA A utilized his left arm to assist him. Throughout the transfer CNA A did not utilize a gait belt . <BR/>During an interview on 03/29/2025 at 5:17 PM, CNA A stated she should have used a gait belt to assist Resident #1 to transfer onto his wheelchair. CNA A stated she should not have used Resident #1's left arm to transfer and should have used a gait belt . CNA A stated she was unaware Resident #1 had a left arm deficit however during this bed to wheelchair transfer, Resident #1 struggled to transfer into the wheelchair. CNA A was asked if she utilized a gait belt when transferring Resident #1, CNA A gave no definitive answer. CNA A stated she left her gait belt in her locker and did usually keep it on her person. CNA A stated she did not use a gait belt because she had left the gait belt in her locker. CNA A stated she was supposed to use a gait belt for transfers but did not have access to it as it was in a destination that was not near Resident #1's room. CNA A stated by not using a gait belt Resident #1 could have fallen and was fortunate that he did not fall. CNA A stated going forward she would ensure to always keep a gait belt with her and would utilize the gait belt when she transferred any resident. CNA A stated she could not recall when she was last in-serviced about resident transfers. <BR/>During an interview on 03/29/2025 at 5:43 PM, the DON stated she was made aware of the observation by CNA A. The DON stated CNA A should have used a gait belt when transferring Resident #1 from the bed to the wheelchair as not only a safety precaution but also to maintain Resident #1's wellbeing. The DON stated CNA A may have compromised Resident #1's well-being as Resident #1 may have fallen. The DON stated all CNAs were supposed to keep a gait belt on their persons. The DON stated going forward she would conduct an impromptu in-service regarding gait belt transfers. <BR/>During an interview on 03/30/2025 at 11:47 AM, ADON B stated Resident #1 was independent during transfers. ADON B stated as she pointed out while reviewing Resident #1's care plan, Resident #1 was independent with transfers, however when asked about the edited date of 03/30/2025, ADON B did not give a definitive answer. ADON B while reviewing Resident #1's MDS stated it appeared Resident #1 was coded for needing assistance with transfer from bed to chair. ADON B stated CNA A could have compromised Resident #1's well-being by not using a gait belt as he could have fallen. ADON B stated CNA A should have used a gait belt while transferring Resident #1 given he was coded for hemiparesis (paralysis) and hemiplegia (weakness). ADON B stated she facilitated an impromptu in-service regarding transfer with gait belts on 03/29/2025. <BR/>Record review of CNA A's 03/08/2025 Lifting, Moving, Positioning, and Transferring competency revealed CNA A completed Transfer Resident from Bed to Chair/Wheelchair or Chair/Wheelchair to bed: <BR/>A. <BR/>(1) Person *Use of Gait Belt.<BR/>B. <BR/>(2) Person *Use of Gait Belt. <BR/>Record review of the facility's gait belt usage in-service, dated 03/29/2025, documented CNA A in attendance.<BR/>Record review of the facility's, undated, One Person Transfer with Gait Belt-Check Off reflected ,<BR/> .4. Position and secure belt properly.<BR/>5. Grasp belt on either side of resident, assist resident to move toward edge of bed. <BR/>6. Place feet firmly on floor under resident. <BR/>8. Face resident, squat with knees bent and your waist at resident's waist level, with back straight use leg muscles to lift to standing position.<BR/>Record review of the facility's, undated, Safe Lifting and Movement of Residents reflected, <BR/>1.Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of resident. <BR/>2.Manual lifting of resident shall be eliminated when feasible.<BR/>4.Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. All manual lifting devices will be made available for use, when necessary, in resident transfer with staff training on usage implement. <BR/>5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving resident when necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure each resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 (Resident #5) of 5 residents reviewed for resident rights. The facility failed to provide Resident #5 with choices concerning her caregivers for personal care. LVN D did not leave the room when Resident #5 asked her multiple times to step out on 08/23/25. LVN D did not treat Resident #5 with respect and dignity on 09/05/25. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth. The findings included:Record review of Resident #5's face sheet reflected a [AGE] year-old female originally admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included paraplegia (the loss of voluntary movement and sensation in both legs), anxiety disorder (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), metabolic encephalopathy (a chemical, or metabolic, problem in the body that can cause brain dysfunctions such as confusion, memory loss, and/or personality changes), and muscle wasting and atrophy (loss of muscle mass and strength), morbid (severe) obesity due to excess calories (weight is more than 80 to 100 pounds above a person's ideal body weight) and neuropathy (damage to nerves outside of the brain and spinal cord that leads to pain, weakness, numbness or tingling in one or more parts of the body). Record review of Resident #5's quarterly MDS dated [DATE] reflected in section C- Cognitive Patterns, a BIMS score of 15 which indicated she was cognitively intact. Section GG- Functional Abilities-Interim reflected Resident #5 was dependent (helper did all the effort, resident did none of the effort, to complete the activity) with toileting hygiene, shower/bathe self, and lower body dressing. Resident #5 required substantial/maximal assistance (helper did more than half the effort) to roll left and right in bed. Section H- Bladder and Bowel reflected Resident #5 had an indwelling urinary catheter, she was always incontinent of bowel, and a bladder and/or bowel toileting program were not being used. Record review of Resident #5's care plan dated 04/11/16 reflected a problem of resident required assistance for all ADL and mobility tasks due to paraplegia, neuropathy, weakness, impaired balance, and poor endurance/ activity tolerance with start date 04/11/16. The goal was resident would be clean/ well-groomed/ appropriately dressed, would have mobility needs met, and would maintain current functional ability through review date. Approaches included resident required extensive X1 staff assistance for personal hygiene tasks, dressing, and clothing changes daily and PRN (start date 01/28/21). Resident #5's care plan also reflected a problem of resident had hx of making false allegations/threats towards staff members. Refused care from all staff at times, had preferences in staff she preferred, and stated staff refused to attend to her needs if staff she preferred were not on schedule, with start date 04/11/16 and edit date 09/30/24. The goal was resident would reduce the number of threatening remarks toward staff throughout next review. Approaches included convey an attitude of acceptance toward the resident, maintain a calm environment and approach to the resident, maintain a calm, understandable approach, repeat as necessary, set acceptable expectations and limits for resident and ensure resident that all needs have been met by staff every day, support appropriate moods/behavior, and when resident begins to become inappropriate, disruptive, accusatory, or threatening, provide for basic needs: assess for pain, hunger, toileting, too hot/cold, etc. dated 01/28/21. Resident #5's care plan further reflected a problem of resident had an electronic monitoring device in bedroom per their and family's wishes with start date 03/07/24. The goal was resident's and family's wishes were to be respected throughout next review (long term goal target date 10/31/24). In an interview on 09/16/25 at 11:12 AM and 09/18/25 at 10:00 AM, Resident #5 stated due to her childhood trauma she had a lot of issues and because of those issues, she would not allow men to change her. Resident #5 stated to her knowledge, all the CNAs were told when they started working at the facility that males would not perform incontinent care for her. Resident #5 stated there were 2 new CNAs that were orienting, and to her knowledge they were both female. Resident #5 stated she found out later that one of them (CNA C) was a male but was representing himself as a female. She stated he was very good at the job he was doing, and she had no complaints other than the fact that some staff knew he was not biologically a female but allowed him to provide incontinent care for her anyway. Resident #5 stated LVN G was taken off her care several years ago and she had not seen her in approximately 5 years. Resident #5 stated, Recently something possessed her, exactly what, I don't know. [LVN G] was upset because [CNA H] was coming to a different hall to change me. Resident #5 stated LVN G came to her door 3 times to rush CNA H and the resident reported her (LVN G). Resident #5 stated she felt like LVN G was getting back at her for complaining about her. Resident #5 stated, They had found out earlier in the week that [CNA C] was a male, but [LVN G] sent him in here anyway. Resident #5 states she was told by CNA H that LVN G stopped her from changing her (Resident #5) and instead sent CNA C to change her. Resident #5 stated CNA H was off for the weekend after that and when she came back CNA H told her she was so sorry, there was nothing she could do about it, but LVN G told CNA C to go change her (Resident #5) and to never tell her that he was not a female. Resident #5 stated, It made me so mad because of all the stuff I'd been through in my childhood. Over time here, I was able to let males help a little bit like adjust my diaper or zinc oxide ointment. But when I found out that the nurse sent him, knowing he was a male, I couldn't understand how a nurse could be so evil. Resident #5 stated she has had to take control of her anxiety and her emotions and talk to her church for emotional support because of LVN G. Resident #5 stated CNA C did not mistreat her in any way, but she felt that he should have been honest with her. Resident #5 stated they did talk to CNA C then he and his sister (also a CNA) both quit. Resident #5 stated she kept a logbook and had a log entry on 08/23/25 at 1:50 AM that stated LVN D barged in her room without knocking to see what CNA H was doing. Resident #5 stated it was the second time that shift LVN D did not knock before entering her room; it had also happened at 8:50 PM. Resident #5 stated, When [LVN D] did it the first time, we had words over knocking on the door because she [LVN D] walked in without knocking to tend to my roommate. [LVN D] stated that I was not going to do to her like I did to the other nurse about knocking. That she was not going to play that game. Resident #5 stated she complained to the DON on 08/24/25 about LVN D's behavior throughout the shift and showed her the video. Resident #5 then showed the surveyor a video dated 08/24/25. In that video, CNA H was performing incontinent care for Resident #5. Resident #5 asked LVN D to step out of the room. LVN D can be heard saying, She can be in here 15 minutes. Resident #5 told LVN D to step out of the room again. LVN replied, I will when I am done speaking to her. I'm the charge nurse. Resident #5 again told LVN D to step out of the room. LVN D stated, No, she will not be in here that long. She will not be in here 45 minutes. LVN D then left the room. In the 16 second video clip, Resident #5 can be heard telling LVN D to step out of the room [ROOM NUMBER] times total. Resident #5 showed the surveyor a video dated 09/05/25 at 10:09 PM. In that video which lasted 48 seconds, Resident #5 was on her left side and LVN D was seen placing a brief under her. Resident #5 asked, Clean it? and pointed to her buttocks area. LVN D replied, No, no, no. Just wait. Scoot over there. Resident #5 stated, You better clean me with soap. LVN D answered, No. No, You just wait 'til I get over there. I was wiping off all the poop first, as she was tucking the brief under Resident #5's hip. LVN D stated, Don't talk to me like that cause I won't do it. I won't come in here. That's for sure. I'm over here making sure that you have nothing on you first. That way we get nothing on the clean diaper, while she was using peri foam to wipe Resident #5 and the video ended. Resident #5 showed the surveyor a video dated 09/05/25 at 10:10 PM. In that video which lasted 1 minute and 46 seconds, LVN D was performing incontinent care for Resident #5 who was rolled to her left side. LVN D told Resident #5, OK, come back. Resident #5 asked her, Did you get the folds? LVN D then answered rudely, Unh-uh. Yes, I did. We had the foam. Yah. I'm not gonna sit there and toalla and toalla (towel and towel in Spanish). No. I do what I. And I used the foam, the peri wash on you and that's all I need to do. And put cream. And cleaned in between your creases. Resident #5 rolled to her back and stated, You need to put cream down here, right here where I got the rash, and pointed to the back of her upper thigh/buttocks area. LVN D said to her, No. No ma'am. Unh-uh. No. This is. I'm already doing this. And that's all I'm gonna do. I have cream, the [name of the ointment] ointment all over the place, while wiping cream on Resident #5's inner thigh. LVN D then handed the packet to the person in the room that was helping her and told Resident #5, OK, roll this way or however you do. Resident #5 rolled to her right side and asked, Am I dirty on that side? LVN D answered, No. I told you I cleaned you with a lot of them and we used the peri foam. Resident #5 asked, OK, you put cream over here on this side? LVN D answered, No, because I did it already. Resident #5 replied, Not on that side. LVN D told her, yes, I did [Resident #5]. Resident #5 rolled onto her back and LVN D stated, Now come on. Let's get this on and I'm going to empty the catheter before I leave. Resident #5 said, Now we gotta get this [unintelligible]. Don't pull it, don't pull it. (Referring to her urinary catheter). LVN D stated, Not right now. OK then, you need to lift up because I'm fixing to walk out. The video ended at that point. In a telephone interview on 09/17/25 at 4:29 PM, CNA C stated he worked at the facility for 2 weeks. He stated he quit, and it was the worst place he had ever worked. CNA C stated the facility was aware that he was a male because his ID showed he was a male, but the night nurses did not know he was a male since he looked like a female and had breasts. CNA C stated when he started, he was just put on the floor alone with no orientation, no teaching, no nothing. CNA C stated it was probably 3 days in, they figured out he was a boy because of a conversation that they had. CNA C stated he did not know it was an issue for him to provide care for Resident #5 until another nurse who, he guessed had been there longer, yelled at him to not go in there because that resident (Resident #5) was not to have care done by males. CNA C stated after that night, he went in her room to clean up and stuff, just not provide incontinent care or anything. CNA C stated Resident #5 did not have any issues with him going in to clean her room or anything, and never told him that she knew he was a boy. CNA C stated, On my last day, I asked [Resident #5] is everything ok because she just randomly asked me who the charge nurse was for this hall and the other hall. When I went to tell the nurse about the interaction, the nurse started yelling at me and calling me stupid for going in there. She was yelling at me that males could not go in there and provide care. That night, the nurses also wouldn't let me go upstairs to get a female CNA to provide care. And they would not go in and provide care. CNA C stated his last night was 9/2/25. CNA C stated, I saw that all of the nurses were rude to her on purpose. On my first day there, they were telling me that I would not want to care for her because she was needy about the way that we change her. Basically, she gets a bed bath every time we change her. You soap her up on the front, wipe it, re-soap it, wipe it, then do the same on the back. Changing her took about an hour. CNA C stated he originally talked to the DON and the HR person. During his interview, the DON asked what shift he wanted to work (he stated overnight), how long had he been a CNA, (he stated 3 months), and how much he wanted to be paid. She then said to come in on Wednesday (08/13/25). CNA C stated, The HR lady just gave me paperwork to fill out. They copied my ID which says I'm male. CNA C stated, After the nurse yelled at me, I was crying and [CNA H] walked with me and said she was sorry, that she did not know I was a boy. [CNA H] said she would have told me about [Resident #5] not wanting a male to provide care. CNA C further stated, The nurses knew before that night that I was a guy, but it was a few days before that they told me not to provide care. 2 days before my last day, I went up to have 2 female CNAs from upstairs switch with me to provide care for Resident #5, but the nurses said to ignore [Resident #5] because she did not want my help. [Resident #5] was on the call light so I told her that I would get someone to help her. An hour later her light was still on, and I asked her if anyone had gone to help her and she said no. I told her that I had told the nurses and that's when she asked me for their names, I told her I didn't know then described them and she told me she knew who they were. So that's when I went out and told the 300 hall nurse that [Resident #5] wanted to know her name. My nurse in the 200 hall is the one who told me to ignore her. She had just put in her 2 week notice that day. She was saying she was quitting because they were so short staffed. The nurses never moved from the nurse's station all night. In an interview on 09/18/25 at 11:44 AM, CNA L stated she had been at the facility for three years and normally worked in Resident #5's hall. She was able to name the abuse coordinator and the types of abuse. She stated if she saw any abuse she would report it right away to the charge nurse and to the Admin. CNA L stated new CNAs oriented on which residents were continent or incontinent, what the daily routine was, and they had a sheet at the nurse's station in the ADL book that listed residents with any special needs. CNA L stated there were special instructions regarding Resident #5's care, but she did not remember specifically what the instructions were. CNA L stated the last in-service over ANE was 09/15/25 and they were every month on the 15th. CNA L stated the in-service covered types of abuse, who to report it to, resident hydration and cleaning. CNA L was not sure what constituted abuse. CNA L stated, [Resident #5] just has her ways and if she did not like you, she would not let you touch her. CNA L stated she was not allowed to take care of Resident #5 because Resident #5 said she was being too rough with her. CNA L stated, [Resident #5] has certain people that she does want to take care of her and certain ones that she doesn't, but she did not remember the names of any of them. In an interview on 09/18/25 at 12:16 PM, CNA N stated she had been at the facility for over 10 years and primarily worked in Resident #5's hall. CNA N stated there were a lot of people that Resident #5 did not like and on the day shift, the only person she liked was CNA N. CNA N stated, If [Resident #5] did not like anyone that was working, she would wait the entire shift to be changed because she would not let anyone she did not like change her. With her it was always 2 people because she was always accusatory, so in the mornings, a nurse had to go with me sometimes if [Resident #5] didn't like any of the other CNAs. CNA N stated Resident #5 did not like men to provide care for her and only 1 male CNA could check to see if she needed to be changed, but he was not allowed to provide incontinent care. CNA A stated the male CNA could be in the room, but he had to face away. CNA N stated ANE in-service was done the 15th of every month, and the last one was 09/15/25. CNA N stated they gave papers with the in-service that went into more detail about the training. In an interview on 09/18/25 at 12:28 PM, ADON A stated Resident #5 complained about LVN D a couple of weeks back. ADON A stated the CNAs took a long time with Resident #5 when care was provided because Resident #5 was very particular about the care and was also very picky about who provided care for her. ADON A stated that evening they had to get the CNA from the other side to take care of Resident #5, and LVN D went in the room and told the CNA she only had 15 minutes to do care for her (Resident #5) while CNA H was providing care. Resident #5 had told LVN D to leave the room and she left the room. LVN D got moved upstairs because she was PRN, and we needed her upstairs. LVN D got fired for that incident on 09/15/25 after we watched the video because of how she talked to Resident #5. ADON A stated in-services on abuse and neglect were done anytime there was an incident and monthly on the 15th of every month or the nearest weekday if the 15th was on a weekend. ADON A stated they went over the types of abuse and asked the staff to identify the different types of abuse. ADON A stated there were not any hand-outs that went with the abuse/neglect in-services, but staff was verbally quizzed about different scenarios, and they were to identify what type of abuse it was. In an interview on 09/18/25 at 12:51 PM, the SW stated Resident #5 had talked to her about LVN D being rude about the CNA taking too long to care for her approximately 1 1/2 to 2 weeks ago. The SW stated, I think she had talked to the DON before she talked to me. I don't know what was done about it, you'd have to ask the DON. The SW stated abuse/neglect in-services were on the agenda for the meetings that were held on the 15th of every month. The SW stated Resident #5 was tying our hands because she would not allow many of the CNAs to provide care. The SW stated there was only one specific CNA downstairs that was allowed to take care of her that she knew of. The SW asked Resident #5 if she wanted to talk to psychiatric services and the following day, Resident #5 stated she did want to talk to them. In an interview on 09/18/25 at 1:01 PM, the DON stated, [Resident #5] has gotten to the point that she doesn't want anyone to care for her. I have 2 nurses and 2 aides on 3-11 that she won't let care for her. The same with day shift. I have asked the ombudsman for help, and she said she didn't have any suggestions. The DON stated Resident #5 took about 45 minutes to change her because she was very particular about what she wanted done and how it was done and when she wanted it done. The DON speculated maybe Resident #5 just wanted company, but they had so many residents that they could not spend an hour at a time in with Resident #5. The DON stated, [Resident #5] always threatens that she has video and will report us. The DON stated Resident #5 complained about LVN D approximately 2 weeks ago and said that LVN D was rude and unprofessional. The DON stated Resident #5 showed her the video a couple of weeks ago, and further stated, I was surprised with [LVN D] being so rude and disrespectful. The DON stated she and ADON A called LVN D into the office the next day and told her that she was unprofessional and asked her why she talked to [Resident #5] like that. The DON stated LVN D said she was tired of doing that all day and Resident #5 was very aggressive and would be on the call light all day long. The DON stated, We talked to [Resident #5] and told her that [LVN D] was not going to work that area anymore. The DON stated LVN D worked one shift after that, and she told them not to let her work anymore. The DON stated, We let her go on 09/15/25 for being disrespectful, rude, and unprofessional. You don't treat a patient like that. When asked if she thought LVN D's behavior was abuse, the DON stated, I would say that it was verbal abuse. I told the Admin about it the same day that I did the interview with [Resident #5], about 2 weeks ago. Me, the ADON and the Admin discussed it and decided it would be better to let the nurse go. The DON stated allegations of abuse were to be reported to the state within 2 hours, but this one was not reported within 2 hours because, We could not get a hold of her (LVN D). The DON stated when she talked to LVN D about it a couple of weeks ago, she (LVN D) said she was not coming back, but she did work another shift after that. The DON stated she told the ADONs not to have her come back in. Later in the interview the DON stated, It did not get reported to state because we were discussing it and listening to the video trying to decide if it was abuse or not, but we had already let her go. In an interview on 09/18/25 at 5:18 PM, the Admin stated he found out about the issue between Resident #5 and LVN D when the ombudsman told him on Monday, 09/15/25, and that he was out of the facility for part of the week between 08/24/25 and 08/30/25. The Admin stated, the SW and I went over to talk to Resident #5, and she showed me a video where LVN D is telling the CNA H that she shouldn't be taking 45 minutes to change the resident. [Resident #5] was telling [LVN D] to get out of the room and [LVN D] kept talking to the CNA instead of leaving. I decided to report it to state even thought I hadn't even completed my investigation yet. When I listened to it, then I looked over the rules and regulations, I wanted to make sure that it would fall under verbal abuse. The more I looked at the video, I don't think she (LVN D) was trying to threaten her (Resident #5) or make her feel afraid, and [Resident #5] said she wasn't afraid of her, but I couldn't find anything that made me feel like it was abuse. The Admin stated that being rude and ugly toward someone did make it reportable and they let her go because they did not want her to be rude or ugly to anyone else. The Admin stated no one told him anything prior to 09/15/25. The Admin stated, For the most part, he did see the grievances. The Admin stated in the mornings he would ask the SW if there were any issues. He further stated he would ask for grievances at every morning meeting. The Admin stated he was surprised to know that there was a grievance about this issues before he heard it from the ombudsman. The Admin stated, If the DON had told me about that grievance, I would have reported it. Once I find out about abuse it's 2 hours to report, everything else is 24 hours. Once I saw the video, I reported it. The DON saw the video first and she came back and told me she was not sure if it was abuse or not, so then I went in with the SW and watched it, talked with corporate, then decided to report it. The Admin stated they had abuse/neglect in-services every month on the 15th. Record review of the facility's grievance dated 08/21/25 at 10:06 AM reflected the following: Resident Name: [Resident #5]Describe the grievance/concern: Resident complain on a CNA that whoever did peri care-had done a very good job-but she did not know weather it was a he or a she- & was very concerned [sic].Expectation of person voicing concern: Resident voiced that she does not want the 2 CNA that work her hall [sic].Findings: Resident also complain on my 2 nurses that work 7P to 7A [sic].Action taken: Spoke to [LVN G] and advise her to please, do not go to her room- never again- because resident hates her. Also on the other nurse, Resident says she does not knock at her room. 8/22/25 Advice to other nurse- to please knoce at her door- this is a state regulation & she must follow up- she agreed. *Note 2 of my CNA & (1) nurse are not allowed to go to her room. Because she resident does not want them [sic].Reportable to outside agency? NoIf yes, was this reported? NoInvestigation findings reported to person voicing concerns? YesHow? In personNote: On the complain above I have an older CNA that will attend her (unreadable name) Now when [CNA H] is off, one of the CNA upstairs will help her [sic].Person Completing Inquiry: [DON] signatureDate: 08/23/25Record Review of the facility's Quality of Life-Dignity Policy dated 02/2020 reflected in part: Policy StatementEach resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.Policy Interpretation and Implementation1. Residents shall be treated with dignity and respect at all times.2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.6. Residents' private space and property shall be respected at all times.a. Staff will knock and request permission before entering residents' rooms.7. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by:b. Promptly responding to the resident's request for toileting assistance.Record review of the facility's undated admission packet reflected in part: Statement of Resident RightsYou, the resident, do not give up rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any facility employee to threaten, coerce, intimidate, or retaliate against you for exercising your rights.If anyone hurts you, threatens to hurt you, neglects your care, takes your property, or violates your dignity, you have the right to file a complaint with the facility administrator or with the Texas Department of Aging and Disability Services by calling [PHONE NUMBER].Dignity and RespectYou have the right to:Be free from abuse, neglect, and exploitation.Be treated with dignity, courtesy, consideration, and respect and be free from discrimination based on age, race, religion, sex, nationality, disability, marital status, or source of payment.Freedom of choice:You have the right to:Make your own choices regarding personal affairs, care, benefits, and services.Participation in your care:You have the right to:Receive all care necessary to have the highest possible level of health.Participate in developing a plan of care, to refuse treatment, and to refuse to participate in experimental research.Complaints:You have the right to:Complain about care or treatment and receive a prompt response to resolve the complaint without fear of reprisal or discrimination.Your rights may be restricted only to the extent necessary to protect you or others, or to protect the rights of others, particularly those rights relating to privacy and confidentiality. These described rights are in add remedies an individual may be entitled to, according to rules under law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) of fifteen residents reviewed for abuse.<BR/>The facility failed to protect Resident #1 from being verbally abused by SA on April 29th 2024. <BR/>The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/29/2024 and ended on 04/29/2024. The facility corrected the non-compliance before the investigation began.<BR/>This failure placed all residents at the facility at risk of severe psychosocial harm by being forced to interact with an employee that verbally abuses residents.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet reflected a [AGE] year-old female with an admission date of 01/12/2023. Pertinent diagnoses included depression unspecified (patient is primarily depressive but does not meet the full criteria for any specific depressive disorder) and type 2 diabetes mellitus.<BR/>Record review of Resident #1's quarterly MDS assessment section C, cognitive patterns, dated 05/29/2024 reflected a BIMS score of 15 (cognition intact). <BR/>Record Review of Resident #5's face sheet reflected a [AGE] year-old male with an admission date of 03/10/2024. Pertinent diagnoses included depression unspecified, generalized anxiety disorder, and alcohol-induced persisting dementia (damage to the brain caused by regularly drinking alcohol over many years resulting in memory loss and difficulty thinking things through).<BR/>Record review of Resident #5's quarterly MDS assessment section C, cognitive patterns, dated 06/06/2024 reflected a BIMS score of 13 (cognition intact).<BR/>Record review of Resident #6's face sheet reflected a [AGE] year-old female with an admission date of 06/04/2024. Pertinent diagnoses included vascular dementia (general term for problems with reasoning, planning, judgement, memory and other thought processes), anxiety disorder, unspecified depression, and bipolar disorder (mental illness causing unusual shifts in a person's mood, energy, activity levels, and concentration).<BR/>Record review of Resident #6's MDS assessment section C, cognitive patterns, dated 06/10/2024 reflected a BIMS score of 13 (cognition intact).<BR/>Record review of the provider investigation report dated 05/01/2024 revealed that on 04/29/2024 The alleged perpetrator (SA) was in the patio washing the concrete area. This is when the alleged victim (Resident #1) started confronting the alleged perpetrator about washing the concrete during smoke break. According to witness' the alleged perpetrator became upset with the alleged victim and cussed at her. Once the facility was advised of the incident at about 2:15 PM., the Administrator suspended the alleged victim pending the outcome of the investigation. The provider investigation report found the results of the investigation to be inconclusive. <BR/>Record review of the provider investigation report dated 05/01/2024 revealed a signed statement from Resident #1 stating I went outside to have a cigarette after lunch. SA was wetting down the patio (smoke area) with the water hose, I asked why he was doing that, he said they asked him to. So I went inside to find his boss (HR) to tell her he was not passing cigarettes because he was cleaning the patio. She asked why I was telling her. I said because you are his boss and I went outside to where he was then pouring liquid soap. Then HR came out and asked if he was giving cigarettes out, he said in a few minutes, but he was on the first part of the patio. At this point I told him his head was a little big with his job, and I was tired of him being so controlling. He said fuck you, I said what did you say to me? He said it a little louder. I am not defending my behavior, but I did not deserve that. I went and to SSD, then administrator and my witnesses came forward and corroborated my complaint. The DON came and talked to me, and again before she left for the night.<BR/>Record review of the provider investigation report dated 05/01/2024 revealed a signed statement from Resident #7 stating I heard SA, the smoke monitor, tell Resident #1 'Fuck you.' 4/29/24<BR/>Record review of the provider investigation report dated 05/01/2024 revealed a signed statement from FT stating On April 29th I was outside SA was scrubbing the patio and Resident #1 came outside and asked for a cigarette. He told her she had to wait she questioned why they had to wait and his reply was after she asked what did you say and he said 'fuck you.'<BR/>Record review of 1:1 in-service titled, Abuse Prevention, Abuse & Neglect Facility Policy, specifically verbal abuse was conducted by the Administrator with the SA on 04/28/24 and signed in ink by both.<BR/>In an interview with SM on 08/06/2024 at 10:41 AM, SM stated that the patio was open to residents that wish to smoke from 7 AM to 7 PM. SM stated there was a lunch break from 12 PM to 1 PM where the patio was closed for smoking. SM stated that he was familiar with SA and he had heard from residents that SA would frequently yell and cuss at all of them. SM stated he was not familiar with any specific incident involving Resident #1, and that he had not started working yet at the facility on 04/29/2024.<BR/>In an interview with Resident #5 on 08/06/2024 at 1:07 AM, Resident #5 stated that SA would cuss and yell at all the residents in the smoking area. Resident #5 stated that he was aware of the incident involving Resident #1 when SA said Fuck you to her on 04/29/2024, but could not elaborate further on other incidents. <BR/>In an interview with Resident #6 on 08/06/2024 at 2:49 PM, Resident #6 stated that SA told one of the ladies in the smoking area to Fuck off. Resident #6 stated that she was not there at the time of the incident, but that she heard it from everyone that goes out to the patio to smoke. <BR/>In an interview with Resident #1 on 08/07/2024 at 9:50 AM, Resident #1 stated that SA said fuck you to her. Resident #1 stated that a lot of other residents were out there and heard it as well. Resident #1 stated that she immediately reported the incident to the Administrator. Resident #1 stated that SA was suspended, but that he came back to work as a maintenance person and that she had seen him walking around the building. <BR/>In an interview with HR on 08/07/2024 at 11:09 AM, HR stated that the last day SA worked was on 07/10/2024. HR stated that SA was not fired after the verbal abuse incident. HR stated the reason SA no longer works at the facility was because he stopped showing up for work after 07/10/2024. <BR/>In an interview with the Administrator on 08/07/2024 at 11:33 AM, the Administrator stated that, during the initial incident on 04/29/2024, Resident #1 was upset because SA was washing the patio and not handing out cigarettes. The Administrator stated that SA allegedly told Resident #1 to fuck off when she told him to stop cleaning the patio. The Administrator stated they reported the incident to Texas Department of Health and Human Services for verbal abuse and suspended SA. The Administrator stated that SA was suspended for a few days before returning to work, but he could not remember exactly how long the suspension lasted. <BR/>In a follow-up interview with Resident #1 on 08/08/2024 at 9:41 AM, Resident #1 stated that when the incident first occurred, she felt embarrassed and anxious because she did not like being talked to that way in front of other residents. Resident #1 stated that after the incident, when she saw SA working in the facility, she felt fearful that he might confront her because she made him change job roles at the facility. Resident #1 stated that there was one incident once SA returned to work at the facility where he was painting other resident's doors outside her room in the 300 hall. Resident #1 stated that a lot of her fear and anxiety returned when she saw him so close to her room. Resident #1 stated that she felt like the facility did not care to protect her from him, or future aggressors if a similar event happened again. <BR/>In a follow-up interview with the Administrator on 08/08/2024 at 10:53 AM, the Administrator stated that the findings of the provider investigation were inconclusive because SA never admitted to saying fuck you. The Administrator refused to answer if he had reasonable suspicion on whether SA said fuck you to Resident #1. The Administrator stated that verbal abuse of this nature does not reach the threshold of needing to call the police. The Administrator stated that the resident never voiced any concerns about SA still working at the facility. The Administrator stated that this incident did not violate Resident #1's rights because she could have waited a few minutes for her cigarette. The Administrator stated that he did not know if SSD did wellness checks on Resident #1 after the incident. <BR/>In an interview with the SSD on 08/08/2024 at 1:20 PM, the SSD stated approximately two weeks after SA was suspended where Resident #1 saw SA painting the doors near Resident #1's room. SSD stated that Resident #1 was upset at that time, but SSD calmed Resident #1 down and let Resident #1 know that SA would finish his work soon. SSD stated that was the only incident she was aware of involving Resident #1 and SA after the incident on 04/29/2024.<BR/>In an interview with the DON on 08/08/2024 at 1:25 PM, the DON stated that she talked with Resident #1 a few weeks after the incident and Resident #1 expressed concerns about SA still working in the facility. The DON stated that she reported this to the Administrator and SSD. <BR/>Record review of the Time Card Report for SA revealed that on the day of the incident, 04/29/2024, SA clocked out at 2:44 PM. The Time Card report revealed that on the day after the incident, 04/30/2024, SA worked from 7:01 AM to 7:16 PM with a break from 11:57 AM to 12:37 PM.<BR/>Record Review of the facility's undated policy titled Abuse Prevention defined Verbal Abuse as The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Following that, in the section titled PROCEDURE: STEPS TO PREVENT, DETECT AND REPORT: SCREENING: #3 stated It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. <BR/>Record review of the facility's policy titled Statement of Resident Rights dated 07/20/2015 stated under the DIGNITIY AND RESPECT section You have the right to: Be free from abuse, neglect, and exploitation. Be treated with dignity, courtesy, consideration, and respect.<BR/>Record review of the facility's abuse and neglect in-service dated 08/08/2024, 08/09/2024 reflected all staff in attendance.<BR/>Record review of the facility's customer service, resident rights, respecting resident wishes in-service dated 08/10/2024 reflect all staff in attendance. <BR/>Record review of the facility's Abuse Prevention policy and procedure undated. <BR/>Record review of the facility's resident safe surveys, including Resident #1, dated 08/09/2024 were reviewed and reflected residents felt safe in the facility environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation for 1 of 5 residents (Resident #1) reviewed for neglect and abuse.<BR/>The facility failed to report verbal abuse by the SA to local law enforcement in accordance with state law on 04/29/24<BR/>The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/29/2024 and ended on 04/29/2024. The facility corrected the non-compliance before the investigation began.<BR/>This failure could place residents at risk of continued victimization, abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. <BR/>Findings included:<BR/>Record review of the undated facility Abuse, Neglect, and Exploitation policy stated the facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Definitions: b). Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Procedure: A. Steps to prevent, detect, and report: Screening: Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and or representative, and as required by state guidelines. In addition, the facility will follow Section 1150B of the Social Security act's time limits for reporting a reasonable crime (immediately but no later than 2 hours if serious bodily injury and 24 hours for all others) In addition to reporting to the state agency, a reasonable suspicion of crime or allegation of abuse, neglect, or misappropriation of resident property is to be reported to at least one law enforcement agency.<BR/>Record review of the facility policy reference to Section 1150B of the Social Security Act: Guidance for Reporting Suspicion of a Crime. Section 1150B of the Social Security Act (the Act), as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), requires specific individuals in applicable long-term care facilities to report any reasonable suspicion of crimes committed against a resident of that facility to State Survey Agencies and Law Enforcement.<BR/>Record review of Resident #1's face sheet revealed a [AGE] year-old female with diagnoses including diabetes, neuropathy, rheumatoid arthritis, heart disease, chronic skin infections, anxiety, left below the knee amputation. <BR/>Record review of Resident #1's MDS Quarterly dated 05/28/24 revealed Resident #1 had a BIMS Score of 15 indicating no cognitive impairment and needed little to no assistance with all ADLs.<BR/>Record review of the provider's investigation dated 05/01/24 described on 04/28/24, the smoking attendant became upset with Resident #1 and cursed at her twice telling her Fuck You each time during a smoking break. There was a total of 4 residents who attested to, witnessed, and confirmed the incident. The provider investigation included Penal Code Title 9 Ch. 42 Sec. 42.01 Disorderly conduct (a) a person commits an offense if he intentionally or knowingly: (1) uses abusive, indecent, profane, or vulgar language in a public place, and the language by its very utterance tends to incite an immediate breach of the peace (a-1) (d) An offense under this section is a class C misdemeanor. There was no Case # and local law enforcement were not contacted. <BR/>There was a signed 1:1 Teachable Moment dated 04/29/24 between the ADM and the SA. The employee was suspended initially and in-serviced on the importance of respecting the residents. The details revealed the employ was in the smoking area and cussed at one of the residents. The SA was not available for interview.<BR/>Record review of 1:1 in-service titled, Abuse Prevention, Abuse & Neglect Facility Policy, specifically verbal abuse reflected the in-service was conducted by the ADM with the SA on 04/28/24 and signed in ink by both.<BR/>Record review of the SA's time sheets dated 03/21/24-07/10/24 documented he was sent home on [DATE] at 2:44 pm. He returned to work on 04/30/24 from 7:01 am-7:16 pm. The record showed he worked Tuesdays, Thursdays, and Saturdays regularly and occasionally on a Monday or Friday. The SA was never suspended for his verbal abuse, he was only sent home early as reflected on his time sheets <BR/>In an interview with Resident #1 on 08/07/2024 at 9:48 am she stated the SA specifically said, fuck you and she asked him, what did you say to me? and he said it again, louder. Resident #1 stated this happened on the smoking patio and lots of other people were out there. She stated she reported it immediately to the SW who sent her to the ADM, and she told him about the incident. She stated, First the SW and DON told her they fired him (the SA), then suspended him, but then he was back. Resident #1 stated, Since then, he (SA) either quit or got fired probably 3-4 weeks ago. She said did not speak to him, nor him to her when he came back. She stated she saw him around 3-4 times, and became very anxious each time. She said seeing him would ruin her day. She said she did not know what she was afraid of but felt unprotected. She said she spoke with the SW and asked the ADM why the SA was still around. She said she asked to see the report he (the ADM) sent because he had gone back & forth with her about when & if he called the state. Resident #1 stated the ADM told her if she kept causing trouble, she could find herself on the street. She stated HR had joined their conversation and told her, The state had more to worry about than her. She stated the ADM was not joking with her and had raised his voice to her. <BR/>In an interview with HR on 08/07/2024 at 11:09 am she stated she (Resident #1) came to me about the smoke guy (SA) and said, who the F was I to let this MF clean the patio when we trying to smoke. HR stated she had never had any situations with the SA, that he was a good guy. HR stated the SA just stopped coming to work on July 10, 2024, and that was the day she terminated him. She stated she tried to call him, but he never answered her calls. HR stated the SA came to pick up his check and he told her his truck broke, and that was that. She stated the ADM had to tell Resident #1 she could not speak that way to them. <BR/>In an interview with the ADM on 08/07/2024 at 11:34 am he stated he was not at the facility during the first encounter Resident #1 had with HR because he was at lunch. He stated Resident #1 wanted to speak to him in his office and she said she told the SA he should not be doing that (washing the smoking patio) right then and that he (the SA) cursed at her. The ADM stated he suspended the SA immediately then reported it to the state for verbal abuse. The ADM stated the SA was allowed to return after his suspension and was moved to a different role (light maintenance and painting) so he would not have any contact with Resident #1. The ADM stated the SA ended up leaving/quitting. <BR/>In an interview with Resident #1 on 08/08/24 at 9:41 am, she stated that she felt embarrassed and anxious because she did not like being talked to by the SA in such a negative way in front of other residents. She stated that she felt fear and anxiety seeing him (the SA) around the facility after the incident. The resident stated that when they did not get rid of him right away, she felt like the facility did not care to protect her. <BR/>In an interview the ADM on 08/08/24 at 10:53 am, he stated, The findings were inconclusive because the man (SA) never admitted to saying fuck you to the resident. He said signing the 1:1 was not an admission of guilt, it only meant he received the 1:1 training. The ADM repeated that the SA never admitted to it. He said a teachable moment (the 1:1 training) was just a record of a verbal reprimand. The ADM said there was no policy that stated what the punishment was for abusing a resident. The ADM said his conclusion of his investigation was inconclusive. He stated the allegation met the definition of verbal abuse, but his findings were inconclusive. The ADM refused to answer whether the incident had reasonable suspicion of a crime (verbal abuse) if the smoking attendant said fuck you to the resident. The ADM stated, In my opinion verbal abuse does not reach the threshold of needing to call the police (meaning he did not notify local law enforcement). If you want to get me for not following my policy, then that is fine. The ADM stated he did not know if the social worker did wellness checks on Resident #1 after the incident. <BR/>In an interview with the DON on 08/08/24 at 1:25 pm, she stated she talked with Resident #1 a few weeks after the incident, and she was concerned about the SA still working in the facility. She stated, I eased her concerns and said he would not bother her. I reported this to the administrator and the social services director. She stated she did not know if the ADM or SW spoke to Resident #1.<BR/>In an interview with the ADM on 8/9/24 at 4:00 PM, he stated, The SA was suspended for 3 or 4 days, then he had some days off behind it, making it seem longer. The ADM had no comment regarding the SA's timesheets.<BR/>Record review of the facility's abuse and neglect in-service dated 08/08/2024, 08/09/2024 reflected all staff in attendance.<BR/>Record review of the facility's customer service, resident rights, respecting resident wishes in-service dated 08/10/2024 reflect all staff in attendance. <BR/>Record review of the facility's Abuse Prevention policy and procedure undated. <BR/>Record review of the facility's resident safe surveys, including Resident #1, dated 08/09/2024 were reviewed and reflected residents felt safe in the facility environment.

Based on interviews and record review, the facility failed to report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures by one staff member (the SW) of five staff members reviewed for reporting of abuse allegations. The facility failed to ensure the SW reported all suspected abuse or mistreatment when a handful of residents informed her RN F and RN G were being mean to them approximately between March and April of 2025. This failure could place residents at risk for physical, mental, and psychosocial harm. The findings include: In an anonymous interview, it was stated, night nurses RN F and RN G would yell at residents to go to bed and would yell at the residents to hurry up. RN F would yell at the residents saying, the call light is not a toy'. RN F made the residents feel scared to ask for help or use the call light. RN F would tell residents If I am investigated by HHS, they will believe me and not you because you have dementia. LVN E and SW were told about the mistreatment by RN F and RN G but unsure of what came about the complaint. RN F and RN G no longer work at the facility and the residents feel safe. Residents felt like nothing was being done when they made complaints about the mistreatment by RN F and RN G. In an anonymous interview, it was stated, RN G would poke residents when she would go in to give them medicine, yelling at residents to get up and would make them feel beneath her. RN F would yell at residents stating, I am tired of cleaning up your shit and both RN F and RN G would make the residents feel like they were alone and could not ask for help, especially since it was nighttime and no administration was around. In an interview on 07/29/25 at 9:10am, LVN E stated the residents would complain to her about their medicine being administered late but never expressed to her they were being mistreated or yelled at by any staff member, including RN F and RN G. LVN E stated she would have reported any suspected abuse to the ADM. In an interview on 07/29/25 at 3:29pm, the SW stated a resident (who was no longer at the facility) informed her that they (night nurses, SW did not get names of who) were rude to them and would not give them their medicine. The SW stated she thought she reported it to the DON and was not sure what happened after that. The SW stated she did not follow up on the grievance and was not sure if anything was investigated. The SW stated the allegation was reported to her several months ago but could not recall when. The SW stated she would hear from a handful of residents that the night nurses were mean to them. The SW stated when the residents informed her of this, they told her not to say anything. The SW stated she did not ask why they felt they should not report anything and did not think it was abuse even though the residents used the word mean. The SW stated she never asked what the residents meant by mean and left it at that. The SW stated she did not write up grievances because the residents told her not to. The SW stated she was aware of what verbal abuse was and that all suspected abuse should be reported to the abuse coordinator. The SW stated in-service on ANE was held every month and the SW was the one who conducted the monthly in-service. The SW stated all suspected abuse should be reported and could not give a reason why she did not report the allegations of the night nurses being mean to the residents other than the resident did not want me to. In an interview on 07/30/25, the DON stated the SW should have reported any and all suspected mistreatment or possible abuse. The DON stated resident safety was important to the facility and any allegations of abuse were taken seriously and needed to be investigated. The DON stated if suspected abuse was not reported, it could cause the residents to become fearful or allow the alleged perpetrator/s to continue or escalate the abuse. In an interview on 7/30/25 at 11:10 am, ADON B if a resident went to her and stated that a nurse was being mean or mistreating them, she would ask the resident for details, remove the nurse from the area and go tell the DON and ADM. ADON B stated a staff member yelling at a resident or cursing at a resident was verbal abuse and should be reported to the DON and ADM immediately. In an interview on 07/30/25 at 11:54pm, the ADM stated the SW should have reported any suspected abuse and the facility takes all allegations of abuse or neglect seriously. The ADM stated he was going to in-service the SW on ANE as well as all staff. The ADM stated the facility staff, including administration, conduct Angel Rounds every morning and residents have not expressed they were being mistreated by any staff. Record review of the facility's Abuse Investigation and Reporting policy not dated reflected: 'Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Record review of the facility's policy on Abuse Prevention not dated reflected: POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. b) Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. 3. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatment shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed. CORRECTIVE ACTION: Any instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies.

**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 the resident's medical, nursing, mental, and psychosocial needs, for one Residents (R#1) of 14 residents reviewed for care plans.<BR/>The facility did not implement the comprehensive person-centered care plan set forth for R #1. <BR/>These failures place residents at risk for not being provided necessary care and services. <BR/>The findings included:<BR/>Upon review of R#1's Face sheet, dated 12/21/2021, documented a [AGE] year-old female admitted on [DATE] and readmitted [DATE] with the diagnosis of vascular dementia (memory loss), psychotic disorder with hallucinations (where a person hears, sees and, in some cases, feels, smells or tastes things that do not exist outside their mind but can feel very real to the person affected by them) , psychotic disorder with delusions (unshakeable belief in something implausible, bizarre, or obviously untrue), Mood disorder (general emotional state or mood is distorted or inconsistent with the circumstances and interferes with ones' ability to function.), Paranoid schizophrenia (predominantly positive symptoms of schizophrenia, including delusions and hallucinations), Major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Impulse disorder (chronic problems in which people lack the ability to maintain self-control).<BR/>Record Review of R#1's Care Plan dated 12/23/2022 documented:<BR/>Resident has physical behavioral symptoms toward others pulling hair, hitting, kicking, pushing, scratching, abusing others. Incident occurred 12/14/22, resident threw apple sauce container at other resident back. Resident has history of verbal altercations with other residents. Altercation with another resident 12/20/22. Goals, Resident will not harm others secondary to physically abusive behavior. Approach, Provide 1:1(staff/personnel with resident always) sessions with resident, obtain a psych consult/psychosocial therapy, transfer out to Geri psych per MD order. Avoid Power struggles with resident. Convey an attitude of acceptance toward resident Maintain a calm environment and approach to the resident, offer one step verbal directions for tasks. Allow for extra time to process the information. <BR/>Record Review of R#1's Minimum Data Set (MDS) dated [DATE] documented:<BR/>Behaviors not exhibited for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others.<BR/>Brief Interview for Mental Status (BIMS) Summary Score: 99. Enter 99 if the resident was unable to complete the interview. <BR/>During an observation of R #1 on 01/19/2023@1:10 PM: Observed R #1 in their room unattended. According to R#1's care plan, R#1 requires 1:1 (staff/personnel with resident always) session with resident. R #1 in wheelchair with food tray placed in front of resident, on bed side table. R #1 is unable to be seen and monitored from nurse's station.<BR/>During a second observation of R #1 01/19/2023@3:37 PM Observed R #1 in room, in wheelchair, no personnel/nurse/staff with resident. <BR/>During an interview with the Director of Nursing (DON), on 01/19/2023@2:35 PM, revealed that the facility no longer required R#1 to have a 1:1 (staff/personnel with resident always). Inquired for clarification and justification as to why the 1:1 status remained on care plan. DON stated 1:1 should not be on care plan and isn't being practiced. DON stated they are doing q15min (every 15 minutes) rounding but currently the intervention has not been added nor updated to R#1's care plan. Inquired as to why the updates had not been completed on R#1's care plan, was not given a definitive answer. <BR/>During an interview with MDS Coordinator, on 01/19/2023@4:03 PM, revealed that the care plan for R#1 still read, Provide 1:1 session with resident. Inquired for the reasoning as to why Provide 1:1 session with resident was still on the care plan if the facility no longer requires R#1 to have a 1:1? The MDS Coordinator stated that they had not updated the care plan to reflect R#1's care plan change. Per the MDS Coordinator, R#1 was transferred many times throughout December 2022, and did not update the care plan for this reason. Per MDS Coordinator, R #1 was transferred to local hospital from [DATE]-[DATE] Geri Psych,/22 as well as 12/30/2022-01/09/2023. residentUpon return of R#1, on 01/09/2023, care plan hadn'thas not been updated to reflect recent interventional changes of removal of 1:1 session with resident, and insertion of q15min rounding upon return MDS Coordinator stated they didn't want to lie and hadn't updated care plan since resident return on 01/09/2023.<BR/>Record Review of the facility's undated Care Plans, Comprehensive Person-Centered policy states:<BR/>12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of required comprehensive assessment (MDS).<BR/>13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.<BR/>14. The interdisciplinary team must review and update the care plan:<BR/>a. when there has been a significant change in the resident's condition. <BR/>c. when the resident has been readmitted to the facility from a hospital stay;.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene, for one (Resident #86) of 3 residents reviewed for activities of daily living. The facility failed to provide Resident #86 with fingernail grooming. This failure could result in decrease in resident self-esteem, embarrassment, and infections. The findings included: Record review of Resident #86's Resident Face Sheet dated 09/18/25 reflected a [AGE] year-old male with an admission date of 09/27/24. Resident #87 had diagnoses which included Dementia (decline in brain functions such as, memory, thinking, problem-solving & language) in other diseases classified elsewhere, mild, with mood disturbance, Other lack of Coordination (difficulty with voluntary movements & balance), Need for assistance with personal care, Type 2 diabetes mellitus (chronic condition where body does not produce enough insulin to regulate blood sugar levels) with diabetic neuropathy (complication of diabetes that damages the nerves, leading to various symptoms and health problems), unspecified, Essential (primary)hypertension (persistent elevated blood pressure without an identifiable underlying cause) and Depression (feeling of sadness, that affects how you think, feel & act, making daily activities difficult), unspecified. Record review of Resident #86's quarterly MDS dated [DATE] reflected a BIMS score of 11 which indicated moderate cognitive impairment. For Functional abilities resident had impairment on both sides of upper extremity (shoulder, elbow, wrist, hand), and Personal hygiene Resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity). Observation and interview on 09/17/25 at 4:12 p.m. revealed Resident #86's nails untrimmed. Nails were observed to be about 2 centimeters in length from the tip of finger, also squared off at the tip of the nail. Resident #86's stated someone had come in about 2 weeks ago and asked him if he wanted them trimmed and he said at the time he was asleep and said no. He said he wanted them trimmed but no one has trimmed them or offered to do so. He said he had requested it. In an interview on 09/17/25 at 5:02pm LVN I said Resident #86 hadn't told him he wanted his fingernails trimmed. LVN I also said he hadn't asked him either. LVN I said no one had mentioned to him about trimming his fingernails. LVN I said only nurses could trim Resident #86's fingernails because he had a diagnosis of diabetes. He said they are inserviced often in the mornings on ADL's which included grooming. LVN I said if fingernails are not trimmed as needed, the resident could scratch himself or get an infection. In an interview on 09/18/25 at 3:38 p.m. CNA O said Resident # 86 usually doesn't like to have his nails cut. She said if he had told her, she would've let the nurse know because she can't cut his nails because he is diabetic. CNA O said they have received constant in-services on grooming residents. She said the last in-service she received was last week. In an interview on 09/18/25 at 4:09 p.m. LVN P said she had offered to trim Resident #86's fingernails about 2 weeks ago but he had declined. She said she had not asked him again. She said the nurses had to do his nail care due to him being a diabetic. LVN P said if his nails aren't trimmed, he could have cut himself or gotten an infection. She said they had received an in-service on grooming about a week ago. In an interview on 09/18/25 at 4:19 p.m. the DON stated the nurses were supposed to do nail grooming for diabetic residents. She said they should have asked residents if they wanted their nails trimmed. She said if resident nails were kept untrimmed it could have caused infections. Record Review of the facility's policy titled, Quality of Life - Dignity, updated on 02/2020 documented, Policy StatementEach resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.Policy Interpretation and Implementation1. Residents shall be treated with dignity and respect at all times.2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.3. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 5 residents reviewed for pharmacy services.<BR/>The facility failed to ensure LVN-A's medication cart on hall 300 contained an accurate count and record for Resident #1's Clonazepam 0.125 MG (a medication used to treat seizure disorders and panic disorder).<BR/>This failure could place residents at risk for drug diversion and/or a delay in medication administration, as well as risk of not having allegations investigated throoughly or timely.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 11/29/2024 revealed a [AGE] year-old female with an admission date of 07/16/2024. Diagnoses included End Stage Renal Disease (last stage of kidney failure), Anxiety, Type 2 Diabetes (chronic condition which occurs when the body cannot use insulin effectively), and Depression.<BR/>Record Review of Resident #1's annual MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15, which revealed intact cognition.<BR/>Record Review of the PIR completed on 11/21/2024 revealed an incorrect narcotic count of Resident #1's Clonazepam 0.125 MG on 11/21/2024 at 8:30 AM. The controlled medication count revealed 11 missing tablets. The incorrect count was identified when oncoming LVN-B counted with off-going LVN-A. Both LVN-A and LVN-B were interviewed and denied taking the pills. ADON-A recounted and determined 11 tablets were missing. According to the PIR, both LVN-A and LVN-B stated the count was correct the previous night when oncoming LVN-A counted with off-going LVN B. Both nurses were suspended pending investigation, with LVN-B ultimately being fired for other reasons.<BR/>Record review of Resident #1's physician orders revealed a revised active order for Clonazepam 0.125 MG revised on 02/05/2025.<BR/>Record review of Resident #1's Individual Drug Administration Record revealed the Clonazepam 0.125 MG count at 9:00 PM on 11/20/2024 was 29, and on 11/21/2024 at 10:15 AM the count was 18.<BR/>In an observation on 06/25/2025 at 6:25 AM revealed off-going LVN-A and on-coming MA-F counting controlled medications whereas MA-F would actually count the medications, but LVN-A just looked to verify the count on the controlled medication sheet was correct. LVN-A was not actually watching MA-F count the medications, and MA-F was not actually looking at the sheet to verify it was correct.<BR/>In an interview with ADON-A on 06/24/2025 at 2:25 PM she stated she was informed of the drug discrepancy on the morning 0f 11/21/2024 and recounted the medications herself. She stated there were 11 missing Clonazepam when she counted, and they were never recovered. She stated in house drug screens were completed and both nurses were suspended pending investigation results with LVN-B ultimately being fired for other issues. She stated both nurses were interviewed at the time of the investigation, but no one else was interviewed at that time. She stated neither Resident #1 nor her RP were interviewed for this investigation. She denied anyone alleging abuse, neglect or misappropriation at that time.<BR/>In an interview with the Administrator on 06/24/2025 at 3:16 PM he stated on the morning of 11/21/2024 the count was wrong with 11 controlled medications missing, so an investigation was started. He stated the nurses involved were drug tested and suspended pending investigation. He stated the nurses were interviewed, but no one else was interviewed at the time of the investigation because he did not see any need to involve anyone else in the investigation. He denied anyone alleging abuse, neglect or misappropriation at that time.<BR/>In an interview with LVN-A on 06/24/2025 at 4:23 PM she stated she was the off-going nurse the morning the controlled medication count was off, but she stated the count was correct when she had come on shift the night before on 11/20/2024 and counted with LVN-B. She stated she was interviewed, a drug screen was done, and she was suspended pending investigation. <BR/>Interview with Resident #1 on 06/24/25 at 4:50 PM she stated she remembered when her medication went missing in November of 2024 because she heard the nurses talking about it, but she stated she was never interviewed or questioned about the missing medication or if she had received or missed any of her medications. She denied ever missing any doses of her medication or any increased anxiety.<BR/>In an interview LVN-A on 6/25/25 at 6:35 AM she stated she was usually here until 7:00 AM, but sometimes the nurses or medication aides came in early, so they went ahead and counted early. LVN-A stated if she was the one off-going she looked at the count sheet to make sure it was correct, and the one who was on-coming actually counted the controlled medication, and they did not typically double check the other was correct or telling the truth. LVN-A stated she had never been told to do the count any other way, but she saw how not verifying the count was correct could be a cause for concern because medications could be missing or stolen if the count was not correct. She also stated if she gave the medication during her shift, she did not technically perform a count after the medication was given but waited until the end of her shift to count. She denied taking any of the controlled medications.<BR/>In an interview with LVN-B on 6/25/25 at 8:30 AM she stated she was the on-coming nurse on 11/21/2024 and counted around 7am. She stated she was the one who noticed the controlled medications were missing. LVN-B stated she was drug tested by the DON, and as far as she knew they were both fired because of the missing medication. She refused to accept the keys to the medication cart because the count was incorrect. <BR/>In an interview with the DON on 06/25/2025 and 9:00 AM she stated on the morning of 11/21/2024 she, along with the ADONs, did a re-count of the controlled medications and found Resident #1's Clonazepam 0.125 MG was missing 11 tablets. She stated both LVN-A and LVN-B were interviewed, drug tested and suspended pending investigation. She stated no residents or RPs were contacted or interviewed for this investigation. She denied anyone alleging abuse, neglect or misappropriation at that time.<BR/>In an interview with ADON-A on 06/26/2025 at 4:55 PM she stated the facility could have and should have done more with the investigation of the missing controlled medications. She stated no resident or RP interviews were done until yesterday (06/25/2025) when they interviewed Resident #1 as well as other residents with high BIMS scores to determine if they were getting their medications as ordered and scheduled, and all residents stated they were. She also stated they did not notify Resident #1's RP until two days ago (06/24/2025). She stated they should have interviewed Resident #1 and her RP when the controlled medication went missing, as well as interviewed residents who were on the same type of medication as the one that went missing. She denied anyone alleging abuse, neglect or misappropriation at that time.<BR/>Record review of the facility's Administering Medications policy, date unknown, revealed 13. During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide.<BR/>Record review of the facility's Medication Storage policy, date unknown, revealed 7. Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for two of six residents (Resident #66 and Resident #93) reviewed for medication errors in that: 1) The facility failed to ensure Resident #66 was administered glargine insulin appropriately within parameters on 08/19/25 and 08/25/25. 2) The facility failed to ensure Resident #93 was administered glargine insulin appropriately by administering expired insulin on 09/16/25 and 09/17/25. These failures could place residents who receive insulin at an increased risk for complications such as hypoglycemia (low blood sugar), hyperglycemia (high blood sugar) and potential hospitalization.The findings included: 1) Record review of Resident #66's face sheet dated 09/17/25 revealed an [AGE] year-old male with an admission date of 10/09/24. Pertinent diagnosis included Type 2 Diabetes (chronic disease where your body becomes resistant to insulin, leading to high blood sugar levels). Record review of Resident #66's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 5 (severe impairment). Record review of Resident #66's comprehensive care plan dated 09/17/25 revealed the problem Resident has Diabetes Mellitus initiated on 04/16/25 and revised on 07/31/25. Approaches listed for the problem included .Administer Glucose Gel / Glucagon [as needed] as ordered initiated on 04/16/25. Record review of Resident #66's order summary revealed an active order for [Glargine] U-100 Insulin solution; 100 unit/mL; [amount]: 10 units; subcutaneous Special instructions: HOLD IF BLOOD SUGAR < 100 Once A Day initiated on 07/17/25. Record review of Resident #66's MAR revealed 10 units of glargine insulin were administered at 6:30 AM in Resident #66's right arm on 08/19/25 and left arm on 08/25/25. Further review revealed Resident #66's blood glucose was measured to be 92 on 08/19/25 and 86 on 08/25/25. Both records have an unknown nurse's initials by them. In an interview with the DON at 9:30 AM on 09/18/25, the DON stated it was important to follow the doctor's orders and only administer medications when necessary. The DON stated administering medications outside of parameters, especially insulin, could lead to severe resident harm or even death. The DON stated the glargine insulin should not have been administered to Resident #66 when his glucose measured less than 100. 2) Record review of Resident #93's face sheet dated 09/17/25 revealed a [AGE] year-old male with an admission date of 04/13/21. Pertinent diagnosis included Type 2 Diabetes (chronic disease where your body becomes resistant to insulin, leading to high blood sugar levels), and long-term use of insulin. Record review of Resident #93's Quarterly MDS assessment dated [DATE] revealed a BIMS score could not be obtained due to the resident rarely being understood. Record review of Resident #93's comprehensive care plan dated 09/17/25 revealed the problem Resident has Diabetes Mellitus initiated on 10/21/22 and revised on 08/02/24. Approaches listed for the problem included .Administer routine [glargine] insulin as ordered. Administer [aspart insulin] for sliding scale as ordered. Administer [dulaglutide] as ordered initiated on 10/21/22. Record review of Resident #93's order summary revealed an active order for [Glargine] U-100 (insulin glargine) solution; 100 unit/mL; [amount]:5 UNITS; subcutaneous Once A Day initiated on 07/13/25. Record review of Resident #93's MAR revealed 5 units of glargine insulin were administered to Resident #93 at 9:00 AM on 09/16/25 and 09/17/25. During an observation of the 2300/2400 Halls medication cart at 2:00 PM on 09/17/25, this state surveyor found a glargine insulin pen with an open date of 08/18/25 and an expiration date of 09/15/25 in the top drawer. The label on the insulin pen revealed it was ordered for Resident #93. In an interview with RN F at 2:40 PM on 09/17/25, RN F stated she administered expired insulin glargine to Resident #93 on both 09/16/25 and 09/17/25. RN F stated she did not check to see if the insulin was expired before administering it to Resident #93. RN F stated insulin pens expired 28 days after opening them. RN F stated administering expired medications to residents could lead to unexpected side effects and ultimately harm the resident. In an interview with the DON at 9:30 AM on 09/18/25, the DON stated it was dangerous to administer expired medications to residents. The DON stated nurses should check medications before administering them to ensure the medication, dose, route, expiration, and resident were all correct. The DON stated there should not have been expired insulin in the medication cart in the first place. The DON stated administering expired medications could lead to hyperglycemia or other unintended side effects. Record review of the undated facility policy titled Storage of Medications revealed the following policy: .2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.Record review of the undated facility policy titled Administering Medications revealed the following policy: .3. Medications must be administered in accordance with the orders, including any required time frame 7. The individual administering the medication shall follow the three rights of medication administration: right resident; right dose; right time 9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 2 of 2 nutrition rooms (first floor and second floor nutrition room) reviewed for sanitation. <BR/>The facility failed to maintain the dish room in a safe, sanitary condition. <BR/>The facility failed to keep the dish room walls and floor clean.<BR/>The facility failed to keep the ice machine clean and free of leaks.<BR/>The facility failed to serve juices and milks in clean drinking glasses.<BR/>The facility failed to keep the air intake filter above the stainless-steel refrigerator clean.<BR/>The facility failed to keep hot dogs in the refrigerator tightly sealed.<BR/>The facility failed to maintain 2 chest type freezers in good working order.<BR/>The facility failed to discard a spatula with peeling edges and kept using it.<BR/>The facility failed to discard eroded non-stick pans and kept using them.<BR/>The facility failed to discard dented pans and kept using them.<BR/>The facility failed to ensure kitchen staff were wearing hairnets while in the kitchen.<BR/>The facility failed to ensure kitchen staff were washing their hands.<BR/>The facility failed to ensure kitchen staff were not using a prep sink to wash their hands.<BR/>The facility failed to ensure kitchen staff were educated on calibrating thermometers. <BR/>The facility failed to ensure kitchen staff were following their cleaning schedules.<BR/>The facility failed to ensure the grease barrel was sealed.<BR/>The facility failed to ensure items on the first floor and second floor nutrition rooms were not expired.<BR/>The facility failed to ensure items on the second-floor nutrition room were refrigerated. <BR/>The facility failed to ensure items in the refrigerators and freezers were labeled and dated.<BR/>The facility failed to keep miscelllaneous items off of a prep table.<BR/>These failures could place residents at risk of foodborne illnesses. <BR/>Findings included: <BR/>Observation and Initial tour of the kitchen on 08/25/24 at 11:15 a.m., revealed multiple gnats flying in the dish room and there was a foul odor. The sink drain was dripping liquid onto the floor. The walls and floor were stained in a dripping pattern with a substance that ranged from brownish to white to dark grey. There was a large electrical box on the wall that had an open hole approximately 4 inches by 2 inches in the bottom corner with rusted, sharp jagged edges and high potential for injury as it was next to the dish counter. The ice machine had white/yellow/black substances around the outside, inside, and around the door hatch. The ice chute had a removable dark grey substance along the edge of it where the ice dropped. There were wet towels on the floor around the perimeter of the ice machine and a basin with a moderate amount of water in it. 12 of 20 drinking cups on the clean rack had a removable white substance on the insides. The air filter above the refrigerator was covered in a thick furry dark grey substance. There were 2 trays of 25 total drinking glasses full of juices and milks in the refrigerator that were unlabeled and undated. There was an opened bag of hot dogs in the refrigerator that were open to air, unlabeled and undated. There were 2 large chest type freezers (A and B). The inside of the top in freezer A was severely cracked and the seal had large gaps missing. The seal in freezer B was not sealing at all and there was ice where the seal should have been, and ice formed on the walls inside. There were 2 large pans on the stove, in use. One had deep and many scratches bottom of the pan and had a loose handle. The other pan was a non-stick surface type, and the entire bottom was bare and scratched. There were 6 small-size steam table holding pans with deep dents in the corners that were in use. There was a tape dispenser and a handheld lighter on a prep table. There was a large spatula with peeling edges on the pot rack. There was a gaping hole approximately 6x6 inches in the base of a wall, adjacent to the floor under the 3-compartment sink. There was what appeared to be rat droppings along the same baseboard near the hole. There was a stainless-steel prep sink that had a thick black and a scaly white substance in the corners and on the insides. [NAME] B scraped some of the black substance with her bare fingernail and stated, It looks like mold and did not wash her hands afterwards but went about the kitchen touching surfaces and handling dishes. [NAME] A did not wash his hands after entering the kitchen from the outside. [NAME] A was not wearing a hair net nor a beard cover. [NAME] A's beard was not closely trimmed. The temperatures written in the log dated 08/25/24 for the lunch service were reg meat 140F, purred meat 135F, spinach 135F. The hand washing sink took 3 minutes to reach a temperature of 110F. The stainless-steel prep sink next to the handwashing sink was instantly at temp. <BR/>Interview with [NAME] B on 08/25/24 at 11:30 a.m. she stated, the large spatula with peeling edges was in use and the particles could come off into the food and make the residents choke. She stated the stainless-steel prep sink that was next to the hand washing sink was also used as a hand washing sink. She said the dirty drinking glasses were on the clean rack, where they would be used for service. She said the large spatula with the peeling edges was used all the time. She said the dented holding pans were used frequently. She said the scratched pan with the broken handle was used all the time, as was the eroded non-stick type pan. She said she guessed the pans should be replaced and did not know who was responsible for replacing them or taking them out of service. [NAME] B said, we clean as we go and did not mention any referral to the cleaning schedule. She said the cleaning schedule was around here somewhere. She said the ice machine had been leaking for a while and that was why there were towels on the floor. She said they wring the towels in the basin then empty the basin in the stainless-steel prep sink.<BR/>Observation and interview with [NAME] A on 08/25/24 at 11:40 a.m., he stated he usually wore a hairnet and beard cover while in the kitchen. He said he was in a hurry today because he thought he was late. He stated, I just started here 3 months ago and I'm still learning. He said he used to be a dietary manager. He said he did not calibrate the thermometer prior to temping for food service. While attempting to calibrate the thermometer he used earlier, he said the temperature he was looking for to calibrate the thermometer in ice water was Negative 34 F or negative 32 F. He prepared a cup of ice water and a cup of hot water. The thermometer had a blue line indicating 32 F and the needle on the thermometer dropped 8 degrees below the blue line. He said he did not know how to adjust the thermometer. He said he guessed the temperatures he had taken earlier were too low for service. He stated the residents could get real sick from foodborne illness if the food was not held at the proper temperatures. <BR/>An interview with DA I on 08/25/24 at 11:45 a.m., she stated the kitchen staff did not use the porcelain sink for hand washing because it took too long to get hot. She stated the staff used the stainless-steel prep sink next to the hand washing sink to wash their hands because it had hot water. She said the tape dispenser and handheld lighter were supposed to be on the other side of the prep table and moved them to the other side of the prep table. She said, we clean as we go and did not mention any referral to the cleaning schedule. She said she had never seen the cleaning schedule. <BR/>Observation and interview with the FSM on 08/25/24 at 11:45 a.m., she stated the ice machine was cleaned weekly inside and out. She stated the ice machine did not look clean and it was leaking. She said it had been leaking several months. She said she had informed maintenance on several occasions. She said she did not say anything to anyone else about the ice [NAME] machine. She stated any utensil or dented pans and pans with non-stick finishes should be removed and replaced immediately when showing that kind of wear. She stated she did not know why the dented pans, spatula, and eroded non-stick pans were still being used. She stated the seals in the white chest type freezers needed to be replaced and she had been telling the maintenance man about it for about 3 months. She stated freezer A needed to be replaced because the lid was badly cracked. She stated the freezers were keeping temps. She said she was unaware of the hole in the baseboard by the 3-compartment sink, the state of the dish room, staff not washing their hands or not wearing hairnets. She said the gnats in the dish room had been an on-going problem. Pest control invoices were requested. Policies for hand washing, Pest control, waste and disposal, cleaning schedules, food storage, and thermometer calibration were requested. In-services/training for the last 3 months were requested.<BR/>Return visit, observation of the kitchen, and interview with [NAME] A on 08/27/24 at 1:10 p.m. revealed the large spatula with peeling edges was still in use and hanging on the pot rack. The grease barrel had a removable lid with a hole in the top to pour grease into and the ring that held the top closed was halfway down the barrel. [NAME] A stated he was responsible for pouring used grease into the barrel, and he just lifted the lid and poured the grease directly into the barrel. He stated the ring on the barrel had never been around the lid, at least for the past 3 months since he had been employed at the facility. He stated he knew the ring was supposed to be around the lid, but it was easier to lift the lid and pour grease directly into the barrel. [NAME] A demonstrated raising the ring and secured it around the lid without difficulty. When [NAME] A raised the ring on the barrel, there was a significant difference in the color of the barrel from where the ring was (halfway down the barrel) and the rest of the barrel. The barrel appeared to be sun-bleached because the color of the barrel under the ring was much brighter, indicating the ring had been in the same position halfway down the barrel for a long time. <BR/>Observation of the kitchen on 08/28/24 at 12:24 PM revealed a female kitchen staff member had a ball cap on over a hair net. Her hair was in a bun on the top of her head that had a separate hairnet over the bun. Her hair was sticking out ~ 4 inches all around the back and sides of her neck. <BR/>An interview with DA J on 08/28/24 at 12:24 PM, she stated she had worked at this facility for three years. She said her head was a strange shape and the hairnets did not fit. She said she did not know what else to do with her hair and she had been wearing the ball cap over the hairnets for as long as she had worked in the kitchen. She said she had not tried to use a different type of hairnet, such as a bonnet and this was the best she could come up with to contain her hair. She said she was aware the hair on her neck was crazy, meaning not contained by hairnet(s).<BR/>Observation of the second-floor nutrition room on 08/28/24 at 10:45 AM, revealed 14, 8-ounce bottles of hand sanitizer with expiration dates of 07/23; three of the bottles had broken seals, and two of the three bottles were partially empty. There was 1, 46-ounce container of thickened, lemon-flavored water with a handwritten open date of 08/02/24, and directions on the box read .after opening may be kept up to 7 days under refrigeration. There were 2, 32-ounce containers of high calorie protein drink with expiration dates of 08/26/24. <BR/>Observation of the first-floor nutrition room on 08/28/24 at 10:55 AM, revealed 17, 1.5-ounce calorie and protein enhancer with expiration dates of 06/20/2024. There were 13, 32-ounce high protein chocolate nutrition drinks with expiration dates of August 26, 2024. <BR/>An interview and record review with the FSM on 08/29/24 at 9:45 a.m., she said she was not sure where the cleaning schedules were but thought they were in her office. She said the cleaning schedule tasks were all marked as having been done, but the kitchen did not reflect cleaning had been done. She said she was responsible for making sure the tasks on the cleaning schedules were done correctly and timely and would not say why the kitchen was not clean.<BR/>An interview with the MS on 08/29/24 at 11:00 a.m., revealed the process of him knowing what needed to be fixed was that they (kitchen staff) contacted him verbally via the FSM and she told him by phone. He said there was a handwritten maintenance log at the nurse's station, but anything related to the kitchen he considered a priority. He said there was currently a bid for the stainless-steel freezer, and the technician was there at the facility Saturday (08/24/24) because the staff was concerned about the blinking outer thermometer. He said the inner thermometer was showing correct readings and holding temps. He said there was an icicle that had formed inside the stainless-steel freezer and the pan needed to be replaced. He said the white chest type freezers were holding temperature and there was no cool air escaping. He stated, Ice forms on the inside if the staff left it (the lid) open. He asked this state surveyor if there was ice on the insides of the white chest type freezers. The MS said the seals/gaskets were checked last month by his maintenance guys, then he said he checked them himself and they were good, and the ice probably formed last week when they (kitchen staff) got a shipment from the food distributor and had it opened. The MS stated there was also a bid on a new ice machine. The MS stated the reason the grease barrel needed to be secured was because it could cause environmental hazards if it got knocked over and cause rodents and other vermin attraction. The maintenance log, pest control log and invoices, and invoice/bid for the stainless-steel refrigerator service on 08/24/24 as well as the bid on the ice machine were requested.<BR/>Record review of the daily 23-item kitchen cleaning schedules, weekly 10-item kitchen cleaning schedules and monthly 7-item kitchen cleaning schedules dated from May 01, 2024-May 31, 2024, June 01, 2024-June 30, 2024, July 01, 2024-July 31, 2024, and August 01, 2024-August 26,2024 revealed all daily, weekly, and monthly cleaning checklists were marked as having been done. <BR/>Pertinent items on the daily kitchen checklist were: #1. All dishes, pots, pans, and utensils are cleaned and stored properly after each meal and snack. 3. All sinks are cleaned and sanitized after each use. #12. Sweep floors after meals and mop daily. #14. Food Service employees wear hair restraints .#15. Clean ice machine exterior. <BR/>Pertinent items on the weekly kitchen checklist were: #2. Delime floor under sinks and ice machine. #5. Clean walls. #8. Polish all stainless-steel surfaces. <BR/>Pertinent items on the monthly kitchen checklist were: #2. Clean all baseboards. #4. Clean ice machine. #6. Pest control report on-hand.<BR/>The exceptions of items not checked as having been done were: on the daily kitchen checklist for Monday, May 20, 2024, #7-Dishwasher is cleaned after each use, #9-Trash can is emptied and cleaned after each meal, #10-Bathroom is cleaned daily or as needed, #13-Oven spills are cleaned and ovens are turned off, #15-Clean ice machine exterior, #16-All tools cleaned, locked, and inventoried, #21-Foods thawed appropriately. Friday May 25 and Saturday May 26, 2024, #7-Dishwasher is cleaned after each use. The weekly kitchen cleaning checklist for July 1-7, 2024, July 8-14, and August 5-11, 12-18, 2024 #8 Polish all stainless-steel surfaces. <BR/>Record review of the facility pest sighting log indicated gnats in the dish room was addressed and initialed by the MS on 01/06/24, 07/13/24 and 07/30/24. Rat droppings were addressed and initialed by the MS on 05/05/24, 07/12/24, and 08/09/24. The Pest control invoices were requested but not received.<BR/>Record review of the facility kitchen policy titled, Sanitation and Infection Control-insect and rodent control revised 05/2016 revealed It is the policy of this home to prevent and control insect and rodent infestations within the dietary services department to prevent food borne illness. Under Procedure, 2. The home will maintain .properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents. 3. The sanitation of the kitchen will be maintained to prevent food sources, breeding places, etc. for insects or rodents. 8. The pest control company will leave a copy of treatments made in the kitchen at the end of each service call.<BR/>Record review of the undated facility kitchen policy titled, Choosing the Right Thermometer revealed under Bimetallic Thermometers, there are two ways to calibrate a bimetallic thermometer: the ice point method and the boiling point method. Ice point Method 1. Start with a container large enough to easily accommodate your thermometer. Fill it with ice. Add tap water to fill and stir. Allow the ice water mixture to cool for a few minutes. 2. Put the thermometer probe into the ice water. It is important to wait about 30 seconds .Be sure the temperature indicator is no longer moving. 3. Look for the nut on the underside of the thermometer, use a wrench and turn the head of the thermometer until the reading on the face of the dial reads 32 F.<BR/>Record review of the facility kitchen policy titled, Sanitation and Infection Control-Food Storage-Refrigerated and frozen foods revised 02/2016 revealed Refrigerators and freezers will be kept clean and sanitized. The procedures to maintain the proper temperatures for storing cold foods will be strictly followed to prevent food borne illness. Procedure 6. Food must be stored in a properly covered container with a date and label identifying what is in the container. 7.Do not block the fan of the refrigerator or freezer. 14. Freezers should be defrosted regularly so that they will operate more effectively .15. A. All of the following terms will be considered expiration dates for cold food products: Expires by date, Best Used By date, Use By date, Sell By date. Once the date has been reached, whether the food has only been partially used or unopened, the food product will be discarded on or by that date.<BR/>Record review of the facility kitchen policy titled, Sanitation/Infection Control-Handwashing revised 06/2013 revealed Dietary employees are to wash hands to ensure sanitary work habits are established when handling or serving foods to residents. Procedure: 1. Employees are to wash hands: a. before starting work, b. between handling of dirty dishes and clean dishes, equipment/utensils, and food, c. after all work breaks, using restroom, tobacco use or eating, h. after touching objects that may be a source of contamination if the next contact with the hands is food or food contact surfaces. 2. Hand washing occurs in sinks provided for that purpose .Food preparation sinks are not to be used for hand washing. <BR/>Record review of the facility titled, Dress Code: dated 01/2016 revealed 4. Hair should be clean and, in a style, suited for food service. Hair must be fully covered with a hairnet or hair bonnet at all times within the department. We do not accept the use of baseball caps, visors, and other cloth covers in dietary. All hair coverings should be disposable. 5, Facial hair is to be closely trimmed and all facial hair is to be covered with a hair restraint.<BR/>Record review of the facility kitchen policy titled, Sanitation and Infection Control-Waste Control and Disposal revised 05/2016 revealed Policy: The dietary services department will handle and dispose of waste in a sanitary manner to prevent cross-contamination and food borne illness. Procedure: 6. All rancid or used grease/oil will be poured into the appropriate grease barrel for recycling. <BR/>Record review of the facility kitchen policy titled, Sanitation/Infection Control-Cleaning Schedule revised 06/2013 revealed Policy: The dietary services department and all equipment in the kitchen will be cleaned on a regularly scheduled basis for daily, weekly, and monthly tasks. 3. It is the responsibility of all employees to follow the cleaning schedule. 6. Items not listed, but part of your kitchen, should be added to the cleaning schedule. 7. The dietary manager is responsible for training staff on proper cleaning procedures<BR/>Kitchen staff in-services and/or training was not received. Bids on equipment and invoices were not received.<BR/>References: U.S. Food and Drug Administration Food Code http://www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/ : <BR/>FDA Food Code 2017, Ch.5, 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. Ch. 4-1-101.11 Characteristics. Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion- resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated warewashings; (D) finished to have a smooth, easily cleanable surface; and Euro Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.<BR/>Ch. 4-101.18 Nonstick Coatings, Use Limitation. Multiuse kitchenware such as frying pans, griddles, saucepans, cookie sheets, and waffle bakers that have a perfluorocarbon resin coating shall be used with nonscoring or nonscratching utensils and cleaning pads.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one (R #1) of three residents that were reviewed for infection control and transmission-based precautions policies and practices, in that:<BR/>LVN A did not remove her contaminated gloves after touching multiple surfaces prior to commencement of PEG tube cleansing as well as maintained usage of same contaminated gloves during care of PEG tube. <BR/>These failures could place residents at risk for infection through cross contamination of pathogens. <BR/>The findings included: <BR/>Record review of R #1's Face Sheet undated, admitted [DATE], documented a [AGE] year-old male with the following diagnoses of: COPD (airflow blockage and breathing-related problems), GERD (acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus)), multiple rib fractures, HIV (virus that attacks the body's immune system), Hepatitis C (infection caused by a virus that attacks the liver and leads to inflammation). <BR/>Record review of R #1's MDS was not conducted due to being unavailable due to the resident being admitted [DATE]<BR/>Record review of R #1's Comprehensive Care Plan unavailable due to being admitted [DATE]<BR/>Observation on 04/12/2023 at 9:58AM, LVN A was permitted by Resident #1 to perform PEG site care. LVN A began PEG tube care by performing hand hygiene with Alcohol Based Hand Rub prior to entry into Resident #1's room. LVN A continued by placing supplies on bedside table and applied clean gloves. While at bedside, LVN A proceeded to touch the pause/hold button on kangaroo pump with the same pair of initial gloves to pause the enteral feed. LVN A continued with same pair of initial gloves to lift resident gown up, remove dirty gauze from PEG tube insertion, clamped tube, and disengaged feeding tube from PEG tube. LVN A proceeded to exit Resident #1's room, retrieved clean 4x4 gauze from treatment cart located by doorway, opened drawer with same pair of gloves, and re-entered Resident #1's room. LVN A proceeded to open clean gauze packet with same initial pair of dirty gloves, saturate gauze with normal saline and performed cleansing of PEG tube insertion. LVN A continued by removal of dirty gloves, performed hand hygiene, and without applying new gloves, retrieved another clean gauze with bare hands, removed gauze from package and applied normal saline to clean gauze. LVN A proceeded to take the saturated normal saline gauze and clean insertion area with bare hand.<BR/>During an interview on 04/12/2023 at 10:23AM LVN A stated, she was unknowledgeable on how to perform site care on the newly admitted Resident #1. LVN A continued by stating it is the duty of night shift nurses to perform all resident cleansing care which included PEG tube site care. LVN A continued by stating she only performs administration of medications and feedings, and was nervous throughout procedure which, per LVN A, kept her from following procedure. LVN A proceeded to state that she should have removed dirty gloves and performed hand hygiene after touching the Kangaroo feeding pump, after removal of dirty gauze, and before PEG tube insertion site cleansing care to promote infection control and prevent potential infection contraction. LVN A stated she had a competency check off two weeks prior to 4/12/2023, which contained written material about g-tubes dressing changes but could not recall what the written education entailed. LVN A stated she was given an education sheet about caring for g-tubes to look over by facility, but not how to care for PEG tube. LVN A continued by stating she only does medication administration via PEG tube.<BR/>During an interview on 04/12/2023 at10:46AM, the DON stated that the expectation of the facility is to follow a specific step by step procedure when performing clean dressing change to eliminate chance of infection contraction. The DON continued by stating it is in the nurse's scope of practice to perform PEG tube site care, and nurses must be competent in performing dressing changes. The DON stated that hand hygiene as well as glove changes must be performed prior, during, and after providing gastric tube site care to promote infection control. The DON continued by stating the procedure was: 1. verify orders 2. knock and provide privacy and explain procedure 3. Wash hands 4. set up clean and dirty areas 5. Put on clean gloves 6. Remove soiled dressing and discard 7. Wash hands and put on clean gloves. The DON continued by stating she provides all nursing staff competency check offs upon hire with educational literature prior to gaining independent admittance onto floor. The DON proceeded to state she also conducts infection control in-services monthly, annually, and as needed for skills maintenance. The DON stated that in no way is it ever acceptable to perform any resident care without the use of gloves. <BR/> Record Review of facility's Clean Dressing Change Check off, undated, stated: <BR/>3. Wash hands<BR/>4. set up clean and dirty areas<BR/>5. Put on clean gloves<BR/>6. Remove soiled dressing and discard<BR/>7. Wash hands and put on clean gloves<BR/>8. Clean wound using circular motion starting from the inside working outward<BR/>9. Remove gloves and sanitize hands<BR/>10. Put on clean gloves to continue with the dressing change.<BR/>Record Review of facility's Infection Control-Prevention and Control Program dated 03/2012 stated, <BR/>2) Prevent and control outbreaks and cross contamination using transmission-based precautions in addition to standard precautions. <BR/>1) Policies, procedures, and practices which promote consistent adherence to evident-based infection control practices.<BR/>10) Implementing measures to prevent the transmission of infectious agents and to reduce risks for device and procedure-related infections. <BR/>Record Review of facility's Hand hygiene Policy dated August 2019 stated, use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, so (antimicrobial or non-antimicrobial) and water for the following situations:<BR/>d. Before performing any non-surgical invasive procedures<BR/>e. Before handling an invasive device.<BR/>g. Before handling clean or soiled dressings, gauze pads etc.<BR/>k. After handling used dressings, contaminated equipment etc.<BR/>m. After removing gloves. <BR/>Record Review of the CDC Guidelines regarding Hand Hygiene in Healthcare Settings, dated January 30, 2020, stated Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, contaminated surfaces, and immediately after glove removal.

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 of 8 halls (Halls 200, 2200, and 2400) reviewed for environment.<BR/>1) The facility failed to keep a storage room containing mouthwash with alcohol on hall 2400 locked while not in use. <BR/>2) The facility failed to keep the shower room on hall 200 and hall 2200 locked while not in use.<BR/>This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment.<BR/>The findings included:<BR/>During an observation on 08/25/2024 at 12:56 PM, a storage room on the 2400 hall was left unlocked while not in use. Inside the storage room was a basket containing approximately 20 unopened bottles of mouthwash containing alcohol. <BR/>During an observation on 08/25/2024 at 1:21 PM, the shower room on the 200 hall was left unlocked while not in use. Inside the shower room was a bottle of disinfectant left out in the open.<BR/>During an observation on 08/25/2024 at 1:36 PM, the shower room on the 2200 hall was left unlocked while not in use. Inside the shower room was a bottle of disinfectant left out in the open.<BR/>In an interview with LVN B on 08/27/2024 at 8:45 AM, LVN B stated the storage room on hall 2400 was used to store various things for the residents to use during activities. LVN B stated there should not have been mouthwash containing alcohol in the storage room. LVN B stated they only used mouthwash without alcohol in the facility. LVN B stated that the shower rooms should have been locked when not in use. LVN B stated that if a resident went into a shower room by themselves they could get a burn from the hot water, slip and fall, or ingest the cleaner fluid. <BR/>In an interview with RN A on 08/27/2024 at 2:05 PM, RN A stated that the shower rooms should have been locked at all times. RN A stated that a resident could have fallen in the shower if they were alone. RN A stated that the storage room on hall 2400 should have been locked. RN A stated that a resident could have drunk the mouthwash containing alcohol and injured themselves. <BR/>In an interview with CNA C on 08/27/2024 at 2:13 PM, CNA C stated that the shower rooms should have been locked at all times. CNA C stated that a resident could have fallen down in the shower room and hurt themselves. CNA C stated that the disinfectant used in the showers should have been in the locked cabinet inside the shower room. CNA C stated that the storage room on hall 2400 should have been locked. CNA C stated that the mouthwash used in the facility did not contain alcohol. CNA C stated there should not have been mouthwash containing alcohol in any storage room in the facility. <BR/>In an interview with the ADM on 08/27/2024 at 2:26 PM, the ADM stated that he believed the mouthwash containing alcohol had only been in the storage room for a few weeks at most. The ADM stated that a resident could have entered the storage room and drank the mouthwash containing alcohol and hurt themselves. The ADM stated that the shower rooms should have been locked at all times. The ADM stated that he has not seen the shower rooms unlocked before. The ADM stated that a resident could have drunk the disinfectant left out in the shower room. <BR/>In an interview with the DON on 08/28/24 at 02:40 PM, the DON stated storage rooms should have been locked at all times and shower rooms should have been locked when not in use, so residents or other individuals would not have access to any hazardous items such as, mouthwash containing alcohol, razors, shampoos, or anything that could have been potentially harmful. The DON stated that after a resident was done receiving a bath, that staff member would have been responsible to ensure the shower room was locked. The DON stated it was a team effort to ensure that all storage and shower rooms were locked for resident safety. <BR/>Record review of the facility policy Hazardous Areas, Devices and Equipment last updated 02/20/2020 revealed the following:<BR/>As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by mitigation of access to environmental hazards.<BR/>Areas identified as potential for environmental hazards will be identified and secured to restrict access of residents in environment.<BR/>A hazard is defined as anything in the environment that has the potential to cause injury or illness.<BR/>Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous.

**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 the resident's medical, nursing, mental, and psychosocial needs, for one Residents (R#1) of 14 residents reviewed for care plans.<BR/>The facility did not implement the comprehensive person-centered care plan set forth for R #1. <BR/>These failures place residents at risk for not being provided necessary care and services. <BR/>The findings included:<BR/>Upon review of R#1's Face sheet, dated 12/21/2021, documented a [AGE] year-old female admitted on [DATE] and readmitted [DATE] with the diagnosis of vascular dementia (memory loss), psychotic disorder with hallucinations (where a person hears, sees and, in some cases, feels, smells or tastes things that do not exist outside their mind but can feel very real to the person affected by them) , psychotic disorder with delusions (unshakeable belief in something implausible, bizarre, or obviously untrue), Mood disorder (general emotional state or mood is distorted or inconsistent with the circumstances and interferes with ones' ability to function.), Paranoid schizophrenia (predominantly positive symptoms of schizophrenia, including delusions and hallucinations), Major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Impulse disorder (chronic problems in which people lack the ability to maintain self-control).<BR/>Record Review of R#1's Care Plan dated 12/23/2022 documented:<BR/>Resident has physical behavioral symptoms toward others pulling hair, hitting, kicking, pushing, scratching, abusing others. Incident occurred 12/14/22, resident threw apple sauce container at other resident back. Resident has history of verbal altercations with other residents. Altercation with another resident 12/20/22. Goals, Resident will not harm others secondary to physically abusive behavior. Approach, Provide 1:1(staff/personnel with resident always) sessions with resident, obtain a psych consult/psychosocial therapy, transfer out to Geri psych per MD order. Avoid Power struggles with resident. Convey an attitude of acceptance toward resident Maintain a calm environment and approach to the resident, offer one step verbal directions for tasks. Allow for extra time to process the information. <BR/>Record Review of R#1's Minimum Data Set (MDS) dated [DATE] documented:<BR/>Behaviors not exhibited for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others.<BR/>Brief Interview for Mental Status (BIMS) Summary Score: 99. Enter 99 if the resident was unable to complete the interview. <BR/>During an observation of R #1 on 01/19/2023@1:10 PM: Observed R #1 in their room unattended. According to R#1's care plan, R#1 requires 1:1 (staff/personnel with resident always) session with resident. R #1 in wheelchair with food tray placed in front of resident, on bed side table. R #1 is unable to be seen and monitored from nurse's station.<BR/>During a second observation of R #1 01/19/2023@3:37 PM Observed R #1 in room, in wheelchair, no personnel/nurse/staff with resident. <BR/>During an interview with the Director of Nursing (DON), on 01/19/2023@2:35 PM, revealed that the facility no longer required R#1 to have a 1:1 (staff/personnel with resident always). Inquired for clarification and justification as to why the 1:1 status remained on care plan. DON stated 1:1 should not be on care plan and isn't being practiced. DON stated they are doing q15min (every 15 minutes) rounding but currently the intervention has not been added nor updated to R#1's care plan. Inquired as to why the updates had not been completed on R#1's care plan, was not given a definitive answer. <BR/>During an interview with MDS Coordinator, on 01/19/2023@4:03 PM, revealed that the care plan for R#1 still read, Provide 1:1 session with resident. Inquired for the reasoning as to why Provide 1:1 session with resident was still on the care plan if the facility no longer requires R#1 to have a 1:1? The MDS Coordinator stated that they had not updated the care plan to reflect R#1's care plan change. Per the MDS Coordinator, R#1 was transferred many times throughout December 2022, and did not update the care plan for this reason. Per MDS Coordinator, R #1 was transferred to local hospital from [DATE]-[DATE] Geri Psych,/22 as well as 12/30/2022-01/09/2023. residentUpon return of R#1, on 01/09/2023, care plan hadn'thas not been updated to reflect recent interventional changes of removal of 1:1 session with resident, and insertion of q15min rounding upon return MDS Coordinator stated they didn't want to lie and hadn't updated care plan since resident return on 01/09/2023.<BR/>Record Review of the facility's undated Care Plans, Comprehensive Person-Centered policy states:<BR/>12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of required comprehensive assessment (MDS).<BR/>13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.<BR/>14. The interdisciplinary team must review and update the care plan:<BR/>a. when there has been a significant change in the resident's condition. <BR/>c. when the resident has been readmitted to the facility from a hospital stay;.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one of four residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to ensure CNA A used a gait belt to transfer Resident #1 from the bed to the wheelchair . <BR/>This failure could place residents at risk for falls, injuries and a decline in health.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 03/30/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 with diagnoses which included muscle wasting and atrophy , abnormalities of gait and mobility, lack of coordination, cerebral infarction (stroke) affecting left non-dominant side, and hemiplegia (paralysis of one side of body) and hemiparesis (weakness on one side of the body). <BR/>Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 14, which meant mild cognitive impairment. Resident #1 needed partial to moderate assistance for chair/bed-to-chair transfer. Resident #1 was coded to have neurological deficits of cerebrovascular accident, transient ischemic attack or stroke and hemiplegia or hemiparesis. Resident #1 was coded for having functional limitation of range of motion with both impairment on one side for both upper and lower extremities. <BR/>Record review of Resident #1's care plan problem start date 10/17/2024 edited on 10/28/2024 revealed ADLs Functional Stat/Rehabilitation Resident requires assistance/supervision for ADL and mobility tasks status post CVA with residual left hemiplegia weakness, impaired balance poor endurance activity tolerance. He has reduced ROM to left upper extremity. He attempts ADLs per self, does not use call light or assist at times, is at risk for falls/injuries. Approach (Interventions): Assist resident with shower three times per week per schedule and PRN. Resident Requires physical x1 staff assistance. Encourage resident to participate to the fullest extent possible with each interaction, task. Encourage resident to turn and reposition Q2 hours and PRN while in bed and up in wheelchair. He is independent for bed mobility and turning and repositioning tasks. Encourage/remind resident to use bell to call for assistance. Check on resident at routine intervals and to assess needs, monitor safety issues and offer/provide assistance as needed. He requires extensive assist x1 staff for dressing and clothing changes daily and PRN. Monitor for changes in functional status and independence for ADLs, strength, balance, safety. Make appropriate referrals PRN. Resident is mobile using wheelchair. He requires supervision and set-up assistance for locomotion on and off of the unit. He is only able to walk very short distances with extensive assistance. Resident requires limited x 1 staff assistance for personal hygiene tasks. The care plan had a revision date of 03/30/2025 to include He is independent for transfer tasks. <BR/>Record review of Resident #1's care plan problem start date 10/17/2024 edited on 03/30/2025, revealed potential for falls due to history of falling, history of CVA with resident left hemiplegia, weakness, impaired balance, unsteady gait, impaired cognitive functioning/ safety awareness/ problem solving with dementia (cognitive impairment) neuropathy (nerve deficit), seizure disorder (brain disorder), arthritis (joint disorder), muscle spasm and cardiovascular, psychotropic, and neuroleptic medication administration. Approach (approach) bed in lowest position, call light in easy reach. Remind resident to call for staff assist when needed and answer call promptly. Check on resident at routine intervals to assess needs, monitor safety issues and offer assist as needed. Intervene with resident to minimize or reduce fall occurrences. Provide adequate staff assistance and support for tasks. <BR/>During an observation on 03/29/2025 at 4:42 PM revealed Resident #1 engaged the call light system in his room and began to situate himself on the side of his bed. CNA A entered Resident #1's room and turned off the call light and asked Resident #1 what he needed. Resident #1 stated he needed to utilize the restroom. Upon initial observation there was observable left sided deficit on both Resident #1's left leg and left arm. CNA A proceeded to retrieve Resident #1's wheelchair and secured it on Resident #1's left side. CNA A then proceeded to assist Resident #1 to stand while she simultaneously grabbed Resident #1's left arm and with strength assisted him into the wheelchair. During Resident #1's transfer, Resident #1 pivoted to the wheelchair, and was observed to struggle while he staggered when pivoting from bed to wheelchair. Resident #1 was observed to have compromising balance as he was observed to be struggling while transferring to the wheelchair. Resident #1 was successful in transferring to the wheelchair while CNA A utilized his left arm to assist him. Throughout the transfer CNA A did not utilize a gait belt . <BR/>During an interview on 03/29/2025 at 5:17 PM, CNA A stated she should have used a gait belt to assist Resident #1 to transfer onto his wheelchair. CNA A stated she should not have used Resident #1's left arm to transfer and should have used a gait belt . CNA A stated she was unaware Resident #1 had a left arm deficit however during this bed to wheelchair transfer, Resident #1 struggled to transfer into the wheelchair. CNA A was asked if she utilized a gait belt when transferring Resident #1, CNA A gave no definitive answer. CNA A stated she left her gait belt in her locker and did usually keep it on her person. CNA A stated she did not use a gait belt because she had left the gait belt in her locker. CNA A stated she was supposed to use a gait belt for transfers but did not have access to it as it was in a destination that was not near Resident #1's room. CNA A stated by not using a gait belt Resident #1 could have fallen and was fortunate that he did not fall. CNA A stated going forward she would ensure to always keep a gait belt with her and would utilize the gait belt when she transferred any resident. CNA A stated she could not recall when she was last in-serviced about resident transfers. <BR/>During an interview on 03/29/2025 at 5:43 PM, the DON stated she was made aware of the observation by CNA A. The DON stated CNA A should have used a gait belt when transferring Resident #1 from the bed to the wheelchair as not only a safety precaution but also to maintain Resident #1's wellbeing. The DON stated CNA A may have compromised Resident #1's well-being as Resident #1 may have fallen. The DON stated all CNAs were supposed to keep a gait belt on their persons. The DON stated going forward she would conduct an impromptu in-service regarding gait belt transfers. <BR/>During an interview on 03/30/2025 at 11:47 AM, ADON B stated Resident #1 was independent during transfers. ADON B stated as she pointed out while reviewing Resident #1's care plan, Resident #1 was independent with transfers, however when asked about the edited date of 03/30/2025, ADON B did not give a definitive answer. ADON B while reviewing Resident #1's MDS stated it appeared Resident #1 was coded for needing assistance with transfer from bed to chair. ADON B stated CNA A could have compromised Resident #1's well-being by not using a gait belt as he could have fallen. ADON B stated CNA A should have used a gait belt while transferring Resident #1 given he was coded for hemiparesis (paralysis) and hemiplegia (weakness). ADON B stated she facilitated an impromptu in-service regarding transfer with gait belts on 03/29/2025. <BR/>Record review of CNA A's 03/08/2025 Lifting, Moving, Positioning, and Transferring competency revealed CNA A completed Transfer Resident from Bed to Chair/Wheelchair or Chair/Wheelchair to bed: <BR/>A. <BR/>(1) Person *Use of Gait Belt.<BR/>B. <BR/>(2) Person *Use of Gait Belt. <BR/>Record review of the facility's gait belt usage in-service, dated 03/29/2025, documented CNA A in attendance.<BR/>Record review of the facility's, undated, One Person Transfer with Gait Belt-Check Off reflected ,<BR/> .4. Position and secure belt properly.<BR/>5. Grasp belt on either side of resident, assist resident to move toward edge of bed. <BR/>6. Place feet firmly on floor under resident. <BR/>8. Face resident, squat with knees bent and your waist at resident's waist level, with back straight use leg muscles to lift to standing position.<BR/>Record review of the facility's, undated, Safe Lifting and Movement of Residents reflected, <BR/>1.Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of resident. <BR/>2.Manual lifting of resident shall be eliminated when feasible.<BR/>4.Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. All manual lifting devices will be made available for use, when necessary, in resident transfer with staff training on usage implement. <BR/>5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving resident when necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) of fifteen residents reviewed for abuse.<BR/>The facility failed to protect Resident #1 from being verbally abused by SA on April 29th 2024. <BR/>The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/29/2024 and ended on 04/29/2024. The facility corrected the non-compliance before the investigation began.<BR/>This failure placed all residents at the facility at risk of severe psychosocial harm by being forced to interact with an employee that verbally abuses residents.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet reflected a [AGE] year-old female with an admission date of 01/12/2023. Pertinent diagnoses included depression unspecified (patient is primarily depressive but does not meet the full criteria for any specific depressive disorder) and type 2 diabetes mellitus.<BR/>Record review of Resident #1's quarterly MDS assessment section C, cognitive patterns, dated 05/29/2024 reflected a BIMS score of 15 (cognition intact). <BR/>Record Review of Resident #5's face sheet reflected a [AGE] year-old male with an admission date of 03/10/2024. Pertinent diagnoses included depression unspecified, generalized anxiety disorder, and alcohol-induced persisting dementia (damage to the brain caused by regularly drinking alcohol over many years resulting in memory loss and difficulty thinking things through).<BR/>Record review of Resident #5's quarterly MDS assessment section C, cognitive patterns, dated 06/06/2024 reflected a BIMS score of 13 (cognition intact).<BR/>Record review of Resident #6's face sheet reflected a [AGE] year-old female with an admission date of 06/04/2024. Pertinent diagnoses included vascular dementia (general term for problems with reasoning, planning, judgement, memory and other thought processes), anxiety disorder, unspecified depression, and bipolar disorder (mental illness causing unusual shifts in a person's mood, energy, activity levels, and concentration).<BR/>Record review of Resident #6's MDS assessment section C, cognitive patterns, dated 06/10/2024 reflected a BIMS score of 13 (cognition intact).<BR/>Record review of the provider investigation report dated 05/01/2024 revealed that on 04/29/2024 The alleged perpetrator (SA) was in the patio washing the concrete area. This is when the alleged victim (Resident #1) started confronting the alleged perpetrator about washing the concrete during smoke break. According to witness' the alleged perpetrator became upset with the alleged victim and cussed at her. Once the facility was advised of the incident at about 2:15 PM., the Administrator suspended the alleged victim pending the outcome of the investigation. The provider investigation report found the results of the investigation to be inconclusive. <BR/>Record review of the provider investigation report dated 05/01/2024 revealed a signed statement from Resident #1 stating I went outside to have a cigarette after lunch. SA was wetting down the patio (smoke area) with the water hose, I asked why he was doing that, he said they asked him to. So I went inside to find his boss (HR) to tell her he was not passing cigarettes because he was cleaning the patio. She asked why I was telling her. I said because you are his boss and I went outside to where he was then pouring liquid soap. Then HR came out and asked if he was giving cigarettes out, he said in a few minutes, but he was on the first part of the patio. At this point I told him his head was a little big with his job, and I was tired of him being so controlling. He said fuck you, I said what did you say to me? He said it a little louder. I am not defending my behavior, but I did not deserve that. I went and to SSD, then administrator and my witnesses came forward and corroborated my complaint. The DON came and talked to me, and again before she left for the night.<BR/>Record review of the provider investigation report dated 05/01/2024 revealed a signed statement from Resident #7 stating I heard SA, the smoke monitor, tell Resident #1 'Fuck you.' 4/29/24<BR/>Record review of the provider investigation report dated 05/01/2024 revealed a signed statement from FT stating On April 29th I was outside SA was scrubbing the patio and Resident #1 came outside and asked for a cigarette. He told her she had to wait she questioned why they had to wait and his reply was after she asked what did you say and he said 'fuck you.'<BR/>Record review of 1:1 in-service titled, Abuse Prevention, Abuse & Neglect Facility Policy, specifically verbal abuse was conducted by the Administrator with the SA on 04/28/24 and signed in ink by both.<BR/>In an interview with SM on 08/06/2024 at 10:41 AM, SM stated that the patio was open to residents that wish to smoke from 7 AM to 7 PM. SM stated there was a lunch break from 12 PM to 1 PM where the patio was closed for smoking. SM stated that he was familiar with SA and he had heard from residents that SA would frequently yell and cuss at all of them. SM stated he was not familiar with any specific incident involving Resident #1, and that he had not started working yet at the facility on 04/29/2024.<BR/>In an interview with Resident #5 on 08/06/2024 at 1:07 AM, Resident #5 stated that SA would cuss and yell at all the residents in the smoking area. Resident #5 stated that he was aware of the incident involving Resident #1 when SA said Fuck you to her on 04/29/2024, but could not elaborate further on other incidents. <BR/>In an interview with Resident #6 on 08/06/2024 at 2:49 PM, Resident #6 stated that SA told one of the ladies in the smoking area to Fuck off. Resident #6 stated that she was not there at the time of the incident, but that she heard it from everyone that goes out to the patio to smoke. <BR/>In an interview with Resident #1 on 08/07/2024 at 9:50 AM, Resident #1 stated that SA said fuck you to her. Resident #1 stated that a lot of other residents were out there and heard it as well. Resident #1 stated that she immediately reported the incident to the Administrator. Resident #1 stated that SA was suspended, but that he came back to work as a maintenance person and that she had seen him walking around the building. <BR/>In an interview with HR on 08/07/2024 at 11:09 AM, HR stated that the last day SA worked was on 07/10/2024. HR stated that SA was not fired after the verbal abuse incident. HR stated the reason SA no longer works at the facility was because he stopped showing up for work after 07/10/2024. <BR/>In an interview with the Administrator on 08/07/2024 at 11:33 AM, the Administrator stated that, during the initial incident on 04/29/2024, Resident #1 was upset because SA was washing the patio and not handing out cigarettes. The Administrator stated that SA allegedly told Resident #1 to fuck off when she told him to stop cleaning the patio. The Administrator stated they reported the incident to Texas Department of Health and Human Services for verbal abuse and suspended SA. The Administrator stated that SA was suspended for a few days before returning to work, but he could not remember exactly how long the suspension lasted. <BR/>In a follow-up interview with Resident #1 on 08/08/2024 at 9:41 AM, Resident #1 stated that when the incident first occurred, she felt embarrassed and anxious because she did not like being talked to that way in front of other residents. Resident #1 stated that after the incident, when she saw SA working in the facility, she felt fearful that he might confront her because she made him change job roles at the facility. Resident #1 stated that there was one incident once SA returned to work at the facility where he was painting other resident's doors outside her room in the 300 hall. Resident #1 stated that a lot of her fear and anxiety returned when she saw him so close to her room. Resident #1 stated that she felt like the facility did not care to protect her from him, or future aggressors if a similar event happened again. <BR/>In a follow-up interview with the Administrator on 08/08/2024 at 10:53 AM, the Administrator stated that the findings of the provider investigation were inconclusive because SA never admitted to saying fuck you. The Administrator refused to answer if he had reasonable suspicion on whether SA said fuck you to Resident #1. The Administrator stated that verbal abuse of this nature does not reach the threshold of needing to call the police. The Administrator stated that the resident never voiced any concerns about SA still working at the facility. The Administrator stated that this incident did not violate Resident #1's rights because she could have waited a few minutes for her cigarette. The Administrator stated that he did not know if SSD did wellness checks on Resident #1 after the incident. <BR/>In an interview with the SSD on 08/08/2024 at 1:20 PM, the SSD stated approximately two weeks after SA was suspended where Resident #1 saw SA painting the doors near Resident #1's room. SSD stated that Resident #1 was upset at that time, but SSD calmed Resident #1 down and let Resident #1 know that SA would finish his work soon. SSD stated that was the only incident she was aware of involving Resident #1 and SA after the incident on 04/29/2024.<BR/>In an interview with the DON on 08/08/2024 at 1:25 PM, the DON stated that she talked with Resident #1 a few weeks after the incident and Resident #1 expressed concerns about SA still working in the facility. The DON stated that she reported this to the Administrator and SSD. <BR/>Record review of the Time Card Report for SA revealed that on the day of the incident, 04/29/2024, SA clocked out at 2:44 PM. The Time Card report revealed that on the day after the incident, 04/30/2024, SA worked from 7:01 AM to 7:16 PM with a break from 11:57 AM to 12:37 PM.<BR/>Record Review of the facility's undated policy titled Abuse Prevention defined Verbal Abuse as The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Following that, in the section titled PROCEDURE: STEPS TO PREVENT, DETECT AND REPORT: SCREENING: #3 stated It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. <BR/>Record review of the facility's policy titled Statement of Resident Rights dated 07/20/2015 stated under the DIGNITIY AND RESPECT section You have the right to: Be free from abuse, neglect, and exploitation. Be treated with dignity, courtesy, consideration, and respect.<BR/>Record review of the facility's abuse and neglect in-service dated 08/08/2024, 08/09/2024 reflected all staff in attendance.<BR/>Record review of the facility's customer service, resident rights, respecting resident wishes in-service dated 08/10/2024 reflect all staff in attendance. <BR/>Record review of the facility's Abuse Prevention policy and procedure undated. <BR/>Record review of the facility's resident safe surveys, including Resident #1, dated 08/09/2024 were reviewed and reflected residents felt safe in the facility environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation for 1 of 5 residents (Resident #1) reviewed for neglect and abuse.<BR/>The facility failed to report verbal abuse by the SA to local law enforcement in accordance with state law on 04/29/24<BR/>The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/29/2024 and ended on 04/29/2024. The facility corrected the non-compliance before the investigation began.<BR/>This failure could place residents at risk of continued victimization, abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. <BR/>Findings included:<BR/>Record review of the undated facility Abuse, Neglect, and Exploitation policy stated the facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Definitions: b). Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Procedure: A. Steps to prevent, detect, and report: Screening: Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and or representative, and as required by state guidelines. In addition, the facility will follow Section 1150B of the Social Security act's time limits for reporting a reasonable crime (immediately but no later than 2 hours if serious bodily injury and 24 hours for all others) In addition to reporting to the state agency, a reasonable suspicion of crime or allegation of abuse, neglect, or misappropriation of resident property is to be reported to at least one law enforcement agency.<BR/>Record review of the facility policy reference to Section 1150B of the Social Security Act: Guidance for Reporting Suspicion of a Crime. Section 1150B of the Social Security Act (the Act), as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), requires specific individuals in applicable long-term care facilities to report any reasonable suspicion of crimes committed against a resident of that facility to State Survey Agencies and Law Enforcement.<BR/>Record review of Resident #1's face sheet revealed a [AGE] year-old female with diagnoses including diabetes, neuropathy, rheumatoid arthritis, heart disease, chronic skin infections, anxiety, left below the knee amputation. <BR/>Record review of Resident #1's MDS Quarterly dated 05/28/24 revealed Resident #1 had a BIMS Score of 15 indicating no cognitive impairment and needed little to no assistance with all ADLs.<BR/>Record review of the provider's investigation dated 05/01/24 described on 04/28/24, the smoking attendant became upset with Resident #1 and cursed at her twice telling her Fuck You each time during a smoking break. There was a total of 4 residents who attested to, witnessed, and confirmed the incident. The provider investigation included Penal Code Title 9 Ch. 42 Sec. 42.01 Disorderly conduct (a) a person commits an offense if he intentionally or knowingly: (1) uses abusive, indecent, profane, or vulgar language in a public place, and the language by its very utterance tends to incite an immediate breach of the peace (a-1) (d) An offense under this section is a class C misdemeanor. There was no Case # and local law enforcement were not contacted. <BR/>There was a signed 1:1 Teachable Moment dated 04/29/24 between the ADM and the SA. The employee was suspended initially and in-serviced on the importance of respecting the residents. The details revealed the employ was in the smoking area and cussed at one of the residents. The SA was not available for interview.<BR/>Record review of 1:1 in-service titled, Abuse Prevention, Abuse & Neglect Facility Policy, specifically verbal abuse reflected the in-service was conducted by the ADM with the SA on 04/28/24 and signed in ink by both.<BR/>Record review of the SA's time sheets dated 03/21/24-07/10/24 documented he was sent home on [DATE] at 2:44 pm. He returned to work on 04/30/24 from 7:01 am-7:16 pm. The record showed he worked Tuesdays, Thursdays, and Saturdays regularly and occasionally on a Monday or Friday. The SA was never suspended for his verbal abuse, he was only sent home early as reflected on his time sheets <BR/>In an interview with Resident #1 on 08/07/2024 at 9:48 am she stated the SA specifically said, fuck you and she asked him, what did you say to me? and he said it again, louder. Resident #1 stated this happened on the smoking patio and lots of other people were out there. She stated she reported it immediately to the SW who sent her to the ADM, and she told him about the incident. She stated, First the SW and DON told her they fired him (the SA), then suspended him, but then he was back. Resident #1 stated, Since then, he (SA) either quit or got fired probably 3-4 weeks ago. She said did not speak to him, nor him to her when he came back. She stated she saw him around 3-4 times, and became very anxious each time. She said seeing him would ruin her day. She said she did not know what she was afraid of but felt unprotected. She said she spoke with the SW and asked the ADM why the SA was still around. She said she asked to see the report he (the ADM) sent because he had gone back & forth with her about when & if he called the state. Resident #1 stated the ADM told her if she kept causing trouble, she could find herself on the street. She stated HR had joined their conversation and told her, The state had more to worry about than her. She stated the ADM was not joking with her and had raised his voice to her. <BR/>In an interview with HR on 08/07/2024 at 11:09 am she stated she (Resident #1) came to me about the smoke guy (SA) and said, who the F was I to let this MF clean the patio when we trying to smoke. HR stated she had never had any situations with the SA, that he was a good guy. HR stated the SA just stopped coming to work on July 10, 2024, and that was the day she terminated him. She stated she tried to call him, but he never answered her calls. HR stated the SA came to pick up his check and he told her his truck broke, and that was that. She stated the ADM had to tell Resident #1 she could not speak that way to them. <BR/>In an interview with the ADM on 08/07/2024 at 11:34 am he stated he was not at the facility during the first encounter Resident #1 had with HR because he was at lunch. He stated Resident #1 wanted to speak to him in his office and she said she told the SA he should not be doing that (washing the smoking patio) right then and that he (the SA) cursed at her. The ADM stated he suspended the SA immediately then reported it to the state for verbal abuse. The ADM stated the SA was allowed to return after his suspension and was moved to a different role (light maintenance and painting) so he would not have any contact with Resident #1. The ADM stated the SA ended up leaving/quitting. <BR/>In an interview with Resident #1 on 08/08/24 at 9:41 am, she stated that she felt embarrassed and anxious because she did not like being talked to by the SA in such a negative way in front of other residents. She stated that she felt fear and anxiety seeing him (the SA) around the facility after the incident. The resident stated that when they did not get rid of him right away, she felt like the facility did not care to protect her. <BR/>In an interview the ADM on 08/08/24 at 10:53 am, he stated, The findings were inconclusive because the man (SA) never admitted to saying fuck you to the resident. He said signing the 1:1 was not an admission of guilt, it only meant he received the 1:1 training. The ADM repeated that the SA never admitted to it. He said a teachable moment (the 1:1 training) was just a record of a verbal reprimand. The ADM said there was no policy that stated what the punishment was for abusing a resident. The ADM said his conclusion of his investigation was inconclusive. He stated the allegation met the definition of verbal abuse, but his findings were inconclusive. The ADM refused to answer whether the incident had reasonable suspicion of a crime (verbal abuse) if the smoking attendant said fuck you to the resident. The ADM stated, In my opinion verbal abuse does not reach the threshold of needing to call the police (meaning he did not notify local law enforcement). If you want to get me for not following my policy, then that is fine. The ADM stated he did not know if the social worker did wellness checks on Resident #1 after the incident. <BR/>In an interview with the DON on 08/08/24 at 1:25 pm, she stated she talked with Resident #1 a few weeks after the incident, and she was concerned about the SA still working in the facility. She stated, I eased her concerns and said he would not bother her. I reported this to the administrator and the social services director. She stated she did not know if the ADM or SW spoke to Resident #1.<BR/>In an interview with the ADM on 8/9/24 at 4:00 PM, he stated, The SA was suspended for 3 or 4 days, then he had some days off behind it, making it seem longer. The ADM had no comment regarding the SA's timesheets.<BR/>Record review of the facility's abuse and neglect in-service dated 08/08/2024, 08/09/2024 reflected all staff in attendance.<BR/>Record review of the facility's customer service, resident rights, respecting resident wishes in-service dated 08/10/2024 reflect all staff in attendance. <BR/>Record review of the facility's Abuse Prevention policy and procedure undated. <BR/>Record review of the facility's resident safe surveys, including Resident #1, dated 08/09/2024 were reviewed and reflected residents felt safe in the facility environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to securely store all drugs and biologicals in locked compartments under proper temperature control, and permit only authorized personnel to have access to keys in that:<BR/> An unknown nurse left Resident #2's discontinued medication in a clear bin, affixed to the ADON's office door, which left it easily accessible to all mobile residents and visitors. <BR/>These deficient practices could affect residents with medications and could result in missing or misuse of drugs by unauthorized personnel.<BR/>The findings included:<BR/>Record review of Resident#2's Face Sheet dated 07/29/2024 revealed, Resident #2 was admitted on [DATE], and was a [AGE] year-old female with diagnoses of dementia (cognitive impairment), cellulitis (tissue inflammation infection), history of urinary problems, and acute cystitis without hematuria (inflammation of the bladder without blood in urine).<BR/>Record review of Resident #2's MAR dated July 2024, revealed Resident #2 for a URI (Upper Respiratory Infection) received 2 Azithromycin Z-pack (an antibiotic) 250mg tablets on 07/26/2024, followed by 1X250mg tablet daily for 4 days. <BR/>Record review of Resident #2's physician order dated 07/26/2024 revealed, Azithromycin 250mg tablets. Take (2) tablets by mouth today (now, 7/26/24), then 1 tablet daily for 4 days. <BR/>During an observation on 08/02/2024 at 12:36PM, on the 2500 Hall, on a door labeled Assistant Director of Nurses was a clear bin with initially, unknown red colored medications. Upon further inspection there was a label with Resident #2's name on the top of the blister pack followed by date 07/26/24, name of the medication Azithromycin 250MG tablet, with instructions that stated take (2) tablets by mouth today (now) then 1 tablet daily for 4 days. <BR/>During a brief interview on 08/03/2024 at 12:38PM the administrator was walking down the 2500 Hallway, and was directed to observe a clear bin, filled with one medication, attached to the ADON's office door. The administer was questioned why the initially unknown medication, was placed in a clear bin, attached to the ADON's door. The administrator responded by asking the same question to the ADONs, ADON A and ADON B. Both ADONs responded that the blister pack in question was supposed to be empty, but upon their further inspection they stated the medication had been completed but the remaining medication was not supposed to be left on the door for easy resident access. Both ADONs stated any blister pack that has medications is supposed to be in a locked box. All three staff members quickly removed items from the clear bin. <BR/>During an interview on 08/03/2024 at 12:46PM ADON A stated an unknown nurse placed Resident #2's medication filled blister pack in the clear box attached to the ADON's door. ADON A stated the expectation of the facility is for nurses to put empty blister packs on the ADON's door, and then the ADONs will pick up those empty cartridges and discard appropriately. ADON A stated any medication blister packs that are not empty must be kept within the locked narcotic box, which will be retrieved by the ADONs/DON the following day to be properly destroyed. ADON A stated she did not know how long the medication was within her clear bin, nor did she know that the medication was in the box prior to being notified. ADON A stated medications should not be left unattended nor accessible to residents. ADON A stated the medications in question should not have been left on the ADON's door but should have been secured/locked within the narcotic box. ADON A stated somebody could have accessed those unattended medications and consumed them. ADON A stated there are many mobile residents on the second floor. ADON A stated some of the mobile residents have cognitive impairments and could have consumed the medication without fully understanding what they were consuming. ADON A stated both floor/levels of the facility, have residents with dementia and cognitively impaired residents. ADON A stated if a resident consumed any non-prescribed medication a resident could potentially develop an adverse respiratory reaction which could lead to stricture of breathing, or anaphylactic shock, which could affect residents negatively. ADON A stated additional adverse reactions would include rashes, nausea, and vomiting. ADON A stated in conjunction with ADON B and the DON, she facilitated a discontinue blister pack in-service on 08/2/24. <BR/>During an interview on 08/03/2024 at 2:02PM ADON B stated she could never figure out who left the medication in the clear bin attached to the ADON's office door. ADON B stated the expected process for medications remaining in the blister packs is for them to be kept within the secured/locked narcotic box, followed by either the ADONs or DON retrieval and proper destruction and disposal. ADON B stated the medication in question, should never have been left in the clear bin accessible to all residents. ADON B stated there is a lot of foot traffic on the second floor/level including cognitively impaired residents. ADON B stated potentially a resident could have consumed the non-prescribed medication and could have ended up having an anaphylactic reaction, which could have led to hospitalization, or worse, death. ADON B stated the clear bin has been removed from the door. ADON B stated in conjunction with ADON A, both began a medication storage in-service on 08/03/2024 and are 90% completed. ADON B stated on 08/02/2024, she began in-services regarding antibiotics that need to be disposed, are left in the narcotic box. <BR/>During an interview on 08/05/2024 at 5:00PM DON stated the medications that were observed on 08/02/2024 should not have been placed in the attached clear bin located on the ADON's office door. The DON stated keeping medications unattended is not allowed and is unacceptable. The DON stated in a collaborative effort with the ADONs, she checks the narcotic boxes daily for any medication that is needing to be destroyed and disposed of. The DON stated medications are supposed to be kept within a locked box or medication room but should never be accessible to residents. The DON stated once she was aware of the easily accessible medication issue, she advocated for the immediate removal of the clear bin. The DON stated it really bothered her. The DON stated if a person consumes non-prescribed medications the residents could potentially experience an allergic reaction with adverse symptoms like vomiting, headaches, and dizziness, which would necessitate immediate life-saving interventions. The DON stated it could also affect the respiratory system like shortness of breath, stricture of airway, or cessation of breathing. The DON stated the facility is very busy and has a lot of foot traffic daily, including resident movement. The DON stated she has been employed with the facility for roughly 3 months. The DON stated this situation should not have occurred. The DON stated the ADONs are currently in-servicing all clinical staff regarding medication storage and medication disposal procedures. <BR/>Record review of Discontinued Blister Packs (Narcotics/Antibiotics) in-service dated 08/02/2024 documented, all nurses please put all discontinued empty narcotics blister packs and sheets inside the container at the nurses' station. ADON's will pick them up every morning. Do not put antibiotics in there if they still have pills left. Leave in narcotic box and we will get them out when we come in. Only empty blister packs in the container. Do not put on Manager's doors anymore. <BR/>Record review of the facility's Medication-discontinued medication/destruction of drugs policy effective date 01/2008 and revision date 11/2013 documented, 1. When a medication has passed its expiration date or is otherwise deteriorated, or has been discontinued, or for a resident no longer a resident at the home, it should be removed from the medication cart as soon as possible and accounted for and kept under lock and key in the medication room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one (R #1) of three residents that were reviewed for infection control and transmission-based precautions policies and practices, in that:<BR/>LVN A did not remove her contaminated gloves after touching multiple surfaces prior to commencement of PEG tube cleansing as well as maintained usage of same contaminated gloves during care of PEG tube. <BR/>These failures could place residents at risk for infection through cross contamination of pathogens. <BR/>The findings included: <BR/>Record review of R #1's Face Sheet undated, admitted [DATE], documented a [AGE] year-old male with the following diagnoses of: COPD (airflow blockage and breathing-related problems), GERD (acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus)), multiple rib fractures, HIV (virus that attacks the body's immune system), Hepatitis C (infection caused by a virus that attacks the liver and leads to inflammation). <BR/>Record review of R #1's MDS was not conducted due to being unavailable due to the resident being admitted [DATE]<BR/>Record review of R #1's Comprehensive Care Plan unavailable due to being admitted [DATE]<BR/>Observation on 04/12/2023 at 9:58AM, LVN A was permitted by Resident #1 to perform PEG site care. LVN A began PEG tube care by performing hand hygiene with Alcohol Based Hand Rub prior to entry into Resident #1's room. LVN A continued by placing supplies on bedside table and applied clean gloves. While at bedside, LVN A proceeded to touch the pause/hold button on kangaroo pump with the same pair of initial gloves to pause the enteral feed. LVN A continued with same pair of initial gloves to lift resident gown up, remove dirty gauze from PEG tube insertion, clamped tube, and disengaged feeding tube from PEG tube. LVN A proceeded to exit Resident #1's room, retrieved clean 4x4 gauze from treatment cart located by doorway, opened drawer with same pair of gloves, and re-entered Resident #1's room. LVN A proceeded to open clean gauze packet with same initial pair of dirty gloves, saturate gauze with normal saline and performed cleansing of PEG tube insertion. LVN A continued by removal of dirty gloves, performed hand hygiene, and without applying new gloves, retrieved another clean gauze with bare hands, removed gauze from package and applied normal saline to clean gauze. LVN A proceeded to take the saturated normal saline gauze and clean insertion area with bare hand.<BR/>During an interview on 04/12/2023 at 10:23AM LVN A stated, she was unknowledgeable on how to perform site care on the newly admitted Resident #1. LVN A continued by stating it is the duty of night shift nurses to perform all resident cleansing care which included PEG tube site care. LVN A continued by stating she only performs administration of medications and feedings, and was nervous throughout procedure which, per LVN A, kept her from following procedure. LVN A proceeded to state that she should have removed dirty gloves and performed hand hygiene after touching the Kangaroo feeding pump, after removal of dirty gauze, and before PEG tube insertion site cleansing care to promote infection control and prevent potential infection contraction. LVN A stated she had a competency check off two weeks prior to 4/12/2023, which contained written material about g-tubes dressing changes but could not recall what the written education entailed. LVN A stated she was given an education sheet about caring for g-tubes to look over by facility, but not how to care for PEG tube. LVN A continued by stating she only does medication administration via PEG tube.<BR/>During an interview on 04/12/2023 at10:46AM, the DON stated that the expectation of the facility is to follow a specific step by step procedure when performing clean dressing change to eliminate chance of infection contraction. The DON continued by stating it is in the nurse's scope of practice to perform PEG tube site care, and nurses must be competent in performing dressing changes. The DON stated that hand hygiene as well as glove changes must be performed prior, during, and after providing gastric tube site care to promote infection control. The DON continued by stating the procedure was: 1. verify orders 2. knock and provide privacy and explain procedure 3. Wash hands 4. set up clean and dirty areas 5. Put on clean gloves 6. Remove soiled dressing and discard 7. Wash hands and put on clean gloves. The DON continued by stating she provides all nursing staff competency check offs upon hire with educational literature prior to gaining independent admittance onto floor. The DON proceeded to state she also conducts infection control in-services monthly, annually, and as needed for skills maintenance. The DON stated that in no way is it ever acceptable to perform any resident care without the use of gloves. <BR/> Record Review of facility's Clean Dressing Change Check off, undated, stated: <BR/>3. Wash hands<BR/>4. set up clean and dirty areas<BR/>5. Put on clean gloves<BR/>6. Remove soiled dressing and discard<BR/>7. Wash hands and put on clean gloves<BR/>8. Clean wound using circular motion starting from the inside working outward<BR/>9. Remove gloves and sanitize hands<BR/>10. Put on clean gloves to continue with the dressing change.<BR/>Record Review of facility's Infection Control-Prevention and Control Program dated 03/2012 stated, <BR/>2) Prevent and control outbreaks and cross contamination using transmission-based precautions in addition to standard precautions. <BR/>1) Policies, procedures, and practices which promote consistent adherence to evident-based infection control practices.<BR/>10) Implementing measures to prevent the transmission of infectious agents and to reduce risks for device and procedure-related infections. <BR/>Record Review of facility's Hand hygiene Policy dated August 2019 stated, use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, so (antimicrobial or non-antimicrobial) and water for the following situations:<BR/>d. Before performing any non-surgical invasive procedures<BR/>e. Before handling an invasive device.<BR/>g. Before handling clean or soiled dressings, gauze pads etc.<BR/>k. After handling used dressings, contaminated equipment etc.<BR/>m. After removing gloves. <BR/>Record Review of the CDC Guidelines regarding Hand Hygiene in Healthcare Settings, dated January 30, 2020, stated Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, contaminated surfaces, and immediately after glove removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to send a copy of the notice of transfer or discharge, and the reasons for the transfer or discharge in writing to the resident, resident representative, or the Office of the State Long-Term Care Ombudsman for two (Residents #37 and #81) of three residents reviewed for transfer and discharge.<BR/>The facility failed to send the notice of transfer or discharge in writing to Residents #37 and #81, their RP or the Ombudsman when Resident #37 transferred to emergency room on 8/13/24, and Resident #81 was transferred to the hospital on 6/28/2024.<BR/>This failure could affect residents by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. <BR/>Findings included: <BR/>1. Record review of Resident #37's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included Type 2 Diabetes (disease in which the body has trouble controlling blood sugar and using it for energy), Hypoxemia (low level of oxygen in the blood), Seasonal Allergies, Pneumonitis (general inflammation of lung tissue), Hematemesis (vomiting blood), Gastroesophageal Reflux (acid reflux and heartburn), Fusion of Spine, Cyst of Left Kidney.<BR/>Interview with Resident #37 on 08/26/24 at 09:54 AM, he stated he was in the hospital recently. <BR/>Record review on 08/28/24 at 09:42 AM of physician's orders dated 08/13/2024 revealed Resident #37 was sent to the emergency room for low saturation and shortness of breath, and he was diagnosed with Covid-19 and Hypoxia. Record Review also revealed Resident #37 returned to facility same day with new orders. <BR/>Record review on 8/28/24 revealed Resident #37s care plans to maintain infection control practices and Covid 19 testing per facility policies. <BR/>Interview with second floor ADON on 8/28/24 at 10:15 AM, the ADON stated that RP for Resident #37 was contacted via phone to let them know Resident #37 was being transferred to the emergency room. The ADON stated that they only notify resident or RP verbally or by phone, but not in writing. <BR/>2. Record review of Resident #81's face sheet revealed he was an [AGE] year-old-male admitted to the facility on [DATE]. Diagnoses include Fracture of Right Femur, Aftercare of Joint Replacement, Presence of Artificial Hip Joint, Protein Calorie Malnutrition, Gastroesophageal Reflux Disease. <BR/>Record review on 8/28/24 of Resident #81's MDS revealed adequate hearing, clear speech, makes self understood, comprehends others, and a BIMS score of 11. <BR/>Interview with Resident #81 on 08/26/24 at 11:08 AM, he stated he broke his hip in June 2024 after falling while trying to get a towel out of the closet and got dizzy. and he was admitted to the hospital on [DATE]. <BR/>Interview with second floor ADON on 08/28/24 at 10:15 AM, she stated Resident #81 was admitted to the hospital on [DATE] and returned to facility on 07/02/24 back to same room. ADON is unsure if the ombudsman was ever notified. ADON stated that RP was contacted via phone to let them know Resident #81 was being transferred to ER. ADON states that they only notify residents or RPs verbally or by phone, but not in writing. <BR/>Record review on 08/29/24 at 09:07 AM of the Transfer or Discharge Policy revealed that when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. <BR/>Interview with the Administrator on 08/29/2024 at 09:05 AM, he stated that the social worker handles all the transfer and discharge notices. <BR/>Interview with the Social Worker on 08/29/2024 at 09:12 AM, she stated that she only handled transfers and discharges that were not medical related, such as AMA (Against Medical Advice) and discharges or transfers to another facility. She stated she did not notify the resident or RP in writing, but called them to inform them, and she would also usually send the Ombudsman an email.<BR/>Interview with the State Ombudsmen on 08/29/2024 at 09:27 AM, she stated the facility should be notifying her of transfers and discharges, and that she had not gotten anything lately. <BR/>Record review on 08/29/2024 of the facility's policy titled Discharge or Transfer Policy revised 01/01/2022 revealed when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to perform preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 1 of 3 residents (Resident #39) reviewed for preadmission screenings. <BR/>The facility failed to perform a PASRR for Resident #39 before or after she was admitted on [DATE] with readmission on [DATE].<BR/>This failure could place residents at risk of receiving inadequate care.<BR/>Findings included:<BR/>Record review of Resident #39's admission record revealed an [AGE] year-old female with an original admission date on 08/13/18 and a readmission on [DATE]. Diagnoses included Alzheimer's, dementia with psychotic disturbance, mood disorder due to known physiological condition, psychotic disorder with delusions due to known physiological condition, anxiety disorder, major depressive disorder, recurrent.<BR/>Record review of Resident #39's care plan dated 08/02/24 revealed pg. 10 identified a problem dated 10/31/22 of potential for Staff report that she appeared to have little interest in doing things, appeared tired and had poor appetite. Potential for increased mood symptoms due to Mood Disorder, Psychotic Disorder, Anxiety, Depression, end stage disease process / Alzheimer's Disease. Edited: 08/28/2024. <BR/>Record review of Resident #39's L1 dated 04/28/20 was negative for MI or IDD. <BR/>In an interview with the MDS nurse on 08/27/24 at 1:41 PM stated she did not know how she missed Resident #39's PASRR L1 that was negative on 04/28/20 and she should have sent a 1012. She said she missed it because Resident #39's PASRR was done way before she started working at the facility as MDS. She said she started working at the facility in 2019. She stated, The new forms automatically grey out once the question for dementia was answered 'yes', even if they (residents) had qualifying diagnoses. She said Resident #39 had diagnoses of Mood disorder, Psychotic disorder, and Major depressive disorder, recurrent. She said a level 2 should be done with those diagnoses, regardless of a diagnosis of dementia. She stated, The resident would not qualify unless she had a psychiatric evaluation at a mental hospital. <BR/>In an interview with the MDS coordinator on 08/27/24 at 3:57 PM, she stated that if a resident already had PASRR, then a new one was not completed. She said she only completed the 1012 form if the individual had a diagnosis of dementia or there was an evaluation done while the resident was admitted to a psychiatric hospital. She stated that she was not aware that the form needed to be completed for change of status or new mental health diagnoses.<BR/>Interview with the MDS nurse on 08/28/24 at 2:25 p.m., revealed she did not have or send a 1012 for Resident #39.<BR/>In an interview with the MDS coordinator and the DON on 08/29/24 at 10:15 a.m., the DON stated the nurse managers followed up and updated the orders and care plans, as well as the MDS, DON and & the ADON. etc. The DON stated the system to ensure the PASRR was being done and correct was those that were already done, she and the nurse managers would be checking for accuracy, and they were now helping. She said she had not put anything in place in the 3 months she had been employed at the facility. She stated they needed to make an improvement to their system, to make sure the data of the patient is accurate. She said the MDS and care plans were used for the aids and nurses to know what the focus on the resident was. She said they needed to improve documentation and focus on the needs of the patients. She said she would be involved in this training. She said she reviewed care plans only when there was a concern and she had not reviewed all of them. She said she saw a failure in care planning and PASRR and they needed to improve that. The MDS nurse said all the nurses were responsible for checking for mental illness correctness-it's a hit & miss because they come from home, hospital, etc. <BR/>Reference: CFR &sect;483.20(k)(2), and the resident remains in the facility longer than 30 days, the facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for 3 residents (Resident #8, Resident #34, and Resident #48) of 18 residents whose care plans were reviewed, in that: <BR/>1) Resident #8's comprehensive care plan was not reviewed or revised to include Resident #8's current code status of Full code, instead of Do Not Resuscitate. <BR/>2) Resident #34's comprehensive care plan was not reviewed or revised to discontinue Resident #34's use of insulin.<BR/>3) Resident #48's comprehensive care plan was not reviewed or revised to discontinue Resident #48's wounds or wound vac (medical device that helps wounds heal by applying negative pressure to the wound site). Resident #48's care plan was also not revised to include that Resident #48 changes out his own urinary catheter monthly.<BR/>These failures could place residents at risk for inadequate care and services. <BR/>The findings included: <BR/>1.) Resident #8 <BR/>Record review of Resident #8's face sheet dated 8/27/24 reflected a [AGE] year-old female with an original admission date of 8/15/2008. Diagnoses included dementia (general decline in cognitive abilities that affects a person's ability to perform everyday activities) and bipolar disorder (mental disorder with periods of depression and periods of abnormally elevated mood). <BR/>Record review of Resident #8's care plan dated 8/7/24 reflected no code status. <BR/>In an interview on 08/27/24 at 01:18 PM, the SW stated she, the DON, ADON, MDS and Activities work on care plan meetings. The SW stated the MDS Coordinator was the main person to work on care plans. The SW stated she could not find the code status in Resident #8's chart, but the code status should be care planned. The SW stated the code status should be care planned so staff could know what the code status was and the goals and what the interventions were. The SW stated she was not sure who audits care plans once they are done by the MDS Coordinator<BR/>In an interview on 08/27/24 at 01:39 PM, the MDS Coordinator stated Resident #8's code status should be care planned. The MDS Coordinator stated the code status should be care planned so nursing staff could know what interventions to take in case of emergency. The MDS Coordinator stated the ADON and the DON audit care plans quarterly and as needed. The MDS Coordinator stated the code status was not in Resident #8's care plan. The MDS stated once upon a time Resident #8 had a code status of do not resuscitate and that code status was discontinued and changed to full code and the change in code status did not get entered in as it was overlooked. The MDS Coordinator stated the nursing staff do not look at the care plans to find the code status, but all code status should be care planned. The MDS Coordinator stated she was going to update Resident #8's care plan immediately to reflect the current code status. <BR/>In an interview on 08/27/24 at 02:07 PM, the DON stated a resident's code status should be care planned. The DON stated resident code status was care planned so nursing staff could know what interventions to take for Resident #8. The DON stated she thought Resident #8 had a code status of do not resuscitate but could not remember because there were so many residents. The DON stated she was not sure who audited care plans, but she had not audited care plans before and does not know who should be. The DON stated the code status was not in the chart but should be. The DON stated she had been at the facility for about 3 months and has not audited any care plans but thinks she should be auditing care plans to ensure accuracy. The DON stated moving forward she was going to be auditing care plans. The DON stated she assists in care plan meetings and helps with more acute changes. The DON stated when there are changes with a resident, in morning meetings it is discussed and addressed. The DON stated once a change is identified, the care plan is updated by either the SW or MDS Coordinator.<BR/>2.) Resident #34<BR/>Record review of Resident #34's face sheet revealed a [AGE] year-old female with an original admission date of 5/3/23. Diagnoses included Type II Diabetes Mellitus (high blood sugar) with chronic kidney disease, dementia (general decline in cognitive abilities that affects a person's ability to perform everyday activities), and left side paralysis (inability to move the left arm or leg) due to cerebral infarction (disrupted blood flow to the brain). <BR/>Record review of Resident #34's admission MDS dated [DATE] revealed a BIMS score of 5 which indicated severe cognitive impairment. <BR/>Record review of Resident #34's Care Plan on 8/28/24 revealed a Problem of Resident receives insulin R/T diabetes mellitus with diabetic CKD (chronic kidney disease) Problem start date: 6/8/23. Edited: 8/2/24. Goal: Resident will not have any episodes of hyperglycemia (high blood sugar)/hypoglycemia (low blood sugar) throughout next review date. Long Term Goal Target Date: 8/31/24. Edited: 8/2/24. Approach: Administer insulin as ordered per md order. Approach start date: 6/8/23. Created: 6/8/23. <BR/>Record review of Resident #34's Active Orders on 8/28/24 revealed no active order for any type of insulin. <BR/>3.) Resident #48<BR/>Record review of Resident #48's face sheet revealed a [AGE] year-old male resident originally admitted on [DATE]. Diagnoses included acute pulmonary edema (fluid build-up in the lungs), vascular dementia (brain damage caused by multiple strokes), paraplegia (paralysis of the lower extremities) due to a gunshot wound, neuromuscular dysfunction of the bladder, urinary retention, urinary tract infection, and pressure ulcers of the sacral region and right buttock.<BR/>Record review of Resident #48's quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated resident was cognitively intact. <BR/>Record review of Resident #48's Care Plan on 8/28/24 revealed a problem of: I am at risk of impaired skin integrity r/t incontinence of bowel and bladder and decreased mobility r/t paraplegia. Admit with multiple pressure ulcers. Stage 4 pressure ulcer with wound vac. Problem start date 6/30/20. Edited: 8/2/24. Goal: My skin integrity will improve over the next review date. Long term goal target date: 8/31/24. Edited: 8/2/24. Approach: Treatment as ordered for all wounds. Wound vac as ordered. Approach start date: 6/30/20. Edited: 7/13/20. The Care Plan also revealed a problem of: Resident at risk for UTI r/t indwelling catheter use DX Neurogenic bladder. Problem start date: 6/30/20. Edited: 8/2/24. Goal: I will be free from infection r/t catheter use through the next review date. There was no approach for foley change by licensed staff or the resident himself. <BR/>In an interview on 8/27/24 2:47 p.m., CNA F stated, Resident #48 prefers to change his foley out himself. Sometimes we offer him help but he says he wants to do it himself. <BR/>In an interview on 8/27/24 at 2:49 p.m., CNA G stated, I believe it is the nurse's job to change Resident #48's foley catheter out. All he does is empty the drainage bag. CNA G stated she did not really know anything about the foley because it is a nurse job.<BR/>In an interview on 8/27/24 at 2:51 p.m., LVN E stated, The night nurse told me that she had taught Resident #48 how to change it and she was in there with him. He likes to be independent. LVN E stated that she would sometimes get the urinary catheter supplies during the day because they could be difficult to find at night.<BR/>In an interview on 8/27/24 at 3:15 p.m., the MDS stated she did not know anything about Resident #48 changing his own urinary catheter and that, that would be a nurse manager thing. The MDS stated it was important to be care planned, so that everyone would know that he does it himself, although he probably shouldn't be doing it himself. The MDS stated she did not know that he was non-compliant with care. The MDS stated that Resident #48 changing out his own urinary catheter should have been discussed in morning meetings. The MDS stated the ADON should have let her know about it in morning meeting and there should have been an order in the chart. The MDS stated, It is the nurse's job to tell the nurse manager, and the nurse manager should bring it up in morning meeting so that everyone is on the same page. The MDS stated It should have been on the 24 hour report also.<BR/>In an interview on 8/28/24 at 10:48 a.m., RN A stated that Resident #48 liked to do a lot of things for himself, and that staff would provide the supplies for him. RN A stated she was not sure if he changed out his own urinary catheter. RN A stated that Resident #48 had asked her for supplies, but that he had never let her change the catheter. RN A stated Resident #48 frequently cussed out staff and would not let them do any care for him. RN A stated she did not know if anyone had taught him how to change his foley. <BR/>In an interview on 8/28/24 at 11:00 a.m., ADON H stated, Resident #48 is a young guy and very private- he is embarrassed for us to do his foley care/change. ADON H stated that one of the night nurses showed Resident #48 how to insert his foley and had him do a return demonstration after she taught him. ADON H stated it had been a while since the night shift nurse told her about Resident #48 being taught how to change his own urinary catheter. ADON H stated, I think the doctor is aware that he changes his own foley. There is not an order or care plan in reference to him changing his own foley. ADON H stated the night nurse should have gotten the order when she taught him how to change the catheter or that she (ADON H) should have gotten the order when she learned of the situation. ADON H stated It was important that there was an order so the doctor was aware that Resident #48 was doing his own foley changes. ADON H stated it was also important to have an order and for it to be care planned so that if anything went wrong, the doctor knew that Resident #48 changed his own foley. ADON H stated it was also important to have an order and a care plan so that staff was aware that Resident #48 changed his own foley. When asked how long Resident #48 has been changing his own urinary catheter, ADON stated, It's been about a year- not too long, that he's been changing his own foley. ADON H stated there had to be an order for the resident to change his own urinary catheter and the resident had to be trained to do it so that he did not cause any urethral trauma or infection. ADON H stated, We're going to contact the physician now and get it care planned.<BR/>In an interview on 8/28/24 at 12:48 p.m., the MD stated that he did not know that Resident #48 was doing his own foley changes. The MD asked how long the resident had been doing it and was told the staff said he had been doing it for about a year. When asked about his thoughts on it, the MD stated, I guess it is ok. When it was clarified to the MD that Resident #48 was changing out his entire urinary catheter, which was a sterile procedure, and the MD was asked if he was still okay with that, the MD asked, what if I say no? The MD was advised that he would have to discuss the situation with the resident and the nursing staff. The MD asked if there was a male nurse that could change the catheter if Resident #48 did not want a female to change it and was told that he would have to ask the facility about staffing. When the MD was told that one of the night nurses had taught Resident #48 how to change his catheter and that Resident #48 did it on his own, the MD replied, Well, I guess it's okay this time, but I will talk to him and the staff the next time I come in.<BR/>In an interview on 8/28/24 at 12:59 p.m., Resident #48 was asked what the process was for changing out his foley. Resident #48 stated, I deflate the balloon, remove the old foley, clean my penis with the iodine swabs, then put together the catheter with the drainage tube, put the lubricant on, insert it, use the wipe to clean off the lubricant and iodine, then inflate the balloon. Resident #48 stated he used the gloves that come in the kit. Resident #48 stated he put them on before he took the old foley out and took them off before he filled the balloon. When asked if he changed gloves after he took the old catheter out and put the new catheter in, Resident #48 stated he did not change gloves. Resident #48 stated he did not think that he had been treated for any urinary tract infections over the past year. Resident #48 stated that there was a nurse in the room when he changed the foley in case he had any issues.<BR/>In an interview on 8/28/24 at 1:06 p.m., the DON stated she had just found out the day before that Resident #48 was changing his own foley. The DON stated, My expectation would be notified right away if the resident is insistent on changing his own foley. The DON stated there were concerns because he could do it wrong and cause urethral trauma or he could cause an infection if he broke sterility. The DON stated the doctor should have been notified, but she was not sure how long the MD had been there. When asked if he should have been notified when he took over, the DON stated, Oh, of course. The DON stated it should have been care planned because it was important for everyone know what was going on with the care of the resident. The DON stated, When we hire the nurses, we tell them to make sure and look at the care plans. When asked whether the nurses looked at the paper or electronic care plans the DON stated they looked at the paper ones. When asked about Resident #48's wounds and wound vac that were on his care plan, the DON stated that he no longer had a stage 4 or a wound vac. The DON asked if that was the latest care plan and was informed that it appeared to be. The DON stated, No, that shouldn't be on there- it should be updated. The DON stated care plans should be updated with any changes but was not sure if it was supposed to be every 30 days or every 60 days. The DON stated it was important that the electronic care plan matched the paper care plan because the nurses did not have access to the electronic one.<BR/>Record review of facility's Care Plans, Comprehensive Person-Centered policy dated 2/20/22 stated: <BR/>A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. <BR/>a. Include measurable objectives and timeframes; <BR/>i. Reflect the resident's expressed wishes regarding care and treatment goals; <BR/>j. Reflect treatment goals, timetables, and objectives in measurable outcomes; <BR/>12. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to securely store all drugs and biologicals in locked compartments under proper temperature control, and permit only authorized personnel to have access to keys in that:<BR/> An unknown nurse left Resident #2's discontinued medication in a clear bin, affixed to the ADON's office door, which left it easily accessible to all mobile residents and visitors. <BR/>These deficient practices could affect residents with medications and could result in missing or misuse of drugs by unauthorized personnel.<BR/>The findings included:<BR/>Record review of Resident#2's Face Sheet dated 07/29/2024 revealed, Resident #2 was admitted on [DATE], and was a [AGE] year-old female with diagnoses of dementia (cognitive impairment), cellulitis (tissue inflammation infection), history of urinary problems, and acute cystitis without hematuria (inflammation of the bladder without blood in urine).<BR/>Record review of Resident #2's MAR dated July 2024, revealed Resident #2 for a URI (Upper Respiratory Infection) received 2 Azithromycin Z-pack (an antibiotic) 250mg tablets on 07/26/2024, followed by 1X250mg tablet daily for 4 days. <BR/>Record review of Resident #2's physician order dated 07/26/2024 revealed, Azithromycin 250mg tablets. Take (2) tablets by mouth today (now, 7/26/24), then 1 tablet daily for 4 days. <BR/>During an observation on 08/02/2024 at 12:36PM, on the 2500 Hall, on a door labeled Assistant Director of Nurses was a clear bin with initially, unknown red colored medications. Upon further inspection there was a label with Resident #2's name on the top of the blister pack followed by date 07/26/24, name of the medication Azithromycin 250MG tablet, with instructions that stated take (2) tablets by mouth today (now) then 1 tablet daily for 4 days. <BR/>During a brief interview on 08/03/2024 at 12:38PM the administrator was walking down the 2500 Hallway, and was directed to observe a clear bin, filled with one medication, attached to the ADON's office door. The administer was questioned why the initially unknown medication, was placed in a clear bin, attached to the ADON's door. The administrator responded by asking the same question to the ADONs, ADON A and ADON B. Both ADONs responded that the blister pack in question was supposed to be empty, but upon their further inspection they stated the medication had been completed but the remaining medication was not supposed to be left on the door for easy resident access. Both ADONs stated any blister pack that has medications is supposed to be in a locked box. All three staff members quickly removed items from the clear bin. <BR/>During an interview on 08/03/2024 at 12:46PM ADON A stated an unknown nurse placed Resident #2's medication filled blister pack in the clear box attached to the ADON's door. ADON A stated the expectation of the facility is for nurses to put empty blister packs on the ADON's door, and then the ADONs will pick up those empty cartridges and discard appropriately. ADON A stated any medication blister packs that are not empty must be kept within the locked narcotic box, which will be retrieved by the ADONs/DON the following day to be properly destroyed. ADON A stated she did not know how long the medication was within her clear bin, nor did she know that the medication was in the box prior to being notified. ADON A stated medications should not be left unattended nor accessible to residents. ADON A stated the medications in question should not have been left on the ADON's door but should have been secured/locked within the narcotic box. ADON A stated somebody could have accessed those unattended medications and consumed them. ADON A stated there are many mobile residents on the second floor. ADON A stated some of the mobile residents have cognitive impairments and could have consumed the medication without fully understanding what they were consuming. ADON A stated both floor/levels of the facility, have residents with dementia and cognitively impaired residents. ADON A stated if a resident consumed any non-prescribed medication a resident could potentially develop an adverse respiratory reaction which could lead to stricture of breathing, or anaphylactic shock, which could affect residents negatively. ADON A stated additional adverse reactions would include rashes, nausea, and vomiting. ADON A stated in conjunction with ADON B and the DON, she facilitated a discontinue blister pack in-service on 08/2/24. <BR/>During an interview on 08/03/2024 at 2:02PM ADON B stated she could never figure out who left the medication in the clear bin attached to the ADON's office door. ADON B stated the expected process for medications remaining in the blister packs is for them to be kept within the secured/locked narcotic box, followed by either the ADONs or DON retrieval and proper destruction and disposal. ADON B stated the medication in question, should never have been left in the clear bin accessible to all residents. ADON B stated there is a lot of foot traffic on the second floor/level including cognitively impaired residents. ADON B stated potentially a resident could have consumed the non-prescribed medication and could have ended up having an anaphylactic reaction, which could have led to hospitalization, or worse, death. ADON B stated the clear bin has been removed from the door. ADON B stated in conjunction with ADON A, both began a medication storage in-service on 08/03/2024 and are 90% completed. ADON B stated on 08/02/2024, she began in-services regarding antibiotics that need to be disposed, are left in the narcotic box. <BR/>During an interview on 08/05/2024 at 5:00PM DON stated the medications that were observed on 08/02/2024 should not have been placed in the attached clear bin located on the ADON's office door. The DON stated keeping medications unattended is not allowed and is unacceptable. The DON stated in a collaborative effort with the ADONs, she checks the narcotic boxes daily for any medication that is needing to be destroyed and disposed of. The DON stated medications are supposed to be kept within a locked box or medication room but should never be accessible to residents. The DON stated once she was aware of the easily accessible medication issue, she advocated for the immediate removal of the clear bin. The DON stated it really bothered her. The DON stated if a person consumes non-prescribed medications the residents could potentially experience an allergic reaction with adverse symptoms like vomiting, headaches, and dizziness, which would necessitate immediate life-saving interventions. The DON stated it could also affect the respiratory system like shortness of breath, stricture of airway, or cessation of breathing. The DON stated the facility is very busy and has a lot of foot traffic daily, including resident movement. The DON stated she has been employed with the facility for roughly 3 months. The DON stated this situation should not have occurred. The DON stated the ADONs are currently in-servicing all clinical staff regarding medication storage and medication disposal procedures. <BR/>Record review of Discontinued Blister Packs (Narcotics/Antibiotics) in-service dated 08/02/2024 documented, all nurses please put all discontinued empty narcotics blister packs and sheets inside the container at the nurses' station. ADON's will pick them up every morning. Do not put antibiotics in there if they still have pills left. Leave in narcotic box and we will get them out when we come in. Only empty blister packs in the container. Do not put on Manager's doors anymore. <BR/>Record review of the facility's Medication-discontinued medication/destruction of drugs policy effective date 01/2008 and revision date 11/2013 documented, 1. When a medication has passed its expiration date or is otherwise deteriorated, or has been discontinued, or for a resident no longer a resident at the home, it should be removed from the medication cart as soon as possible and accounted for and kept under lock and key in the medication room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 2 of 2 nutrition rooms (first floor and second floor nutrition room) reviewed for sanitation. <BR/>The facility failed to maintain the dish room in a safe, sanitary condition. <BR/>The facility failed to keep the dish room walls and floor clean.<BR/>The facility failed to keep the ice machine clean and free of leaks.<BR/>The facility failed to serve juices and milks in clean drinking glasses.<BR/>The facility failed to keep the air intake filter above the stainless-steel refrigerator clean.<BR/>The facility failed to keep hot dogs in the refrigerator tightly sealed.<BR/>The facility failed to maintain 2 chest type freezers in good working order.<BR/>The facility failed to discard a spatula with peeling edges and kept using it.<BR/>The facility failed to discard eroded non-stick pans and kept using them.<BR/>The facility failed to discard dented pans and kept using them.<BR/>The facility failed to ensure kitchen staff were wearing hairnets while in the kitchen.<BR/>The facility failed to ensure kitchen staff were washing their hands.<BR/>The facility failed to ensure kitchen staff were not using a prep sink to wash their hands.<BR/>The facility failed to ensure kitchen staff were educated on calibrating thermometers. <BR/>The facility failed to ensure kitchen staff were following their cleaning schedules.<BR/>The facility failed to ensure the grease barrel was sealed.<BR/>The facility failed to ensure items on the first floor and second floor nutrition rooms were not expired.<BR/>The facility failed to ensure items on the second-floor nutrition room were refrigerated. <BR/>The facility failed to ensure items in the refrigerators and freezers were labeled and dated.<BR/>The facility failed to keep miscelllaneous items off of a prep table.<BR/>These failures could place residents at risk of foodborne illnesses. <BR/>Findings included: <BR/>Observation and Initial tour of the kitchen on 08/25/24 at 11:15 a.m., revealed multiple gnats flying in the dish room and there was a foul odor. The sink drain was dripping liquid onto the floor. The walls and floor were stained in a dripping pattern with a substance that ranged from brownish to white to dark grey. There was a large electrical box on the wall that had an open hole approximately 4 inches by 2 inches in the bottom corner with rusted, sharp jagged edges and high potential for injury as it was next to the dish counter. The ice machine had white/yellow/black substances around the outside, inside, and around the door hatch. The ice chute had a removable dark grey substance along the edge of it where the ice dropped. There were wet towels on the floor around the perimeter of the ice machine and a basin with a moderate amount of water in it. 12 of 20 drinking cups on the clean rack had a removable white substance on the insides. The air filter above the refrigerator was covered in a thick furry dark grey substance. There were 2 trays of 25 total drinking glasses full of juices and milks in the refrigerator that were unlabeled and undated. There was an opened bag of hot dogs in the refrigerator that were open to air, unlabeled and undated. There were 2 large chest type freezers (A and B). The inside of the top in freezer A was severely cracked and the seal had large gaps missing. The seal in freezer B was not sealing at all and there was ice where the seal should have been, and ice formed on the walls inside. There were 2 large pans on the stove, in use. One had deep and many scratches bottom of the pan and had a loose handle. The other pan was a non-stick surface type, and the entire bottom was bare and scratched. There were 6 small-size steam table holding pans with deep dents in the corners that were in use. There was a tape dispenser and a handheld lighter on a prep table. There was a large spatula with peeling edges on the pot rack. There was a gaping hole approximately 6x6 inches in the base of a wall, adjacent to the floor under the 3-compartment sink. There was what appeared to be rat droppings along the same baseboard near the hole. There was a stainless-steel prep sink that had a thick black and a scaly white substance in the corners and on the insides. [NAME] B scraped some of the black substance with her bare fingernail and stated, It looks like mold and did not wash her hands afterwards but went about the kitchen touching surfaces and handling dishes. [NAME] A did not wash his hands after entering the kitchen from the outside. [NAME] A was not wearing a hair net nor a beard cover. [NAME] A's beard was not closely trimmed. The temperatures written in the log dated 08/25/24 for the lunch service were reg meat 140F, purred meat 135F, spinach 135F. The hand washing sink took 3 minutes to reach a temperature of 110F. The stainless-steel prep sink next to the handwashing sink was instantly at temp. <BR/>Interview with [NAME] B on 08/25/24 at 11:30 a.m. she stated, the large spatula with peeling edges was in use and the particles could come off into the food and make the residents choke. She stated the stainless-steel prep sink that was next to the hand washing sink was also used as a hand washing sink. She said the dirty drinking glasses were on the clean rack, where they would be used for service. She said the large spatula with the peeling edges was used all the time. She said the dented holding pans were used frequently. She said the scratched pan with the broken handle was used all the time, as was the eroded non-stick type pan. She said she guessed the pans should be replaced and did not know who was responsible for replacing them or taking them out of service. [NAME] B said, we clean as we go and did not mention any referral to the cleaning schedule. She said the cleaning schedule was around here somewhere. She said the ice machine had been leaking for a while and that was why there were towels on the floor. She said they wring the towels in the basin then empty the basin in the stainless-steel prep sink.<BR/>Observation and interview with [NAME] A on 08/25/24 at 11:40 a.m., he stated he usually wore a hairnet and beard cover while in the kitchen. He said he was in a hurry today because he thought he was late. He stated, I just started here 3 months ago and I'm still learning. He said he used to be a dietary manager. He said he did not calibrate the thermometer prior to temping for food service. While attempting to calibrate the thermometer he used earlier, he said the temperature he was looking for to calibrate the thermometer in ice water was Negative 34 F or negative 32 F. He prepared a cup of ice water and a cup of hot water. The thermometer had a blue line indicating 32 F and the needle on the thermometer dropped 8 degrees below the blue line. He said he did not know how to adjust the thermometer. He said he guessed the temperatures he had taken earlier were too low for service. He stated the residents could get real sick from foodborne illness if the food was not held at the proper temperatures. <BR/>An interview with DA I on 08/25/24 at 11:45 a.m., she stated the kitchen staff did not use the porcelain sink for hand washing because it took too long to get hot. She stated the staff used the stainless-steel prep sink next to the hand washing sink to wash their hands because it had hot water. She said the tape dispenser and handheld lighter were supposed to be on the other side of the prep table and moved them to the other side of the prep table. She said, we clean as we go and did not mention any referral to the cleaning schedule. She said she had never seen the cleaning schedule. <BR/>Observation and interview with the FSM on 08/25/24 at 11:45 a.m., she stated the ice machine was cleaned weekly inside and out. She stated the ice machine did not look clean and it was leaking. She said it had been leaking several months. She said she had informed maintenance on several occasions. She said she did not say anything to anyone else about the ice [NAME] machine. She stated any utensil or dented pans and pans with non-stick finishes should be removed and replaced immediately when showing that kind of wear. She stated she did not know why the dented pans, spatula, and eroded non-stick pans were still being used. She stated the seals in the white chest type freezers needed to be replaced and she had been telling the maintenance man about it for about 3 months. She stated freezer A needed to be replaced because the lid was badly cracked. She stated the freezers were keeping temps. She said she was unaware of the hole in the baseboard by the 3-compartment sink, the state of the dish room, staff not washing their hands or not wearing hairnets. She said the gnats in the dish room had been an on-going problem. Pest control invoices were requested. Policies for hand washing, Pest control, waste and disposal, cleaning schedules, food storage, and thermometer calibration were requested. In-services/training for the last 3 months were requested.<BR/>Return visit, observation of the kitchen, and interview with [NAME] A on 08/27/24 at 1:10 p.m. revealed the large spatula with peeling edges was still in use and hanging on the pot rack. The grease barrel had a removable lid with a hole in the top to pour grease into and the ring that held the top closed was halfway down the barrel. [NAME] A stated he was responsible for pouring used grease into the barrel, and he just lifted the lid and poured the grease directly into the barrel. He stated the ring on the barrel had never been around the lid, at least for the past 3 months since he had been employed at the facility. He stated he knew the ring was supposed to be around the lid, but it was easier to lift the lid and pour grease directly into the barrel. [NAME] A demonstrated raising the ring and secured it around the lid without difficulty. When [NAME] A raised the ring on the barrel, there was a significant difference in the color of the barrel from where the ring was (halfway down the barrel) and the rest of the barrel. The barrel appeared to be sun-bleached because the color of the barrel under the ring was much brighter, indicating the ring had been in the same position halfway down the barrel for a long time. <BR/>Observation of the kitchen on 08/28/24 at 12:24 PM revealed a female kitchen staff member had a ball cap on over a hair net. Her hair was in a bun on the top of her head that had a separate hairnet over the bun. Her hair was sticking out ~ 4 inches all around the back and sides of her neck. <BR/>An interview with DA J on 08/28/24 at 12:24 PM, she stated she had worked at this facility for three years. She said her head was a strange shape and the hairnets did not fit. She said she did not know what else to do with her hair and she had been wearing the ball cap over the hairnets for as long as she had worked in the kitchen. She said she had not tried to use a different type of hairnet, such as a bonnet and this was the best she could come up with to contain her hair. She said she was aware the hair on her neck was crazy, meaning not contained by hairnet(s).<BR/>Observation of the second-floor nutrition room on 08/28/24 at 10:45 AM, revealed 14, 8-ounce bottles of hand sanitizer with expiration dates of 07/23; three of the bottles had broken seals, and two of the three bottles were partially empty. There was 1, 46-ounce container of thickened, lemon-flavored water with a handwritten open date of 08/02/24, and directions on the box read .after opening may be kept up to 7 days under refrigeration. There were 2, 32-ounce containers of high calorie protein drink with expiration dates of 08/26/24. <BR/>Observation of the first-floor nutrition room on 08/28/24 at 10:55 AM, revealed 17, 1.5-ounce calorie and protein enhancer with expiration dates of 06/20/2024. There were 13, 32-ounce high protein chocolate nutrition drinks with expiration dates of August 26, 2024. <BR/>An interview and record review with the FSM on 08/29/24 at 9:45 a.m., she said she was not sure where the cleaning schedules were but thought they were in her office. She said the cleaning schedule tasks were all marked as having been done, but the kitchen did not reflect cleaning had been done. She said she was responsible for making sure the tasks on the cleaning schedules were done correctly and timely and would not say why the kitchen was not clean.<BR/>An interview with the MS on 08/29/24 at 11:00 a.m., revealed the process of him knowing what needed to be fixed was that they (kitchen staff) contacted him verbally via the FSM and she told him by phone. He said there was a handwritten maintenance log at the nurse's station, but anything related to the kitchen he considered a priority. He said there was currently a bid for the stainless-steel freezer, and the technician was there at the facility Saturday (08/24/24) because the staff was concerned about the blinking outer thermometer. He said the inner thermometer was showing correct readings and holding temps. He said there was an icicle that had formed inside the stainless-steel freezer and the pan needed to be replaced. He said the white chest type freezers were holding temperature and there was no cool air escaping. He stated, Ice forms on the inside if the staff left it (the lid) open. He asked this state surveyor if there was ice on the insides of the white chest type freezers. The MS said the seals/gaskets were checked last month by his maintenance guys, then he said he checked them himself and they were good, and the ice probably formed last week when they (kitchen staff) got a shipment from the food distributor and had it opened. The MS stated there was also a bid on a new ice machine. The MS stated the reason the grease barrel needed to be secured was because it could cause environmental hazards if it got knocked over and cause rodents and other vermin attraction. The maintenance log, pest control log and invoices, and invoice/bid for the stainless-steel refrigerator service on 08/24/24 as well as the bid on the ice machine were requested.<BR/>Record review of the daily 23-item kitchen cleaning schedules, weekly 10-item kitchen cleaning schedules and monthly 7-item kitchen cleaning schedules dated from May 01, 2024-May 31, 2024, June 01, 2024-June 30, 2024, July 01, 2024-July 31, 2024, and August 01, 2024-August 26,2024 revealed all daily, weekly, and monthly cleaning checklists were marked as having been done. <BR/>Pertinent items on the daily kitchen checklist were: #1. All dishes, pots, pans, and utensils are cleaned and stored properly after each meal and snack. 3. All sinks are cleaned and sanitized after each use. #12. Sweep floors after meals and mop daily. #14. Food Service employees wear hair restraints .#15. Clean ice machine exterior. <BR/>Pertinent items on the weekly kitchen checklist were: #2. Delime floor under sinks and ice machine. #5. Clean walls. #8. Polish all stainless-steel surfaces. <BR/>Pertinent items on the monthly kitchen checklist were: #2. Clean all baseboards. #4. Clean ice machine. #6. Pest control report on-hand.<BR/>The exceptions of items not checked as having been done were: on the daily kitchen checklist for Monday, May 20, 2024, #7-Dishwasher is cleaned after each use, #9-Trash can is emptied and cleaned after each meal, #10-Bathroom is cleaned daily or as needed, #13-Oven spills are cleaned and ovens are turned off, #15-Clean ice machine exterior, #16-All tools cleaned, locked, and inventoried, #21-Foods thawed appropriately. Friday May 25 and Saturday May 26, 2024, #7-Dishwasher is cleaned after each use. The weekly kitchen cleaning checklist for July 1-7, 2024, July 8-14, and August 5-11, 12-18, 2024 #8 Polish all stainless-steel surfaces. <BR/>Record review of the facility pest sighting log indicated gnats in the dish room was addressed and initialed by the MS on 01/06/24, 07/13/24 and 07/30/24. Rat droppings were addressed and initialed by the MS on 05/05/24, 07/12/24, and 08/09/24. The Pest control invoices were requested but not received.<BR/>Record review of the facility kitchen policy titled, Sanitation and Infection Control-insect and rodent control revised 05/2016 revealed It is the policy of this home to prevent and control insect and rodent infestations within the dietary services department to prevent food borne illness. Under Procedure, 2. The home will maintain .properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents. 3. The sanitation of the kitchen will be maintained to prevent food sources, breeding places, etc. for insects or rodents. 8. The pest control company will leave a copy of treatments made in the kitchen at the end of each service call.<BR/>Record review of the undated facility kitchen policy titled, Choosing the Right Thermometer revealed under Bimetallic Thermometers, there are two ways to calibrate a bimetallic thermometer: the ice point method and the boiling point method. Ice point Method 1. Start with a container large enough to easily accommodate your thermometer. Fill it with ice. Add tap water to fill and stir. Allow the ice water mixture to cool for a few minutes. 2. Put the thermometer probe into the ice water. It is important to wait about 30 seconds .Be sure the temperature indicator is no longer moving. 3. Look for the nut on the underside of the thermometer, use a wrench and turn the head of the thermometer until the reading on the face of the dial reads 32 F.<BR/>Record review of the facility kitchen policy titled, Sanitation and Infection Control-Food Storage-Refrigerated and frozen foods revised 02/2016 revealed Refrigerators and freezers will be kept clean and sanitized. The procedures to maintain the proper temperatures for storing cold foods will be strictly followed to prevent food borne illness. Procedure 6. Food must be stored in a properly covered container with a date and label identifying what is in the container. 7.Do not block the fan of the refrigerator or freezer. 14. Freezers should be defrosted regularly so that they will operate more effectively .15. A. All of the following terms will be considered expiration dates for cold food products: Expires by date, Best Used By date, Use By date, Sell By date. Once the date has been reached, whether the food has only been partially used or unopened, the food product will be discarded on or by that date.<BR/>Record review of the facility kitchen policy titled, Sanitation/Infection Control-Handwashing revised 06/2013 revealed Dietary employees are to wash hands to ensure sanitary work habits are established when handling or serving foods to residents. Procedure: 1. Employees are to wash hands: a. before starting work, b. between handling of dirty dishes and clean dishes, equipment/utensils, and food, c. after all work breaks, using restroom, tobacco use or eating, h. after touching objects that may be a source of contamination if the next contact with the hands is food or food contact surfaces. 2. Hand washing occurs in sinks provided for that purpose .Food preparation sinks are not to be used for hand washing. <BR/>Record review of the facility titled, Dress Code: dated 01/2016 revealed 4. Hair should be clean and, in a style, suited for food service. Hair must be fully covered with a hairnet or hair bonnet at all times within the department. We do not accept the use of baseball caps, visors, and other cloth covers in dietary. All hair coverings should be disposable. 5, Facial hair is to be closely trimmed and all facial hair is to be covered with a hair restraint.<BR/>Record review of the facility kitchen policy titled, Sanitation and Infection Control-Waste Control and Disposal revised 05/2016 revealed Policy: The dietary services department will handle and dispose of waste in a sanitary manner to prevent cross-contamination and food borne illness. Procedure: 6. All rancid or used grease/oil will be poured into the appropriate grease barrel for recycling. <BR/>Record review of the facility kitchen policy titled, Sanitation/Infection Control-Cleaning Schedule revised 06/2013 revealed Policy: The dietary services department and all equipment in the kitchen will be cleaned on a regularly scheduled basis for daily, weekly, and monthly tasks. 3. It is the responsibility of all employees to follow the cleaning schedule. 6. Items not listed, but part of your kitchen, should be added to the cleaning schedule. 7. The dietary manager is responsible for training staff on proper cleaning procedures<BR/>Kitchen staff in-services and/or training was not received. Bids on equipment and invoices were not received.<BR/>References: U.S. Food and Drug Administration Food Code http://www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/ : <BR/>FDA Food Code 2017, Ch.5, 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. Ch. 4-1-101.11 Characteristics. Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion- resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated warewashings; (D) finished to have a smooth, easily cleanable surface; and Euro Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.<BR/>Ch. 4-101.18 Nonstick Coatings, Use Limitation. Multiuse kitchenware such as frying pans, griddles, saucepans, cookie sheets, and waffle bakers that have a perfluorocarbon resin coating shall be used with nonscoring or nonscratching utensils and cleaning pads.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stainless-steel refrigerator, 2 of 2 chest type freezers (freezer A and freezer B), 1 of 1 refrigerator intake filter, 1 of 1 electrical box, and 1 sink drain reviewed for essential equipment in the kitchen. <BR/>The facility failed to maintain sink drainage in the dish room of the kitchen, and there was a foul odor in the dish room. <BR/>The facility failed to maintain an electrical box in the dish room of the kitchen. <BR/>The facility failed to maintain the seals/gaskets on 2 chest type freezers. <BR/>The facility failed to keep the air intake filter above the stainless-steel refrigerator clean.<BR/>The facility failed to keep the ice machine clean and free of leaks.<BR/>These failures could place residents at risk of foodborne illness from improper refrigeration of refrigerated and frozen foods, and potential injury to kitchen staff.<BR/>The findings were:<BR/>Observation and Initial tour of the kitchen on 08/25/24 at 11:15 a.m., revealed the sink drain was dripping liquid directly onto the floor, and there was a foul odor in the dish room of the kitchen. There was a large electrical box on the wall that had an open hole approximately 4 inches by 2 inches in the bottom corner with rusted, sharp jagged edges and high potential for injury as it was next to the dish counter. The ice machine had white/yellow/black substances around the outside, inside, and around the door hatch. The ice chute had a removable dark grey substance along the edge of it where the ice dropped. There were wet towels on the floor around the perimeter of the ice machine and a basin with a moderate amount of water in it.<BR/>Oservation of the dish room and interview with the FSM on 08/25/24 at 11:45 a.m., revealed she stated the ice machine was cleaned weekly inside and out. She stated the ice machine did not look clean and it was leaking. She said it had been leaking several months. She said she had informed maintenance on several occasions. She said she did not say anything to anyone else about the ice machine. She stated the seals in the white chest type freezers needed to be replaced and she had been telling the maintenance man about them for about 3 months. She stated freezer A needed to be replaced because the lid was badly cracked. She stated the freezers were keeping temps. She said she was unaware of the state of the dish room and she would let maintenance know about the dripping sink, odor, and electrical box.<BR/>An interview with the MS on 08/29/24 at 11:00 a.m., he stated he was unaware the air filter above the stainless-steel refrigerator was covered in a thick furry dark grey substance. He said there was currently a bid for the stainless-steel freezer, and the technician was there at the facility Saturday (08/24/24) because the staff was concerned about the blinking outer thermometer. He said the inner thermometer was showing correct readings and holding temps. He said there was an icicle that had formed inside the stainless-steel freezer and the pan needed to be replaced. The MS stated he was unaware of the odor, electrical box, and dripping sink in the dish room of the kitchen. He said the white chest type freezers were holding temperature and there was no cool air escaping from around the lids. He stated, Ice forms on the inside if the staff left it (the lid) open. He asked this state surveyor if there was ice on the insides of the white chest type freezers. The MS said the seals/gaskets were checked last month by his maintenance guys, then he said he checked them himself by holding his hand near the lid, and they were good, and the ice probably formed last week when they (kitchen staff) got a shipment from the food distributor and had it opened. The MS stated there was a bid on a new ice machine. He said the process of him knowing what needed to be fixed was that they (kitchen staff) contacted him verbally via the FSM and she told him by phone. He said there was a handwritten maintenance log at the nurse's station, but anything related to the kitchen he considered a priority. The maintenance log, facility policy on maintaiining equipment, and invoice/bid for the stainless-steel refrigerator service on 08/24/24 as well as the bid on the ice machine were requested, but not received.<BR/>References: U.S. Food and Drug Administration Food Code http://www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/ : <BR/>FDA Food Code 2022, Ch.4-16, 4-501 Equipment, 4-501.11Good Repair and Proper Adjustment. (B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition. (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. 5-501.110 Storing Refuse, Recyclables, and Returnables. REFUSE, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (1) Contain FOOD residue and are not in continuous use; or (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT.

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 of 8 halls (Halls 200, 2200, and 2400) reviewed for environment.<BR/>1) The facility failed to keep a storage room containing mouthwash with alcohol on hall 2400 locked while not in use. <BR/>2) The facility failed to keep the shower room on hall 200 and hall 2200 locked while not in use.<BR/>This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment.<BR/>The findings included:<BR/>During an observation on 08/25/2024 at 12:56 PM, a storage room on the 2400 hall was left unlocked while not in use. Inside the storage room was a basket containing approximately 20 unopened bottles of mouthwash containing alcohol. <BR/>During an observation on 08/25/2024 at 1:21 PM, the shower room on the 200 hall was left unlocked while not in use. Inside the shower room was a bottle of disinfectant left out in the open.<BR/>During an observation on 08/25/2024 at 1:36 PM, the shower room on the 2200 hall was left unlocked while not in use. Inside the shower room was a bottle of disinfectant left out in the open.<BR/>In an interview with LVN B on 08/27/2024 at 8:45 AM, LVN B stated the storage room on hall 2400 was used to store various things for the residents to use during activities. LVN B stated there should not have been mouthwash containing alcohol in the storage room. LVN B stated they only used mouthwash without alcohol in the facility. LVN B stated that the shower rooms should have been locked when not in use. LVN B stated that if a resident went into a shower room by themselves they could get a burn from the hot water, slip and fall, or ingest the cleaner fluid. <BR/>In an interview with RN A on 08/27/2024 at 2:05 PM, RN A stated that the shower rooms should have been locked at all times. RN A stated that a resident could have fallen in the shower if they were alone. RN A stated that the storage room on hall 2400 should have been locked. RN A stated that a resident could have drunk the mouthwash containing alcohol and injured themselves. <BR/>In an interview with CNA C on 08/27/2024 at 2:13 PM, CNA C stated that the shower rooms should have been locked at all times. CNA C stated that a resident could have fallen down in the shower room and hurt themselves. CNA C stated that the disinfectant used in the showers should have been in the locked cabinet inside the shower room. CNA C stated that the storage room on hall 2400 should have been locked. CNA C stated that the mouthwash used in the facility did not contain alcohol. CNA C stated there should not have been mouthwash containing alcohol in any storage room in the facility. <BR/>In an interview with the ADM on 08/27/2024 at 2:26 PM, the ADM stated that he believed the mouthwash containing alcohol had only been in the storage room for a few weeks at most. The ADM stated that a resident could have entered the storage room and drank the mouthwash containing alcohol and hurt themselves. The ADM stated that the shower rooms should have been locked at all times. The ADM stated that he has not seen the shower rooms unlocked before. The ADM stated that a resident could have drunk the disinfectant left out in the shower room. <BR/>In an interview with the DON on 08/28/24 at 02:40 PM, the DON stated storage rooms should have been locked at all times and shower rooms should have been locked when not in use, so residents or other individuals would not have access to any hazardous items such as, mouthwash containing alcohol, razors, shampoos, or anything that could have been potentially harmful. The DON stated that after a resident was done receiving a bath, that staff member would have been responsible to ensure the shower room was locked. The DON stated it was a team effort to ensure that all storage and shower rooms were locked for resident safety. <BR/>Record review of the facility policy Hazardous Areas, Devices and Equipment last updated 02/20/2020 revealed the following:<BR/>As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by mitigation of access to environmental hazards.<BR/>Areas identified as potential for environmental hazards will be identified and secured to restrict access of residents in environment.<BR/>A hazard is defined as anything in the environment that has the potential to cause injury or illness.<BR/>Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a physician, physician assistant, nurse practitioner, or clinical nurse specialist provided for the resident's immediate care and needs for 1 of 5 residents (Resident #3) reviewed for physician services.<BR/>The facility failed to ensure there were orders for R#3's type 2 diabetes mellitus with hyperglycemia. <BR/>On 12/22/23 at 3:55 PM an Immediate Jeopardy (IJ) was identified., while the IJ was removed on 12/23/23 at 6:30pm, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. <BR/>This failure could cause a delay in appropriate medical care and a worsening in symptoms, condition or illness up to and including death.<BR/>The findings included:<BR/>Record review of R#3's Face Sheet, dated 12/22/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Type 2 Diabetes Mellitus ( a chronic condition that affects the way the body processes blood sugar ) with hyperglycemia (high blood sugar), cerebral infarction (damage to tissue in the brain due to disrupted blood supply and restricted oxygen supply) unspecified, Osteomyelitis (infection of the bone), unspecified and urinary tract infection (infection in any part of the urinary system, the kidneys, bladder or urethra), site not specified. <BR/>Record review of R#3's undated baseline care plan revealed a section titled DIABETES, with a goal of Efforts will be made to ensure symptom control without complication, Documentation in this section was comprised of check of questions and areas to be filled in. First line checked had a FSBS q (fingerstick blood sugars to be each/every) printed with AC/HS (before meals and at bedtime) written in. Third line was checked off and had Sliding Scale? printed with As ordered 12/15/23 written in. The 5th line that stated Monitor for S&S (signs and symptoms) of hypo/hyperglycemia (Low and high blood sugar) was not checked off and had no written documentation noted. <BR/>Record review of R#3's undated MDS (Minimum Data Set) assessment received on 12/22/23 revealed R#3 had a BIMS score of 10 which meant the resident was moderately cognitively impaired. R#3's MDS also revealed he had clear speech, was able to make self-understood, and understood others.<BR/>Record review of R#3's hospital's Discharge summary dated [DATE] stated, T2DM (type 2 diabetes melilotus), SSI (sliding scale insulin), Continue glargine (insulin) 10 units and Monitor closely for worsening hyperglycemia (high blood sugar) in the context of Solu-Medrol (steroid). <BR/>Record review of R#3's discharge home medication list from the hospital dated 12/05/23 did not include any diabetic medication, injection, or blood sugar checks. <BR/>Record Review of R#3's Admission/readmission data summary dated 12/06/23 and completed by LVN A stated R#3 had a diagnosis of Diabetes Mellitus and hyperosmolar hyperglycemic (life threatening complication from diabetes, happens when blood sugar is too high for long period of time, leading to severe dehydration and confusion). R#3 was documented as alert and able to make self-understood and understand others. LVN A documented that she verified medication with nurse from the hospital due to the improper list sent from the hospital and had the orders documented as verified with NP C (nurse practitioner) by LVN A.<BR/>Record review of R#3's orders revealed he had no orders for any diabetic medication, injection, or blood sugar check until 12/15/23. <BR/>Record review of R#3's orders revealed an order for CBC (complete blood count), CMP (comprehensive metabolic panel), ESR (erythrocyte sedimentation rate), CRP (c-reactive protein) Q (every) week while on ABT (antibiotic therapy) IV (intravenous) dated 12/06/23.<BR/>Record review of R#3's laboratory results date collected 12/09/23, revealed R#3's glucose result of 288mg/dL (reference range 70-100) and was flagged as high, no A1C (blood test that shows what your average blood sugar (glucose) level was over the past two to three months) was noted as ordered. Written note on this document stated Physician D was notified on 12/11/23 but did not indicate by who. <BR/>Record review of R#3's nursing note dated 12/14/23 at 7:40pm by RN B stated R#3 appeared confused and agitated. R#3's speech was impaired and was unable to be understood and was unable to answer simple questions. Vitals were documented however there was no fingerstick blood sugar completed. <BR/>Record review of R#3's transfer form completed by RN B on 12/14/23 at 7:40pm stated R#3 was sent to the emergency room due to a change in LOC (level of consciousness).<BR/>Record review of R#3's hospital document titled Patient Visit Information dated 12/14/23 stated R#3 was seen for hyperglycemia, UTI, and dehydration. This document also included Dr's instructions to Make sure that you are checking your blood sugars and having them taken care of with your medicines. You were found to have a urinary tract infection. There is no evidence of diabetic ketoacidosis today.<BR/>During interview with hospital staff member on 12/21/23 at 12:34pm, hospital staff member reviewed R#3's hospital stay information from 12/14/23, she stated blood sugars taken by the EMS who transported resident read high and did not provide a numerical reading. R#3's blood sugar was taken at the hospital on [DATE] at 8:51pm and it was at 647. R#3 was given 15 units of insulin. R#3 was found with a primary impression of hyperglycemia, a secondary impression of UTI, and dehydration with discharge instructions provided on 12/14/23 at 11:57pm. <BR/>R#3's hospital documentation has been requested but not yet received as of 01/04/23. <BR/>During an interview with NP C on 12/20/23 at 4:43pm, he stated he did not recall if he had ordered an A1C for R#3. He stated an A1C should have been ordered. NP C stated diabetic patients should be put on monitoring and did not know why R#3 was not. NP C stated R#3 should have been put on insulin per protocol with a sliding scale, blood sugar check, and lab work. NP C stated he was at the facility on 12/09/23, 12/10/23, and 12/11/23 and he reviewed R#3's medications and chart. He stated, for whatever reason it went right over my head and there was a decrease in observance in this one particular item. <BR/>During an interview on 12/22/23 at 2:45pm with LVN A, she stated she was the admitting nurse when R#3 was admitted . She stated when R#3 came into the facility the medication list she received was not the same one they usually receive. LVN A stated she called the nurse at the hospital to go over the medications and to check if it was correct. LVN A stated the only changes made was to the blood pressure medication. LVN A stated she did not recall if she asked the hospital nurse about insulin. LVN A stated she asked the hospital nurse if anything else needed to be added and she told her no. LVN A stated R#3's admission paperwork did state he had diabetes but did not have orders for insulin or blood sugar checks. LVN A stated she called NP C and went over the medications. LVN A stated when she asked about the labs, NP C stated he would go over the hospital labs and would see R#3 when he was at the facility. LVN A stated she had told NP C about R#3's diagnosis of hyperglycemia and NP C did not add any new orders. LVN A stated she did not recall if she asked NP C about blood sugar checks. <BR/>During an interview with RN B on 12/27/23 at 8:47am she stated on 12/14/23 she had been rounding on R#3 and he was in bed acting normal. RN B stated right before 8:00pm R#3's family went to RN B and told her they thought something was wrong with R#3. RN B stated when she entered R#3's room she noted him to be all over the bed and he looked completely different. RN B stated R#3 was flopping about the bed but not purposely, and he appeared anxious and unable to focus. RN B stated R#3 looked at her like a stranger and she knew he was checked out. RN B stated she took one look at his pupils and called 911. RN B stated R#3 had a serious change in LOC (level of consciousness). RN B stated she had no idea what happened to him. RN B stated she took R#3's vital signs. She stated they were not horrible or wonderful. She stated at the time R#3's blood pressure was running high and was not unexpected. RN B stated she did not take blood sugar reading for R#3,she did not know R#3 was diabetic, but later in the interview she stated she knew he was diabetic. RN B stated R#3 did not have any orders for blood sugar checks, diabetic medication, or insulin. RN B stated when the EMS staff (emergency medical service) arrived R#3 had a blood sugar reading greater than 500 per EMS. RN B stated she never asked NP C or Physician D about orders for blood sugar checks or diabetic medication/insulin. <BR/>During an interview with NP C on 12/27/23 at 9:10am, he stated the process for medication reconciliation upon admission was the staff should call him to review the medication discharge list with him. He stated, to see if they want to keep the medications, add, or subtract medications. NP C stated he could not recall if someone called him to go over R#3's medications. NP C stated everyone was responsible, himself, the nurses, and the hospital at discharge for ensuring residents had the appropriate orders to meet their needs and maintain their safety. NP C stated he did not know if he knew R#3 was diabetic on 12/06/23. NP C stated he was aware R#3 was a diabetic when they told him R#3 had elevated blood sugars and they treated him immediately. NP C stated protocol for a regular diabetic would be to start them back on medication, sliding scale insulin, to monitor daily blood sugars throughout the day, and get lab work completed. NP C was asked about R#3's lab results from 12/09/23 and he stated a glucose level of 288 was considered elevated. NP C stated he usually does not treat unless glucose is over 150 and it depended on the patient's compliance. NP C stated he did not remember if any staff from the facility including the DON, or nursing staff asked him or physician D about adding blood sugar checks and/or diabetic medication/insulin. NP C stated he did not know why nothing was put in place for R#3 until 12/15/23. When asked about the facilities policy regarding monitoring, supervising, and getting orders for diabetic medication, insulin, and blood sugar checks NP C stated he did not know. He stated they had protocols but not everyone got blood sugar checks. NP C stated a resident would have to be assessed to see the circumstances before testing them. NP C stated he monitored residents to ensure appropriate orders were in place for their needs by rounding on them multiple times a month, reviewing their medications, looking at notes, and speaking with nursing about any incidents or concerns that may have occurred between his visits. He stated he also visits with the residents. NP C was asked how not monitoring blood sugars or not administering diabetic medication/insulin to a diabetic can negatively impact them, and he stated it was not that the resident was not monitored. He stated when he received the elevated sugars he was treated immediately. NP C stated he reviewed R#3's medications and stated he managed medication and symptoms as they presented themselves. <BR/>During an interview on 12/27/23 at 9:51am with LVN A, she stated depending on the orders, the admitting nurse or anyone such as the ADON or the DON who checked the admission afterwards, would be responsible for identifying if a resident was diabetic and required blood sugar checks. LVN A stated when working and receiving a new patient with a diagnosis of diabetes, she usually looked for any oral diabetic medications, insulin, or sliding scales.<BR/>During an interview with Physician D on 12/27/23 at 10:51am, he stated the process for medication reconciliation upon admission was for the admitting nurse to discuss whether to continue or hold medications with the mid-level professional (NP C). If the mid-level (NP C) was not available the admitting nurse would discuss medications with Physician D. Physician D stated he did not get the initial admission so it would have been his mid-level, NP C. Physician D stated all of us were responsible for ensuring residents had the appropriate orders to meet their needs and maintain their safety. Physician D stated he had reviewed R#3's hospital information and the note he saw on the discharge summary stated R#3 was diabetic and hyperosmolar hyperglycemia state. He was aware R#3 had been given 10 units of insulin and on a sliding scale due tohis sugar level that went up to 600 and required an increase of insulin to 20 units. Physician D stated he read where it stated to monitor and watch for hypoglycemia when tapering the steroid (Solu-Medrol). Physician D stated the way it was written, was as if R#3's blood sugars were rampant due to the steroid he was taking, and saw it as R#3's increase in sugar levels were steroid induced. Physician D stated when R#3 was discharged from the hospital his discharge medication list had no diabetic medications. Physician D stated he checked with the DON to see if anything was communicated from the hospital nurses to facility nurses about blood sugar checks, insulin, diabetic medication, or if R#3 was diabetically fragile and the DON stated no. Physician D stated they were monitoring R#3's labs and there was 1 lab done on admission. He stated the blood sugar was trending down after the initial admission labs. Physician D was asked about R#3's lab results from 12/09/23, Physician D stated he thought he saw those lab results on 12/13/23 or 12/14/23. Physician D stated glucose of 288 was high but not critical and stated R#3 still had the steroid in his system. Physician D stated he did not give any new orders at that time for blood sugar checks or diabetic medication or insulin. Physician D stated they had discussed blood sugars and previous steroids and decided they would continue to monitor and see how it was trending. Physician D stated ideally, yes, a diabetic would get fingerstick blood sugar checks and an A1C. He stated they did not get communication, so the transition of care was poor, and took a little long for them to pick up on the issue. Once it was picked up, they acted immediately. Physician D stated R#3 went to the hospital and ended up having a UTI. Physician D stated R#3 did not have any orders for blood sugar checks or diabetic medication/insulin because they were not aware. He stated if they knew they were diabetic then blood sugar checks, A1C, and diabetic regimen based off labs would be protocol. Physician D stated no staff asked him or NP C about adding blood sugar checks or diabetic medication/insulin. Physician D stated he was not personally notified of R#3's change in level of consciousness on 12/14/23. He stated that would have gone through NP C. Physician D stated based on facility policy if they knew 100% the resident was a diabetic and depending on their needs, would require various monitoring such as more frequent blood sugar checks, sliding scale, and A1C several times a year to adjust regimen. Physician D stated he monitored residents to ensure appropriate orders were in place for their needs through the DON. The nursing staff look at the resident and communicate anything that had come up with himself or NP C during their visits. Physician D stated, this was a one off because from the hospital side what transpired and their lack of whatever. Physician D stated not monitoring blood sugar checks, A1C's, and not administering diabetic medication and insulin to a diabetic resident could negatively impact to become hypoglycemic or hyperglycemic. <BR/>During an interview with the DON on 12/27/23 at 3:55pm, she stated the process for medication reconciliation upon admission was for the admitting nurse to review medication with the nurse practitioner or physician. The DON stated on 12/07/23 she reviewed R#3's chart thoroughly and went over it with Physician D and they agreed to stay with the medication and regimen the way it was. The DON stated she was aware R#3 was a diabetic in the context of Solu-Medrol (steroid) and had not read the part in the hospital discharge summary that stated to continue with blood sugar monitoring due to high sugars. She stated she did not go based off that because it was from 12/05/23 and he was discharged [DATE]. The DON stated R#3 was not sent with any insulin and when LVN A reviewed medications with the nurse from hospital she did not say anything. The DON stated Physician D received R#3's updated chart on 12/07/23 when she reviewed it with him. She stated NP C got the information in their general admission email. The DON stated LVN A had documented that she went over the medication list with NP C. The DON was asked about R#3's lab results from 12/09/23 and stated a glucose level of 288 was considered high. The DON stated when she spoke to Physician D on 12/11/23, about labs from 12/09/23, they also reviewed labs from 12/06/23 in the hospital and stated they noted a lower glucose than his hospital labs on 12/06/23. The DON stated she received a call back on 12/11/23 at 11:32am and received no new orders for diabetic interventions, insulin, or blood sugar checks. The DON stated she followed the physicians' orders and stated Physician D was convinced R#3's blood sugars were in the context of Solu-Medrol (steroid). The DON stated she reviewed with Physician D and he was saying they were going in the right direction that the Solu-Medrol was going out of R#3's system and his glucose was decreasing. The DON stated the nurse (LVN B) on 12/14/23 documented that R#3 had a change in level of consciousness and told her R#3 could not get his words out correctly. The DON stated they do diabetic protocol as ordered by the physician. The DON stated she monitored residents to ensure appropriate orders were in place for their needs by collecting all orders from medical records every morning and making sure they were in place. She stated she will run order audits, especially with labs stating she would note any abnormal labs and if physician was notified. The DON stated normally they were on their diabetic residents, stating it was just this one case that was different because of the Solu-Medrol. The DON was asked how not monitoring blood sugars, not administering diabetic medication/insulin to a diabetic can negatively impact them and she stated they could go into diabetic keto acidosis (DKA- A serious diabetes complication where the body produces excess blood acids).<BR/>During an interview on 12/27/2 at 4:50pm with R#3, he stated on 12/14/23 his sugar was too high. R#3 stated when he was in the hospital prior to arriving at the facility they were giving him shots (insulin) and when he arrived at the facility the shots stopped. R#3 stated when he was at the facility he was not on insulin and took his medications and thought he was on Metformin (diabetic medication). R3# stated at time of incident on 12/14/23 he was not having his blood sugar checked at the facility.<BR/>Record review of the facility's Policy titled, Resident Assessment admission Orders with an effective date implemented 11/28/2017 stated, The facility must have physician orders for the residents immediate care.<BR/>Record review of the facility's Policy titled, Physician Services/Physician Supervision with an effective date implemented 11/28/2017 stated, A physician must supervise the medical care of each resident.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 12/22/23 at 3:55 PM. The administrator and the DON were notified. The Administrator and the DON were provided with the IJ template on 12/22/23 at 4:08pm<BR/>The following Plan of Removal (POR) submitted by the facility was accepted on 12/23/23 at 12:06 PM: <BR/> PLAN OF REMOVAL<BR/>F710<BR/>The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of physician services:<BR/>Regional Director of Operations re-educated Administrator on ensuring residents were receiving necessary and accurate physician services on new admissions on 12/22/2023.<BR/>Regional Nurse Consultant for facility educated Director of Nursing on receiving practitioner's intended protocols for alleged deficient practice as related to physician services on 12/22/2023. <BR/>Licensed facility personnel to perform audit on all current residents to assess diagnoses that could require order for diagnostics and present to practitioner for evaluation and orders as determined by primary care practitioner or designee. 12/23/2023.<BR/>DON/designee to have complete re-education of licensed nursing personnel on new admission orders, including communication with the practitioner about diagnostics and diagnoses as ordered by practitioner by 12/23/2023.<BR/>Facility DON and administrator discussed findings from survey allegations with medical director and practitioner responsible for resident care in question with understanding of allegation noted and medical director implementing standing orders for labs to indicate further monitoring needed upon MD, and practitioner under his/her direction, assessment of findings from labs drawn. Orders to be given by MD and/or practitioner under his/her direction, based on their clinical expertise and licensing, with facility to follow orders as indicated. 12/22/2023 <BR/>Protocol to be initiated for lab and diagnostics on new admissions as facility practitioner designates and orders by 12/23/2023.<BR/>Interventions and Monitoring Plan to Ensure Compliance Quickly:<BR/>oThe Director of Nursing/Designee educating all licensed nursing staff on documentation in the clinical record of new admission verification and reconciliation of orders to include labs and diagnostics per resident practitioner orders. Initiated: 12/21/2023 Completion: 12/23/2023<BR/>oStanding orders for admission labs received from medical director with follow up orders on continuation of labs to be determined by practitioner according to findings and evaluation of individual resident needs. Initiated: 12/22/2023 Completed: 12/22/2023<BR/>oNew admission order assessment and completion audits will be completed 3 times a week for 4 weeks and then weekly from thereafter by DON/ADON/Designee. Initiated: 12/22/2023 Completion: 12/23/2023<BR/>oImmediate action to notify physician and receive new orders on residents identified through audit findings for potential adverse notations in diagnostics with appropriate documentation at such time of notification. Initiated: 12/22/2023 Completion: 12/23/2023<BR/>oStaff that are on leave from the facility will be re-educated by DON/ADON/Designee on documentation in the clinical record of new admission verification and reconciliation of orders to include labs and diagnostics per resident practitioner orders before starting their next shift. This facility does not employ the use of agency personnel. Initiated: 12/22/2023 Completion: 12/23/2023.<BR/>oFacility will initiate weekly admission meeting with interdisciplinary team to review previous week admissions to include physician and/or designee for re-verification of orders. Initiated: 12/22/2023 Completion 12/23/2023<BR/>oAudit sheets for admissions to be reviewed by DON/ADON/Designee for completion at least weekly during facility admission meeting. Initiated: 12/22/2023 Completed: 12/23/2023<BR/>oThe policy and procedure already in place for orders and physician services was reviewed by Regional [NAME] President of Operations and Regional Nurse Consultant with no changes to policies to be implemented. Continue to follow policy on physician services as previously implemented, to include any new procedures as ordered. Initiated: 12/22/2023 Completed: 12/23/2023 <BR/>oFacility Administrator will ensure implementation and completion of interventions through individual communication with team members and medical practitioners, as well as weekly CAR meetings and QAPI meetings as indicated below. Initiated: 12/22/2023 Completed: 12/23/2023<BR/>The QAPI Team, led by the Administrator, will meet weekly for 3 weeks to discuss that coordination and completion of all education, assessments, and interventions are utilized to ensure that appropriate physician services, including new admission orders, are followed and maintained per current facility policy on physician services. The Medical Director was notified of Immediate Jeopardy on 12/22/2023 and will be part of the QAPI intervention meetings. Procedures on new admissions and physician services to be added to the QAPI monthly for 3 months following the initial 3 weeks to monitor program progress.<BR/>The state surveyor confirmed the facility's Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy that included:<BR/>Interview with the Administrator on 12/23/23 at 12:45 PM revealed he was responsible for ensuring all POR interventions were implemented. The Administrator said he implemented a meeting with all IDT every morning Monday-Friday (initiated 12/22/23) to discuss corrective action plan coordination, completion, and follow-up for 3 weeks. The Administrator said he would review all in-services and along with IDT, would review all new admission orders for maintenance of the facility's physician services policy. The Administrator said the IDT, including himself, would discuss and review POR/POC status monthly for the next 3 months.<BR/>Interview with the DON on 12/23/23 at 12:59 PM revealed she acknowledged she received training and provided her nursing staff training on: Standing Laboratory Orders (new procedure implemented after IJ) to include: CBC, CMP, HA1C, TSH, Lipid Panel (blood test to measure amount of cholesterol and triglycerides in your blood), Pre-Albumin (a protein that's made by the liver) for all new admissions to get a baseline of each resident. The DON said she also provided in-servicing for her licensed staff regarding admission documentation to include medication reconciliation, known history, diagnostics, and assessments. The DON said she informed/reminded her licensed staff on immediate notification of physician upon new admissions, reviewing of medications, orders, and history of diagnoses. The DON said she and her ADON conducted 100% of chart reviews which included 49 residents with a history of or current diagnosis of diabetes. The DON said 9 residents did not have a HA1C, or diabetic blood glucose monitoring ordered so their physicians were called and lab and monitoring orders were received. The DON added that 9 residents receiving hospice services did not have any labs ordered which the physicians were contacted, and orders remained the same. The DON said she implemented a Monitoring Tool - admission Audit Form which she and the ADON were responsible for conducting audits of every new admission to ensure: consent for treatment were received, Notify Physician of Admission, Diagnosis, Meds, Diagnostics, Lab Standing Orders initiated, Documentation of medications, dx, diagnostics .The DON stated the audits would continue for at least 3 months and results would be reviewed by IDT monthly in QAPI meetings.<BR/>Interview with the following staff on 12/23/23 revealed they were able to verbalize the procedure for reporting a change in resident condition which included to immediately notify the nurse of any change in condition:<BR/>1:05 PM - CNA E (6A-2P shift)<BR/>1:15 PM - CNA F (6A-2P shift)<BR/>1:27 PM - CNA G (6A-2P shift)<BR/>1:35 PM - CNA H (6A-2P shift)<BR/>2:00 PM - CNA I (2P-10P shift)<BR/>2:13 PM - CNA J (2P-10P shift)<BR/>2:22 PM - CNA K (2P-10P shift)<BR/>2:28 PM - CNA L (10P-6A shift)<BR/>2:33 PM - CNA M (10P-6A shift<BR/>The following staff (from different shifts) were interviewed on 12/23/23 and revealed all staff were trained on 12/22/23 regarding admission Standing Lab Orders, Physician Services, admission Documentation, Contacting Physician of New Admissions, Diabetic Monitoring. All staff were aware and verbalized the procedures per the facility's policy and procedures.<BR/>2:48 PM - LVN N (7P-7A shift)<BR/>3:20 PM - LVN O (11P-7A shift)<BR/>3:32 PM- LVN P (7P-7A shift)<BR/>3:40 PM -LVN Q (7A-3P shift)<BR/>3:56 PM -RN R (Weekend/PRN shift)<BR/>4:10 PM -LVN S (7A-3P shift)<BR/>4:29 PM -LVN T (7A-3P shift)<BR/>4:40 PM -RN B (7P-7A shift)<BR/>4:57 PM - LVN U (3P-11P shift)<BR/>Record review of the facility in-services provided by the Regional Nurse Consultant reflected the DON received education on 12/22/23 Regarding Physician Services specifically addressing oversight by the DON of monitoring adherence to current policies and procedures for physician services and order reviews to include lab monitoring for specific diagnoses and documentation of physician or practitioner preferences and orders. Understanding of all education verbalized with plan for QAPI utilization and involvement as well as audits in place for monitoring of adherence.<BR/>Record review of the facility in-services provided by the Regional [NAME] President of Operations reflected the Administrator received education on 12/22/23 Regarding the importance of physician services specifically addressing oversight and monitoring adherence to current policies and procedures for physician services and order reviews.<BR/>Record review of the facility in-services provided by the Administrator reflected the Physician D and NP C received education on 12/22/23 Regarding Physician Services, specifically the indication of monitoring of diagnoses to be addressed on a case-by-case basis. Both individuals acknowledged their understanding of monitoring of said diagnosis.<BR/>Interview with NP C on 12/23/23 at 5:14 PM revealed he acknowledged he received training regarding physician orders, specifically ordering lab, monitoring, and treatment for specific diagnoses: Diabetes. The NP said moving forward he will ask every nurse who call and/or report to him of any resident if the resident was diabetic and if Hemoglobin A1C and daily monitoring was ordered. <BR/>Record review of the following resident records revealed they had a diagnosis of diabetes mellitus and had a HA1C and an order for diabetic glucose monitoring; Care plans were current and reflected diagnosis:<BR/>-R#3<BR/>-R#6<BR/>-R#7<BR/>-R#8<BR/>The Administrator was informed the Immediate Jeopardy (IJ) was removed on 12/23/23 at 6:30PM. The facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one (R #1) of three residents that were reviewed for infection control and transmission-based precautions policies and practices, in that:<BR/>LVN A did not remove her contaminated gloves after touching multiple surfaces prior to commencement of PEG tube cleansing as well as maintained usage of same contaminated gloves during care of PEG tube. <BR/>These failures could place residents at risk for infection through cross contamination of pathogens. <BR/>The findings included: <BR/>Record review of R #1's Face Sheet undated, admitted [DATE], documented a [AGE] year-old male with the following diagnoses of: COPD (airflow blockage and breathing-related problems), GERD (acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus)), multiple rib fractures, HIV (virus that attacks the body's immune system), Hepatitis C (infection caused by a virus that attacks the liver and leads to inflammation). <BR/>Record review of R #1's MDS was not conducted due to being unavailable due to the resident being admitted [DATE]<BR/>Record review of R #1's Comprehensive Care Plan unavailable due to being admitted [DATE]<BR/>Observation on 04/12/2023 at 9:58AM, LVN A was permitted by Resident #1 to perform PEG site care. LVN A began PEG tube care by performing hand hygiene with Alcohol Based Hand Rub prior to entry into Resident #1's room. LVN A continued by placing supplies on bedside table and applied clean gloves. While at bedside, LVN A proceeded to touch the pause/hold button on kangaroo pump with the same pair of initial gloves to pause the enteral feed. LVN A continued with same pair of initial gloves to lift resident gown up, remove dirty gauze from PEG tube insertion, clamped tube, and disengaged feeding tube from PEG tube. LVN A proceeded to exit Resident #1's room, retrieved clean 4x4 gauze from treatment cart located by doorway, opened drawer with same pair of gloves, and re-entered Resident #1's room. LVN A proceeded to open clean gauze packet with same initial pair of dirty gloves, saturate gauze with normal saline and performed cleansing of PEG tube insertion. LVN A continued by removal of dirty gloves, performed hand hygiene, and without applying new gloves, retrieved another clean gauze with bare hands, removed gauze from package and applied normal saline to clean gauze. LVN A proceeded to take the saturated normal saline gauze and clean insertion area with bare hand.<BR/>During an interview on 04/12/2023 at 10:23AM LVN A stated, she was unknowledgeable on how to perform site care on the newly admitted Resident #1. LVN A continued by stating it is the duty of night shift nurses to perform all resident cleansing care which included PEG tube site care. LVN A continued by stating she only performs administration of medications and feedings, and was nervous throughout procedure which, per LVN A, kept her from following procedure. LVN A proceeded to state that she should have removed dirty gloves and performed hand hygiene after touching the Kangaroo feeding pump, after removal of dirty gauze, and before PEG tube insertion site cleansing care to promote infection control and prevent potential infection contraction. LVN A stated she had a competency check off two weeks prior to 4/12/2023, which contained written material about g-tubes dressing changes but could not recall what the written education entailed. LVN A stated she was given an education sheet about caring for g-tubes to look over by facility, but not how to care for PEG tube. LVN A continued by stating she only does medication administration via PEG tube.<BR/>During an interview on 04/12/2023 at10:46AM, the DON stated that the expectation of the facility is to follow a specific step by step procedure when performing clean dressing change to eliminate chance of infection contraction. The DON continued by stating it is in the nurse's scope of practice to perform PEG tube site care, and nurses must be competent in performing dressing changes. The DON stated that hand hygiene as well as glove changes must be performed prior, during, and after providing gastric tube site care to promote infection control. The DON continued by stating the procedure was: 1. verify orders 2. knock and provide privacy and explain procedure 3. Wash hands 4. set up clean and dirty areas 5. Put on clean gloves 6. Remove soiled dressing and discard 7. Wash hands and put on clean gloves. The DON continued by stating she provides all nursing staff competency check offs upon hire with educational literature prior to gaining independent admittance onto floor. The DON proceeded to state she also conducts infection control in-services monthly, annually, and as needed for skills maintenance. The DON stated that in no way is it ever acceptable to perform any resident care without the use of gloves. <BR/> Record Review of facility's Clean Dressing Change Check off, undated, stated: <BR/>3. Wash hands<BR/>4. set up clean and dirty areas<BR/>5. Put on clean gloves<BR/>6. Remove soiled dressing and discard<BR/>7. Wash hands and put on clean gloves<BR/>8. Clean wound using circular motion starting from the inside working outward<BR/>9. Remove gloves and sanitize hands<BR/>10. Put on clean gloves to continue with the dressing change.<BR/>Record Review of facility's Infection Control-Prevention and Control Program dated 03/2012 stated, <BR/>2) Prevent and control outbreaks and cross contamination using transmission-based precautions in addition to standard precautions. <BR/>1) Policies, procedures, and practices which promote consistent adherence to evident-based infection control practices.<BR/>10) Implementing measures to prevent the transmission of infectious agents and to reduce risks for device and procedure-related infections. <BR/>Record Review of facility's Hand hygiene Policy dated August 2019 stated, use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, so (antimicrobial or non-antimicrobial) and water for the following situations:<BR/>d. Before performing any non-surgical invasive procedures<BR/>e. Before handling an invasive device.<BR/>g. Before handling clean or soiled dressings, gauze pads etc.<BR/>k. After handling used dressings, contaminated equipment etc.<BR/>m. After removing gloves. <BR/>Record Review of the CDC Guidelines regarding Hand Hygiene in Healthcare Settings, dated January 30, 2020, stated Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, contaminated surfaces, and immediately after glove removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one of four residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to ensure CNA A used a gait belt to transfer Resident #1 from the bed to the wheelchair . <BR/>This failure could place residents at risk for falls, injuries and a decline in health.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 03/30/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 with diagnoses which included muscle wasting and atrophy , abnormalities of gait and mobility, lack of coordination, cerebral infarction (stroke) affecting left non-dominant side, and hemiplegia (paralysis of one side of body) and hemiparesis (weakness on one side of the body). <BR/>Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 14, which meant mild cognitive impairment. Resident #1 needed partial to moderate assistance for chair/bed-to-chair transfer. Resident #1 was coded to have neurological deficits of cerebrovascular accident, transient ischemic attack or stroke and hemiplegia or hemiparesis. Resident #1 was coded for having functional limitation of range of motion with both impairment on one side for both upper and lower extremities. <BR/>Record review of Resident #1's care plan problem start date 10/17/2024 edited on 10/28/2024 revealed ADLs Functional Stat/Rehabilitation Resident requires assistance/supervision for ADL and mobility tasks status post CVA with residual left hemiplegia weakness, impaired balance poor endurance activity tolerance. He has reduced ROM to left upper extremity. He attempts ADLs per self, does not use call light or assist at times, is at risk for falls/injuries. Approach (Interventions): Assist resident with shower three times per week per schedule and PRN. Resident Requires physical x1 staff assistance. Encourage resident to participate to the fullest extent possible with each interaction, task. Encourage resident to turn and reposition Q2 hours and PRN while in bed and up in wheelchair. He is independent for bed mobility and turning and repositioning tasks. Encourage/remind resident to use bell to call for assistance. Check on resident at routine intervals and to assess needs, monitor safety issues and offer/provide assistance as needed. He requires extensive assist x1 staff for dressing and clothing changes daily and PRN. Monitor for changes in functional status and independence for ADLs, strength, balance, safety. Make appropriate referrals PRN. Resident is mobile using wheelchair. He requires supervision and set-up assistance for locomotion on and off of the unit. He is only able to walk very short distances with extensive assistance. Resident requires limited x 1 staff assistance for personal hygiene tasks. The care plan had a revision date of 03/30/2025 to include He is independent for transfer tasks. <BR/>Record review of Resident #1's care plan problem start date 10/17/2024 edited on 03/30/2025, revealed potential for falls due to history of falling, history of CVA with resident left hemiplegia, weakness, impaired balance, unsteady gait, impaired cognitive functioning/ safety awareness/ problem solving with dementia (cognitive impairment) neuropathy (nerve deficit), seizure disorder (brain disorder), arthritis (joint disorder), muscle spasm and cardiovascular, psychotropic, and neuroleptic medication administration. Approach (approach) bed in lowest position, call light in easy reach. Remind resident to call for staff assist when needed and answer call promptly. Check on resident at routine intervals to assess needs, monitor safety issues and offer assist as needed. Intervene with resident to minimize or reduce fall occurrences. Provide adequate staff assistance and support for tasks. <BR/>During an observation on 03/29/2025 at 4:42 PM revealed Resident #1 engaged the call light system in his room and began to situate himself on the side of his bed. CNA A entered Resident #1's room and turned off the call light and asked Resident #1 what he needed. Resident #1 stated he needed to utilize the restroom. Upon initial observation there was observable left sided deficit on both Resident #1's left leg and left arm. CNA A proceeded to retrieve Resident #1's wheelchair and secured it on Resident #1's left side. CNA A then proceeded to assist Resident #1 to stand while she simultaneously grabbed Resident #1's left arm and with strength assisted him into the wheelchair. During Resident #1's transfer, Resident #1 pivoted to the wheelchair, and was observed to struggle while he staggered when pivoting from bed to wheelchair. Resident #1 was observed to have compromising balance as he was observed to be struggling while transferring to the wheelchair. Resident #1 was successful in transferring to the wheelchair while CNA A utilized his left arm to assist him. Throughout the transfer CNA A did not utilize a gait belt . <BR/>During an interview on 03/29/2025 at 5:17 PM, CNA A stated she should have used a gait belt to assist Resident #1 to transfer onto his wheelchair. CNA A stated she should not have used Resident #1's left arm to transfer and should have used a gait belt . CNA A stated she was unaware Resident #1 had a left arm deficit however during this bed to wheelchair transfer, Resident #1 struggled to transfer into the wheelchair. CNA A was asked if she utilized a gait belt when transferring Resident #1, CNA A gave no definitive answer. CNA A stated she left her gait belt in her locker and did usually keep it on her person. CNA A stated she did not use a gait belt because she had left the gait belt in her locker. CNA A stated she was supposed to use a gait belt for transfers but did not have access to it as it was in a destination that was not near Resident #1's room. CNA A stated by not using a gait belt Resident #1 could have fallen and was fortunate that he did not fall. CNA A stated going forward she would ensure to always keep a gait belt with her and would utilize the gait belt when she transferred any resident. CNA A stated she could not recall when she was last in-serviced about resident transfers. <BR/>During an interview on 03/29/2025 at 5:43 PM, the DON stated she was made aware of the observation by CNA A. The DON stated CNA A should have used a gait belt when transferring Resident #1 from the bed to the wheelchair as not only a safety precaution but also to maintain Resident #1's wellbeing. The DON stated CNA A may have compromised Resident #1's well-being as Resident #1 may have fallen. The DON stated all CNAs were supposed to keep a gait belt on their persons. The DON stated going forward she would conduct an impromptu in-service regarding gait belt transfers. <BR/>During an interview on 03/30/2025 at 11:47 AM, ADON B stated Resident #1 was independent during transfers. ADON B stated as she pointed out while reviewing Resident #1's care plan, Resident #1 was independent with transfers, however when asked about the edited date of 03/30/2025, ADON B did not give a definitive answer. ADON B while reviewing Resident #1's MDS stated it appeared Resident #1 was coded for needing assistance with transfer from bed to chair. ADON B stated CNA A could have compromised Resident #1's well-being by not using a gait belt as he could have fallen. ADON B stated CNA A should have used a gait belt while transferring Resident #1 given he was coded for hemiparesis (paralysis) and hemiplegia (weakness). ADON B stated she facilitated an impromptu in-service regarding transfer with gait belts on 03/29/2025. <BR/>Record review of CNA A's 03/08/2025 Lifting, Moving, Positioning, and Transferring competency revealed CNA A completed Transfer Resident from Bed to Chair/Wheelchair or Chair/Wheelchair to bed: <BR/>A. <BR/>(1) Person *Use of Gait Belt.<BR/>B. <BR/>(2) Person *Use of Gait Belt. <BR/>Record review of the facility's gait belt usage in-service, dated 03/29/2025, documented CNA A in attendance.<BR/>Record review of the facility's, undated, One Person Transfer with Gait Belt-Check Off reflected ,<BR/> .4. Position and secure belt properly.<BR/>5. Grasp belt on either side of resident, assist resident to move toward edge of bed. <BR/>6. Place feet firmly on floor under resident. <BR/>8. Face resident, squat with knees bent and your waist at resident's waist level, with back straight use leg muscles to lift to standing position.<BR/>Record review of the facility's, undated, Safe Lifting and Movement of Residents reflected, <BR/>1.Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of resident. <BR/>2.Manual lifting of resident shall be eliminated when feasible.<BR/>4.Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. All manual lifting devices will be made available for use, when necessary, in resident transfer with staff training on usage implement. <BR/>5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving resident when necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one (R #1) of three residents that were reviewed for infection control and transmission-based precautions policies and practices, in that:<BR/>LVN A did not remove her contaminated gloves after touching multiple surfaces prior to commencement of PEG tube cleansing as well as maintained usage of same contaminated gloves during care of PEG tube. <BR/>These failures could place residents at risk for infection through cross contamination of pathogens. <BR/>The findings included: <BR/>Record review of R #1's Face Sheet undated, admitted [DATE], documented a [AGE] year-old male with the following diagnoses of: COPD (airflow blockage and breathing-related problems), GERD (acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus)), multiple rib fractures, HIV (virus that attacks the body's immune system), Hepatitis C (infection caused by a virus that attacks the liver and leads to inflammation). <BR/>Record review of R #1's MDS was not conducted due to being unavailable due to the resident being admitted [DATE]<BR/>Record review of R #1's Comprehensive Care Plan unavailable due to being admitted [DATE]<BR/>Observation on 04/12/2023 at 9:58AM, LVN A was permitted by Resident #1 to perform PEG site care. LVN A began PEG tube care by performing hand hygiene with Alcohol Based Hand Rub prior to entry into Resident #1's room. LVN A continued by placing supplies on bedside table and applied clean gloves. While at bedside, LVN A proceeded to touch the pause/hold button on kangaroo pump with the same pair of initial gloves to pause the enteral feed. LVN A continued with same pair of initial gloves to lift resident gown up, remove dirty gauze from PEG tube insertion, clamped tube, and disengaged feeding tube from PEG tube. LVN A proceeded to exit Resident #1's room, retrieved clean 4x4 gauze from treatment cart located by doorway, opened drawer with same pair of gloves, and re-entered Resident #1's room. LVN A proceeded to open clean gauze packet with same initial pair of dirty gloves, saturate gauze with normal saline and performed cleansing of PEG tube insertion. LVN A continued by removal of dirty gloves, performed hand hygiene, and without applying new gloves, retrieved another clean gauze with bare hands, removed gauze from package and applied normal saline to clean gauze. LVN A proceeded to take the saturated normal saline gauze and clean insertion area with bare hand.<BR/>During an interview on 04/12/2023 at 10:23AM LVN A stated, she was unknowledgeable on how to perform site care on the newly admitted Resident #1. LVN A continued by stating it is the duty of night shift nurses to perform all resident cleansing care which included PEG tube site care. LVN A continued by stating she only performs administration of medications and feedings, and was nervous throughout procedure which, per LVN A, kept her from following procedure. LVN A proceeded to state that she should have removed dirty gloves and performed hand hygiene after touching the Kangaroo feeding pump, after removal of dirty gauze, and before PEG tube insertion site cleansing care to promote infection control and prevent potential infection contraction. LVN A stated she had a competency check off two weeks prior to 4/12/2023, which contained written material about g-tubes dressing changes but could not recall what the written education entailed. LVN A stated she was given an education sheet about caring for g-tubes to look over by facility, but not how to care for PEG tube. LVN A continued by stating she only does medication administration via PEG tube.<BR/>During an interview on 04/12/2023 at10:46AM, the DON stated that the expectation of the facility is to follow a specific step by step procedure when performing clean dressing change to eliminate chance of infection contraction. The DON continued by stating it is in the nurse's scope of practice to perform PEG tube site care, and nurses must be competent in performing dressing changes. The DON stated that hand hygiene as well as glove changes must be performed prior, during, and after providing gastric tube site care to promote infection control. The DON continued by stating the procedure was: 1. verify orders 2. knock and provide privacy and explain procedure 3. Wash hands 4. set up clean and dirty areas 5. Put on clean gloves 6. Remove soiled dressing and discard 7. Wash hands and put on clean gloves. The DON continued by stating she provides all nursing staff competency check offs upon hire with educational literature prior to gaining independent admittance onto floor. The DON proceeded to state she also conducts infection control in-services monthly, annually, and as needed for skills maintenance. The DON stated that in no way is it ever acceptable to perform any resident care without the use of gloves. <BR/> Record Review of facility's Clean Dressing Change Check off, undated, stated: <BR/>3. Wash hands<BR/>4. set up clean and dirty areas<BR/>5. Put on clean gloves<BR/>6. Remove soiled dressing and discard<BR/>7. Wash hands and put on clean gloves<BR/>8. Clean wound using circular motion starting from the inside working outward<BR/>9. Remove gloves and sanitize hands<BR/>10. Put on clean gloves to continue with the dressing change.<BR/>Record Review of facility's Infection Control-Prevention and Control Program dated 03/2012 stated, <BR/>2) Prevent and control outbreaks and cross contamination using transmission-based precautions in addition to standard precautions. <BR/>1) Policies, procedures, and practices which promote consistent adherence to evident-based infection control practices.<BR/>10) Implementing measures to prevent the transmission of infectious agents and to reduce risks for device and procedure-related infections. <BR/>Record Review of facility's Hand hygiene Policy dated August 2019 stated, use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, so (antimicrobial or non-antimicrobial) and water for the following situations:<BR/>d. Before performing any non-surgical invasive procedures<BR/>e. Before handling an invasive device.<BR/>g. Before handling clean or soiled dressings, gauze pads etc.<BR/>k. After handling used dressings, contaminated equipment etc.<BR/>m. After removing gloves. <BR/>Record Review of the CDC Guidelines regarding Hand Hygiene in Healthcare Settings, dated January 30, 2020, stated Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, contaminated surfaces, and immediately after glove removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy during care, for one (Residents #1) of five Residents reviewed for privacy issues, in that:<BR/>1. CNA A and B did not provide complete privacy when providing Resident #1 with perineal catheter care.<BR/>This failure could place residents at risk for embarrassment, poor self-esteem, and unmet needs.<BR/>Findings included: <BR/>Record review of Resident #1's Face Sheet dated 01/17/2023 documented a [AGE] year-old female admitted [DATE], with readmission date 05/26/2022, with the diagnoses of: Hemiplegia (paralysis of one side of the body), Neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), Atrophy (muscle wasting), Generalized muscle weakness, Hypertensive (high blood pressure). <BR/>Record review of Resident #1's Annual Minimum Data Set, dated [DATE] revealed a BIMS score of 9 -moderately impaired cognitive skills for decision making. Resident #1 required extensive assistance with two-person physical assist for bed mobility, transfers, dressing, and personal hygiene. Resident #1 was always incontinent of bladder and bowel. Resident #1 pressure ulcer/injury was noted upon admission and maintains risk of ulcer progression. <BR/>Record review of Resident #1's comprehensive care plan dated 06/04/2021 documented:<BR/>[Resident #1] requires assistance for all ADL and mobility tasks due to weakness impaired balance, poor endurance/activities tolerance. [Resident #1] often refuses to be out of bed. Potential for unavoidable decline with progressive weakness second to [Resident #1] preferences. <BR/>Observation of Resident #1 on 03/06/2023 at 10:19 AM revealed [Resident #1] lying in bed, on their back, with head of bed elevated. Resident #1 was unable to correctly state their name, location, and was not aware of the date/day. Attempted further interview Resident #1 and was unsuccessful.<BR/>Observation of Resident #1 on 03/06/2023 at 10:31 AM, revealed Resident #1 receiving perineal catheter care. Resident #1 was exposed while provided personal care with their door remaining open, as well as curtain open. Resident incontinent care visible to staff and visitors walking by, with a clear view of their perineal area. <BR/>In an interview with CNA B on 03/06/2023 at10:42 AM, CNA B stated, the door is not open, it is ajar, but yes the door needs to be closed for privacy and for the resident's dignity. <BR/>Interview with CNA A on 03/06/2023 at 10:50 AM, CNA A during inquiry about the doors position stated, it was open. Inquired if the door was to be open during resident care, CNA stated No. Asked about the reason about the door remaining closed during care, CNA A stated, the door needed to be closed to give resident right to privacy.<BR/>Interviewed DON on 03/06/2023 at 3:39PM, Inquired about measures taken to promote resident's right to privacy during care, DON stated closing the door and curtains. DON provided Perineal Care Checkoff used by facility as their competency form states, Provide for privacy (closed door, pulled curtain, closed blinds). DON stated the vitality to promote resident's right to dignity and privacy. <BR/>Record review of the facility's policy dated 11/28/2017 Titled: Resident Rights, documented A facility must treat each resident with respect and dignity and care for each resident in a manner and in environment that promotes maintenance or enhancement of his or her quality of life .The facility must protect and promote the rights of the resident. <BR/>Record review of the facility's Perineal Care Checkoff, undated, Titled Perineal Care Checkoff, documented Provide for privacy (closed door, pulled curtain, closed blinds).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one of four residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to ensure CNA A used a gait belt to transfer Resident #1 from the bed to the wheelchair . <BR/>This failure could place residents at risk for falls, injuries and a decline in health.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 03/30/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 with diagnoses which included muscle wasting and atrophy , abnormalities of gait and mobility, lack of coordination, cerebral infarction (stroke) affecting left non-dominant side, and hemiplegia (paralysis of one side of body) and hemiparesis (weakness on one side of the body). <BR/>Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 14, which meant mild cognitive impairment. Resident #1 needed partial to moderate assistance for chair/bed-to-chair transfer. Resident #1 was coded to have neurological deficits of cerebrovascular accident, transient ischemic attack or stroke and hemiplegia or hemiparesis. Resident #1 was coded for having functional limitation of range of motion with both impairment on one side for both upper and lower extremities. <BR/>Record review of Resident #1's care plan problem start date 10/17/2024 edited on 10/28/2024 revealed ADLs Functional Stat/Rehabilitation Resident requires assistance/supervision for ADL and mobility tasks status post CVA with residual left hemiplegia weakness, impaired balance poor endurance activity tolerance. He has reduced ROM to left upper extremity. He attempts ADLs per self, does not use call light or assist at times, is at risk for falls/injuries. Approach (Interventions): Assist resident with shower three times per week per schedule and PRN. Resident Requires physical x1 staff assistance. Encourage resident to participate to the fullest extent possible with each interaction, task. Encourage resident to turn and reposition Q2 hours and PRN while in bed and up in wheelchair. He is independent for bed mobility and turning and repositioning tasks. Encourage/remind resident to use bell to call for assistance. Check on resident at routine intervals and to assess needs, monitor safety issues and offer/provide assistance as needed. He requires extensive assist x1 staff for dressing and clothing changes daily and PRN. Monitor for changes in functional status and independence for ADLs, strength, balance, safety. Make appropriate referrals PRN. Resident is mobile using wheelchair. He requires supervision and set-up assistance for locomotion on and off of the unit. He is only able to walk very short distances with extensive assistance. Resident requires limited x 1 staff assistance for personal hygiene tasks. The care plan had a revision date of 03/30/2025 to include He is independent for transfer tasks. <BR/>Record review of Resident #1's care plan problem start date 10/17/2024 edited on 03/30/2025, revealed potential for falls due to history of falling, history of CVA with resident left hemiplegia, weakness, impaired balance, unsteady gait, impaired cognitive functioning/ safety awareness/ problem solving with dementia (cognitive impairment) neuropathy (nerve deficit), seizure disorder (brain disorder), arthritis (joint disorder), muscle spasm and cardiovascular, psychotropic, and neuroleptic medication administration. Approach (approach) bed in lowest position, call light in easy reach. Remind resident to call for staff assist when needed and answer call promptly. Check on resident at routine intervals to assess needs, monitor safety issues and offer assist as needed. Intervene with resident to minimize or reduce fall occurrences. Provide adequate staff assistance and support for tasks. <BR/>During an observation on 03/29/2025 at 4:42 PM revealed Resident #1 engaged the call light system in his room and began to situate himself on the side of his bed. CNA A entered Resident #1's room and turned off the call light and asked Resident #1 what he needed. Resident #1 stated he needed to utilize the restroom. Upon initial observation there was observable left sided deficit on both Resident #1's left leg and left arm. CNA A proceeded to retrieve Resident #1's wheelchair and secured it on Resident #1's left side. CNA A then proceeded to assist Resident #1 to stand while she simultaneously grabbed Resident #1's left arm and with strength assisted him into the wheelchair. During Resident #1's transfer, Resident #1 pivoted to the wheelchair, and was observed to struggle while he staggered when pivoting from bed to wheelchair. Resident #1 was observed to have compromising balance as he was observed to be struggling while transferring to the wheelchair. Resident #1 was successful in transferring to the wheelchair while CNA A utilized his left arm to assist him. Throughout the transfer CNA A did not utilize a gait belt . <BR/>During an interview on 03/29/2025 at 5:17 PM, CNA A stated she should have used a gait belt to assist Resident #1 to transfer onto his wheelchair. CNA A stated she should not have used Resident #1's left arm to transfer and should have used a gait belt . CNA A stated she was unaware Resident #1 had a left arm deficit however during this bed to wheelchair transfer, Resident #1 struggled to transfer into the wheelchair. CNA A was asked if she utilized a gait belt when transferring Resident #1, CNA A gave no definitive answer. CNA A stated she left her gait belt in her locker and did usually keep it on her person. CNA A stated she did not use a gait belt because she had left the gait belt in her locker. CNA A stated she was supposed to use a gait belt for transfers but did not have access to it as it was in a destination that was not near Resident #1's room. CNA A stated by not using a gait belt Resident #1 could have fallen and was fortunate that he did not fall. CNA A stated going forward she would ensure to always keep a gait belt with her and would utilize the gait belt when she transferred any resident. CNA A stated she could not recall when she was last in-serviced about resident transfers. <BR/>During an interview on 03/29/2025 at 5:43 PM, the DON stated she was made aware of the observation by CNA A. The DON stated CNA A should have used a gait belt when transferring Resident #1 from the bed to the wheelchair as not only a safety precaution but also to maintain Resident #1's wellbeing. The DON stated CNA A may have compromised Resident #1's well-being as Resident #1 may have fallen. The DON stated all CNAs were supposed to keep a gait belt on their persons. The DON stated going forward she would conduct an impromptu in-service regarding gait belt transfers. <BR/>During an interview on 03/30/2025 at 11:47 AM, ADON B stated Resident #1 was independent during transfers. ADON B stated as she pointed out while reviewing Resident #1's care plan, Resident #1 was independent with transfers, however when asked about the edited date of 03/30/2025, ADON B did not give a definitive answer. ADON B while reviewing Resident #1's MDS stated it appeared Resident #1 was coded for needing assistance with transfer from bed to chair. ADON B stated CNA A could have compromised Resident #1's well-being by not using a gait belt as he could have fallen. ADON B stated CNA A should have used a gait belt while transferring Resident #1 given he was coded for hemiparesis (paralysis) and hemiplegia (weakness). ADON B stated she facilitated an impromptu in-service regarding transfer with gait belts on 03/29/2025. <BR/>Record review of CNA A's 03/08/2025 Lifting, Moving, Positioning, and Transferring competency revealed CNA A completed Transfer Resident from Bed to Chair/Wheelchair or Chair/Wheelchair to bed: <BR/>A. <BR/>(1) Person *Use of Gait Belt.<BR/>B. <BR/>(2) Person *Use of Gait Belt. <BR/>Record review of the facility's gait belt usage in-service, dated 03/29/2025, documented CNA A in attendance.<BR/>Record review of the facility's, undated, One Person Transfer with Gait Belt-Check Off reflected ,<BR/> .4. Position and secure belt properly.<BR/>5. Grasp belt on either side of resident, assist resident to move toward edge of bed. <BR/>6. Place feet firmly on floor under resident. <BR/>8. Face resident, squat with knees bent and your waist at resident's waist level, with back straight use leg muscles to lift to standing position.<BR/>Record review of the facility's, undated, Safe Lifting and Movement of Residents reflected, <BR/>1.Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of resident. <BR/>2.Manual lifting of resident shall be eliminated when feasible.<BR/>4.Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. All manual lifting devices will be made available for use, when necessary, in resident transfer with staff training on usage implement. <BR/>5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving resident when necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one (R #1) of three residents that were reviewed for infection control and transmission-based precautions policies and practices, in that:<BR/>LVN A did not remove her contaminated gloves after touching multiple surfaces prior to commencement of PEG tube cleansing as well as maintained usage of same contaminated gloves during care of PEG tube. <BR/>These failures could place residents at risk for infection through cross contamination of pathogens. <BR/>The findings included: <BR/>Record review of R #1's Face Sheet undated, admitted [DATE], documented a [AGE] year-old male with the following diagnoses of: COPD (airflow blockage and breathing-related problems), GERD (acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus)), multiple rib fractures, HIV (virus that attacks the body's immune system), Hepatitis C (infection caused by a virus that attacks the liver and leads to inflammation). <BR/>Record review of R #1's MDS was not conducted due to being unavailable due to the resident being admitted [DATE]<BR/>Record review of R #1's Comprehensive Care Plan unavailable due to being admitted [DATE]<BR/>Observation on 04/12/2023 at 9:58AM, LVN A was permitted by Resident #1 to perform PEG site care. LVN A began PEG tube care by performing hand hygiene with Alcohol Based Hand Rub prior to entry into Resident #1's room. LVN A continued by placing supplies on bedside table and applied clean gloves. While at bedside, LVN A proceeded to touch the pause/hold button on kangaroo pump with the same pair of initial gloves to pause the enteral feed. LVN A continued with same pair of initial gloves to lift resident gown up, remove dirty gauze from PEG tube insertion, clamped tube, and disengaged feeding tube from PEG tube. LVN A proceeded to exit Resident #1's room, retrieved clean 4x4 gauze from treatment cart located by doorway, opened drawer with same pair of gloves, and re-entered Resident #1's room. LVN A proceeded to open clean gauze packet with same initial pair of dirty gloves, saturate gauze with normal saline and performed cleansing of PEG tube insertion. LVN A continued by removal of dirty gloves, performed hand hygiene, and without applying new gloves, retrieved another clean gauze with bare hands, removed gauze from package and applied normal saline to clean gauze. LVN A proceeded to take the saturated normal saline gauze and clean insertion area with bare hand.<BR/>During an interview on 04/12/2023 at 10:23AM LVN A stated, she was unknowledgeable on how to perform site care on the newly admitted Resident #1. LVN A continued by stating it is the duty of night shift nurses to perform all resident cleansing care which included PEG tube site care. LVN A continued by stating she only performs administration of medications and feedings, and was nervous throughout procedure which, per LVN A, kept her from following procedure. LVN A proceeded to state that she should have removed dirty gloves and performed hand hygiene after touching the Kangaroo feeding pump, after removal of dirty gauze, and before PEG tube insertion site cleansing care to promote infection control and prevent potential infection contraction. LVN A stated she had a competency check off two weeks prior to 4/12/2023, which contained written material about g-tubes dressing changes but could not recall what the written education entailed. LVN A stated she was given an education sheet about caring for g-tubes to look over by facility, but not how to care for PEG tube. LVN A continued by stating she only does medication administration via PEG tube.<BR/>During an interview on 04/12/2023 at10:46AM, the DON stated that the expectation of the facility is to follow a specific step by step procedure when performing clean dressing change to eliminate chance of infection contraction. The DON continued by stating it is in the nurse's scope of practice to perform PEG tube site care, and nurses must be competent in performing dressing changes. The DON stated that hand hygiene as well as glove changes must be performed prior, during, and after providing gastric tube site care to promote infection control. The DON continued by stating the procedure was: 1. verify orders 2. knock and provide privacy and explain procedure 3. Wash hands 4. set up clean and dirty areas 5. Put on clean gloves 6. Remove soiled dressing and discard 7. Wash hands and put on clean gloves. The DON continued by stating she provides all nursing staff competency check offs upon hire with educational literature prior to gaining independent admittance onto floor. The DON proceeded to state she also conducts infection control in-services monthly, annually, and as needed for skills maintenance. The DON stated that in no way is it ever acceptable to perform any resident care without the use of gloves. <BR/> Record Review of facility's Clean Dressing Change Check off, undated, stated: <BR/>3. Wash hands<BR/>4. set up clean and dirty areas<BR/>5. Put on clean gloves<BR/>6. Remove soiled dressing and discard<BR/>7. Wash hands and put on clean gloves<BR/>8. Clean wound using circular motion starting from the inside working outward<BR/>9. Remove gloves and sanitize hands<BR/>10. Put on clean gloves to continue with the dressing change.<BR/>Record Review of facility's Infection Control-Prevention and Control Program dated 03/2012 stated, <BR/>2) Prevent and control outbreaks and cross contamination using transmission-based precautions in addition to standard precautions. <BR/>1) Policies, procedures, and practices which promote consistent adherence to evident-based infection control practices.<BR/>10) Implementing measures to prevent the transmission of infectious agents and to reduce risks for device and procedure-related infections. <BR/>Record Review of facility's Hand hygiene Policy dated August 2019 stated, use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, so (antimicrobial or non-antimicrobial) and water for the following situations:<BR/>d. Before performing any non-surgical invasive procedures<BR/>e. Before handling an invasive device.<BR/>g. Before handling clean or soiled dressings, gauze pads etc.<BR/>k. After handling used dressings, contaminated equipment etc.<BR/>m. After removing gloves. <BR/>Record Review of the CDC Guidelines regarding Hand Hygiene in Healthcare Settings, dated January 30, 2020, stated Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, contaminated surfaces, and immediately after glove removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy during care, for one (Residents #1) of five Residents reviewed for privacy issues, in that:<BR/>1. CNA A and B did not provide complete privacy when providing Resident #1 with perineal catheter care.<BR/>This failure could place residents at risk for embarrassment, poor self-esteem, and unmet needs.<BR/>Findings included: <BR/>Record review of Resident #1's Face Sheet dated 01/17/2023 documented a [AGE] year-old female admitted [DATE], with readmission date 05/26/2022, with the diagnoses of: Hemiplegia (paralysis of one side of the body), Neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), Atrophy (muscle wasting), Generalized muscle weakness, Hypertensive (high blood pressure). <BR/>Record review of Resident #1's Annual Minimum Data Set, dated [DATE] revealed a BIMS score of 9 -moderately impaired cognitive skills for decision making. Resident #1 required extensive assistance with two-person physical assist for bed mobility, transfers, dressing, and personal hygiene. Resident #1 was always incontinent of bladder and bowel. Resident #1 pressure ulcer/injury was noted upon admission and maintains risk of ulcer progression. <BR/>Record review of Resident #1's comprehensive care plan dated 06/04/2021 documented:<BR/>[Resident #1] requires assistance for all ADL and mobility tasks due to weakness impaired balance, poor endurance/activities tolerance. [Resident #1] often refuses to be out of bed. Potential for unavoidable decline with progressive weakness second to [Resident #1] preferences. <BR/>Observation of Resident #1 on 03/06/2023 at 10:19 AM revealed [Resident #1] lying in bed, on their back, with head of bed elevated. Resident #1 was unable to correctly state their name, location, and was not aware of the date/day. Attempted further interview Resident #1 and was unsuccessful.<BR/>Observation of Resident #1 on 03/06/2023 at 10:31 AM, revealed Resident #1 receiving perineal catheter care. Resident #1 was exposed while provided personal care with their door remaining open, as well as curtain open. Resident incontinent care visible to staff and visitors walking by, with a clear view of their perineal area. <BR/>In an interview with CNA B on 03/06/2023 at10:42 AM, CNA B stated, the door is not open, it is ajar, but yes the door needs to be closed for privacy and for the resident's dignity. <BR/>Interview with CNA A on 03/06/2023 at 10:50 AM, CNA A during inquiry about the doors position stated, it was open. Inquired if the door was to be open during resident care, CNA stated No. Asked about the reason about the door remaining closed during care, CNA A stated, the door needed to be closed to give resident right to privacy.<BR/>Interviewed DON on 03/06/2023 at 3:39PM, Inquired about measures taken to promote resident's right to privacy during care, DON stated closing the door and curtains. DON provided Perineal Care Checkoff used by facility as their competency form states, Provide for privacy (closed door, pulled curtain, closed blinds). DON stated the vitality to promote resident's right to dignity and privacy. <BR/>Record review of the facility's policy dated 11/28/2017 Titled: Resident Rights, documented A facility must treat each resident with respect and dignity and care for each resident in a manner and in environment that promotes maintenance or enhancement of his or her quality of life .The facility must protect and promote the rights of the resident. <BR/>Record review of the facility's Perineal Care Checkoff, undated, Titled Perineal Care Checkoff, documented Provide for privacy (closed door, pulled curtain, closed blinds).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that two residents with an indwelling urinary catheter received appropriate treatment and services for two (R #1 and R #2) of six residents reviewed for urinary catheters, in that:<BR/>1.) CNA A and CNA B did not ensure Resident #1's indwelling catheter tubing, was allowed to flow freely via gravity drainage, as indicated in Resident #1's physician's orders. R #1's catheter bag was incorrectly positioned on top of the resident's bed, which situated above the resident's bladder for an undetermined amount of time, during the whole duration of perineal catheter cleaning. Back-flow of urine was observed during the catheter cleaning. <BR/>2.) CNA C and CNA D did not ensure Resident #2's indwelling catheter tubing, was allowed to flow freely via gravity drainage, as indicated in Resident 2's physician's orders. R 2's catheter bag was incorrectly positioned on top of the resident's bed, which situated above the resident's bladder for an undetermined amount of time, during the whole duration of perineal catheter cleaning, with observable back-flow of urine.<BR/>This deficient practice affected two residents who had indwelling urinary catheters and placed them at risk for infection.<BR/>The findings include:<BR/>1.) Resident #1 <BR/>Record review of Resident #1's Face Sheet dated 01/17/2023 documented a [AGE] year-old female admitted [DATE], with readmission date 05/26/2022, with the diagnoses of: Hemiplegia (paralysis of one side of the body), Neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), Atrophy (muscle wasting), Generalized muscle weakness, Hypertensive (high blood pressure).<BR/>R #65's Nursing admission Data Collection dated 02/07/18 revealed R #65 had an indwelling urinary catheter.<BR/>Record review of Resident #1's Annual Minimum Data Set, dated [DATE] revealed Resident #1 had a brief interview of mental status score of 9 -moderately impaired cognitive skills for decision making. Resident #1 required extensive assistance with two-person physical assist for bed mobility, transfers, dressing, and personal hygiene. Resident #1 was incontinent of bladder and bowel. Resident #1 pressure ulcer/injury was noted upon admission and maintains risk of ulcer progression. <BR/>R #1's Comprehensive Care Plan dated 03/02/2021 documented:<BR/>-Problem: Resident has neuromuscular dysfunction of bladder requiring indwelling foley catheter. [Resident #1] has uninhibited bowel. Potential for UTI. Potential for constipation. Goal: Resident will have neuromuscular dysfunction of bladder effectively managed without complications related to indwelling foley catheter, will be clean/dry/ odor free, will be from signs and symptoms of UTI and will have regular bowel movement patterns through next review. Approach: 18 French/ 5 CC foley catheter to gravity drainage as ordered. Change 18FR 5CC Foley catheter and drainage bag Q Months and PRN; Check on resident at routine intervals to assess needs and offer assist with toileting tasks. Resident is dependent x1 staff for toileting tasks/ incontinent care. Encourage physical activity within limits of physical ability, endurance, activity tolerance. Ensure cloths and linen are clean, and dry; change PRN. Provide incontinent care promptly when found wet or soiled. Foley catheter care Q shift and PRN. Monitor for s/s of UTI. <BR/>Observation and interview of Resident #1 on 03/06/2023 at 10:19AM revealed Resident #1 lying in bed, on their back, with head of bed elevated. Upon observation foley catheter anchored in place, with foley catheter situated below bladder, hanging on fixed metal part of bed. Resident #1 was unable to correctly state their name, location, and was not aware of the date/day. Attempted further interview Resident #1 and was unsuccessful. During perineal catheter care, CNA B, removed foley catheter bag from fixed metal part of bed, and placed it on top of the bed during the entire perineal catheter cleaning. During perineal catheter care there was observed urine back-flow. <BR/>Interview with CNA B on 03/06/2023 at 10:31AM, when asked about the correct positioning of foley catheter bag, CNA B responded they position the foley catheter on the bed all the time to eliminate pulling catheter from insertion placement. Inquired about reasons why foley catheters are positioned on fixed portions of bed, below bladder, CNA B responded with no definitive answer and reiterated they position foley catheter bags on the bed to eliminate pulling catheter from insertion placement. Inquired why resident #1 utilized on anchor on leg, CNA B declined to respond and continued with daily work. <BR/>Interview with CNA A on 03/06/2023 at 10:50 AM Inquired about position of foley catheter placements during perineal care, CNA A stated it was on the bed. When asked for the reason as to why the foley catheter bag is positioned on top of the bed, CNA A did not give definitive answer. Inquired what could happen if the foley catheter bag is positioned above the bladder, CNA A stated, they did not know. Inquired about any education provided about catheter care, CNA A responded upon hire. <BR/>Interview with ADON, which is also the Infection Preventionist on 03/06/2023 at 3:39PM, Inquired about the proper positioning of a foley catheter bag. ADON responded, below the bladder. Inquired about reasons why the foley catheter bag must be positioned below the bladder, ADON responded, to prevent urine back-flow which could cause infections. Inquired about the positioning of foley catheter bags during perineal care, ADON stated again, foley bags are to be positioned below the bladder, and not to be placed on top the bed, due to risk of urine back- flow that would put the resident at risk of infection. <BR/>2.) Resident #2<BR/>Record review of Resident #2's Face Sheet dated 01/17/2023 documented a [AGE] year-old female admitted [DATE], readmitted [DATE] with the following diagnoses: Paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) Epigastric pain (pain in the upper abdomen), Urinary tract infection (An infection in any part of the urinary system, the kidneys, bladder, or urethra), Diabetes mellitus (a group of diseases that affect how the body uses blood sugar), Nausea (the feeling of being sick to your stomach)<BR/>Record review of Resident #2's admission Minimum Data Set, dated [DATE] revealed, Brief Interview Mental Status (BIMS) Summary Score of 13 and is cognitively intact. was totally dependent on staff for bed mobility, transfers, dressing, bathing, toileting, and personal hygiene. Resident #2 was always incontinent of bladder and bowel. Resident #2 was at risk of pressure ulcer/injury development due to paraplegia. Resident #2 did not have any pressure ulcers/injuries upon admission.<BR/>Review of Resident #2's Care Plan revealed Problem start date: 04/11/2016 and was edited on 10/12/2022; revealed Resident has uninhibited bowel and is dependent on indwelling foley catheter due to neuromuscular dysfunction of bladder, retention of urine, obstructive uropathy. Has history of and is at risk for UTIs. Potential for constipation. Recently required antibiotic treatment for bacterial diarrhea. Goal: Resident will be clean/dry/odor free, will be free from complications related to indwelling foley catheter use, will have bladder dysfunction/ obstructive uropathy effectively managed, will be free rom s/s of UTI and will have regular bowel movements through next review. Approach: Check on resident at routine intervals to assess needs and offer assist with toileting tasks. Resident is dependent x1 staff for toileting tasks/ incontinent care/ foley catheter management. Encourage completion of meals and beverages served with meals. Encourage physical activity within limits of physical ability, endurance activity tolerance. Ensure cloths and linen are clean and dry; change PRN. Provide incontinent care promptly when found wet or soiled. Monitor for S/S of UTI. Foley catheter care Q shift and PRN. Change foley catheter 18FR/ 10CC and bag Q month and PRN. <BR/>Observation on 03/06/2023 at 3:03PM; While walking with CNA D through hallway, was notified that Resident #2 had an indwelling catheter. We knocked on Resident #2's door, opened door, were granted permission to observe their perineal catheter care. Upon knocking on door and opening door, direct sight of CNA C performing catheter care, curtains were not being utilized, catheter bag was on bed and stayed throughout catheter care. While observing catheter care, visible back-flow of urine was observed traveling back up the catheter tubing. Foley catheter bag on bed for undetermined amount of time and stayed throughout the remainder of perineal catheter care. <BR/>Interview on 03/06/2023 at 3:19PM with CNA C; Inquired about any in services attended that educated on steps and protocols to perfom perineal care, CNA C stated yes, they have to go through checkoffs. Asked if the position of the foley catheter bag was on top the bed, CNA C responded, yes. Inquired if the foley bag was to remain to be on top the bed, CNA C responded, no. and continued with the reason, to prevent backflow of urine. CNA C continued response with, I shouldn't have put it on the bed. CNA C stated their last in-service regarding catheter catheter care was a couple of months ago maybe.<BR/>Interview on 03/06/2023 AT 3:29 PM with CNA D; Inquired, if catheter bag on top of the bed upon arrival to Resident #2's bedside, which CNA D responded, yes. CNA D stated I don't think so when asked about acceptability of positioning foley bag on top of bed. CNA D, continued response stating, we put the bag on the bed, to keep it from pulling on resident, during changing and cleaning the resident. When questioned about the purpose of hanging catheter bag below bladder, CNA D responded with, I can't remember. <BR/>Interview on 03/06/2023 at 11:46 AM with DON; Inquired about the expectation of catheter care regarding positioning of catheter bag, DON responded, to be below the bladder, and empty. DON stated that staff must be mindful and not compromise and pull catheter. Inquired about the usage of leg anchors, and the utilization to minimize chance of pulling catheter out, which DON stated, To be honest I don't know. DON stated they were just hired in October 2022 and is catching up with competencies. DON stated that drainage bags are to be positioned below the bladder. DON stated, when caring or positioning resident, the expectation is to quickly move bag to perform procedure and place immediately back down. Is it okay to keep the foley catheter bag on the resident's bed during perineal care? Absolutely not. DON stated they do in-services for CNAs and Nurses,<BR/>The facility's Catheter Care, Urinary Policy and Procedure dated revision September 2014, documented The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. <BR/>The facility's Medicare and Medicaid Services Form 672 dated 03/06/23 identified six residents with indwelling catheters or external catheters.

**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 the resident's medical, nursing, mental, and psychosocial needs, for one Residents (R#1) of 14 residents reviewed for care plans.<BR/>The facility did not implement the comprehensive person-centered care plan set forth for R #1. <BR/>These failures place residents at risk for not being provided necessary care and services. <BR/>The findings included:<BR/>Upon review of R#1's Face sheet, dated 12/21/2021, documented a [AGE] year-old female admitted on [DATE] and readmitted [DATE] with the diagnosis of vascular dementia (memory loss), psychotic disorder with hallucinations (where a person hears, sees and, in some cases, feels, smells or tastes things that do not exist outside their mind but can feel very real to the person affected by them) , psychotic disorder with delusions (unshakeable belief in something implausible, bizarre, or obviously untrue), Mood disorder (general emotional state or mood is distorted or inconsistent with the circumstances and interferes with ones' ability to function.), Paranoid schizophrenia (predominantly positive symptoms of schizophrenia, including delusions and hallucinations), Major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Impulse disorder (chronic problems in which people lack the ability to maintain self-control).<BR/>Record Review of R#1's Care Plan dated 12/23/2022 documented:<BR/>Resident has physical behavioral symptoms toward others pulling hair, hitting, kicking, pushing, scratching, abusing others. Incident occurred 12/14/22, resident threw apple sauce container at other resident back. Resident has history of verbal altercations with other residents. Altercation with another resident 12/20/22. Goals, Resident will not harm others secondary to physically abusive behavior. Approach, Provide 1:1(staff/personnel with resident always) sessions with resident, obtain a psych consult/psychosocial therapy, transfer out to Geri psych per MD order. Avoid Power struggles with resident. Convey an attitude of acceptance toward resident Maintain a calm environment and approach to the resident, offer one step verbal directions for tasks. Allow for extra time to process the information. <BR/>Record Review of R#1's Minimum Data Set (MDS) dated [DATE] documented:<BR/>Behaviors not exhibited for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others.<BR/>Brief Interview for Mental Status (BIMS) Summary Score: 99. Enter 99 if the resident was unable to complete the interview. <BR/>During an observation of R #1 on 01/19/2023@1:10 PM: Observed R #1 in their room unattended. According to R#1's care plan, R#1 requires 1:1 (staff/personnel with resident always) session with resident. R #1 in wheelchair with food tray placed in front of resident, on bed side table. R #1 is unable to be seen and monitored from nurse's station.<BR/>During a second observation of R #1 01/19/2023@3:37 PM Observed R #1 in room, in wheelchair, no personnel/nurse/staff with resident. <BR/>During an interview with the Director of Nursing (DON), on 01/19/2023@2:35 PM, revealed that the facility no longer required R#1 to have a 1:1 (staff/personnel with resident always). Inquired for clarification and justification as to why the 1:1 status remained on care plan. DON stated 1:1 should not be on care plan and isn't being practiced. DON stated they are doing q15min (every 15 minutes) rounding but currently the intervention has not been added nor updated to R#1's care plan. Inquired as to why the updates had not been completed on R#1's care plan, was not given a definitive answer. <BR/>During an interview with MDS Coordinator, on 01/19/2023@4:03 PM, revealed that the care plan for R#1 still read, Provide 1:1 session with resident. Inquired for the reasoning as to why Provide 1:1 session with resident was still on the care plan if the facility no longer requires R#1 to have a 1:1? The MDS Coordinator stated that they had not updated the care plan to reflect R#1's care plan change. Per the MDS Coordinator, R#1 was transferred many times throughout December 2022, and did not update the care plan for this reason. Per MDS Coordinator, R #1 was transferred to local hospital from [DATE]-[DATE] Geri Psych,/22 as well as 12/30/2022-01/09/2023. residentUpon return of R#1, on 01/09/2023, care plan hadn'thas not been updated to reflect recent interventional changes of removal of 1:1 session with resident, and insertion of q15min rounding upon return MDS Coordinator stated they didn't want to lie and hadn't updated care plan since resident return on 01/09/2023.<BR/>Record Review of the facility's undated Care Plans, Comprehensive Person-Centered policy states:<BR/>12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of required comprehensive assessment (MDS).<BR/>13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.<BR/>14. The interdisciplinary team must review and update the care plan:<BR/>a. when there has been a significant change in the resident's condition. <BR/>c. when the resident has been readmitted to the facility from a hospital stay;.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation, interview, and record review, the facility failed to ensure the water temperature was safe, clean, comfortable, and homelike for 1 out of 4 halls reviewed for water temperature.<BR/>The facility did not provide water in the 200 hall shower that was between 100 and 110 degrees F<BR/>This failure could place residents that resided on Hall 200 at risk for an unpleasant bathing experience, inadequate hygiene, burns, and a decreased quality of life.<BR/>Findings included: <BR/>During an interview on 05/08/23 at 08:59 AM with Resident #62 of room [ROOM NUMBER] A, he said that his showers are Monday, Wednesday, and Friday and that the water turns hot or cold regardless of controlling temp on the 200-hall shower room. Resident #62 stated it happened often but not all of the time. Resident #62 stated he needed assistance while showering due to left side weakness but can pretty much shower himself. Resident #62 stated when the water temperature fluctuates, it was hard for him to move and change the temperature of the water because of his left sided weakness. <BR/>During an observation on 5/8/2023 at about 1:00 PM the temperature of the water in the 300-hall shower was checked. The thermometer was checked for calibration before the shower water temperatures were taken and found to be accurate. Hot water temperature in the 300-hall shower was at 97 degrees after running for about three minutes. <BR/>During an observation on 5/8/2023 at about 1:15 PM the temperature of the water in the 200-hall shower was checked. The thermometer was checked for calibration before the shower water temperatures were taken and found to be accurate. Hot water temperature in the 200 hall was 119 degrees F after running for about three minutes.<BR/>During an interview and observation with the administrator and the maintenance director on 5/8/2023 at 2:00 PM, the hot water temperatures in the 300-hall shower was found to be 101 degrees after running for about three minutes. Hot water temperature in the 200 hall was found to be 121 degrees F after running for about three minutes. The maintenance director said the temperature should be around 103 degrees. <BR/>During an interview with the DON on 5/10/2023 at 1:00 PM she said the residents were getting bed baths and been giving bed baths since the 8th because the shower water temperature could not be regulated. The DON stated there are a few residents that are not happy and some residents are happy because they are not going in the shower. The DON stated some of the residents do not like showers. She stated she did not ask the residents why they do not like to shower. The DON stated Resident 68 and resident 62were not happy. Resident 68 was very clean. Resident 62 just wanted a shower, he said he does not feel clean when he just had a bed bath. The staff must get water from the sink to bathe the residents. <BR/>During an interview with resident 75 on 5/10/2023 at 1:05 PM he stated he did not want to take a bed bath and would wait for the shower to be fixed. <BR/>During an interview with resident 62 on 5/10/2023 at 1:15 PM he asked when the showers would be fixed. He stated he did not want to take a bed bath. <BR/>During an interview with resident 45 on 5/10/2023 at 1:25 PM he stated he was not happy that the shower was broken. He said he usually took a shower on Tuesday, Thursday, and Saturday, and he hadn't had a shower Tuesday, 5/9/2023, or today. <BR/>During an interview with the ADON on 5/10/2023 at 1:35 PM she said no residents have been burned from taking a shower. She said she was told on 5/8/2023 that the temperature was too high, and no residents complained about the water temperature. She said none of the residents had complained to her that they must take a bed bath. <BR/>During an interview with maintenance director on 5/10/2023 at 11:15 AM he relayed he had worked at the facility four years. He said he had a water temperature log and ran the water for 5 minutes before taking the temperature. He said there were four water heaters in the building, and they all come into one mixing valve. He said there were several water lines in the building and the Kitchen was separate from the rest of the facility. He said the facility suspended all showers and use on 5/08/23 at 2:45 PM . He said at 3:00 he called Smart Plumbing, and they showed up at 3:45 PM. The maintenance director said Smart Plumbing located the issue: the mixing valve was broken. (It had accumulated calcium) and that would explain the variances in temperature as the water ran. He said it was not fixed yet: the valve needed to come from another state and would be fixed in a few days. <BR/>Review of an Estimate from Smart Plumbing dated 5/9/2023 for replacement of mixing valve indicated a price of 3,282.00. The proposal was accepted and signed by the administrator on 5/9/2023. <BR/>During an observation of room [ROOM NUMBER] on 5/10/2023 at 1:10 PM the sink hot water temperature was 102.4 after running for 5 minutes. room [ROOM NUMBER] was about &frac12; way down the hall. <BR/>Review of the facility Water temperature log January 2023 through May 2023, taken on the first of the month. (Temperatures between 100 - 110 for all hallways) <BR/>Review of the facility's policy F323 titled Safety and Supervision of Residents Water Temperature dated (11/28/2017) indicated:<BR/>Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures between 100 and 110 degrees F per state regulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one of four residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to ensure CNA A used a gait belt to transfer Resident #1 from the bed to the wheelchair . <BR/>This failure could place residents at risk for falls, injuries and a decline in health.<BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 03/30/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 with diagnoses which included muscle wasting and atrophy , abnormalities of gait and mobility, lack of coordination, cerebral infarction (stroke) affecting left non-dominant side, and hemiplegia (paralysis of one side of body) and hemiparesis (weakness on one side of the body). <BR/>Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 14, which meant mild cognitive impairment. Resident #1 needed partial to moderate assistance for chair/bed-to-chair transfer. Resident #1 was coded to have neurological deficits of cerebrovascular accident, transient ischemic attack or stroke and hemiplegia or hemiparesis. Resident #1 was coded for having functional limitation of range of motion with both impairment on one side for both upper and lower extremities. <BR/>Record review of Resident #1's care plan problem start date 10/17/2024 edited on 10/28/2024 revealed ADLs Functional Stat/Rehabilitation Resident requires assistance/supervision for ADL and mobility tasks status post CVA with residual left hemiplegia weakness, impaired balance poor endurance activity tolerance. He has reduced ROM to left upper extremity. He attempts ADLs per self, does not use call light or assist at times, is at risk for falls/injuries. Approach (Interventions): Assist resident with shower three times per week per schedule and PRN. Resident Requires physical x1 staff assistance. Encourage resident to participate to the fullest extent possible with each interaction, task. Encourage resident to turn and reposition Q2 hours and PRN while in bed and up in wheelchair. He is independent for bed mobility and turning and repositioning tasks. Encourage/remind resident to use bell to call for assistance. Check on resident at routine intervals and to assess needs, monitor safety issues and offer/provide assistance as needed. He requires extensive assist x1 staff for dressing and clothing changes daily and PRN. Monitor for changes in functional status and independence for ADLs, strength, balance, safety. Make appropriate referrals PRN. Resident is mobile using wheelchair. He requires supervision and set-up assistance for locomotion on and off of the unit. He is only able to walk very short distances with extensive assistance. Resident requires limited x 1 staff assistance for personal hygiene tasks. The care plan had a revision date of 03/30/2025 to include He is independent for transfer tasks. <BR/>Record review of Resident #1's care plan problem start date 10/17/2024 edited on 03/30/2025, revealed potential for falls due to history of falling, history of CVA with resident left hemiplegia, weakness, impaired balance, unsteady gait, impaired cognitive functioning/ safety awareness/ problem solving with dementia (cognitive impairment) neuropathy (nerve deficit), seizure disorder (brain disorder), arthritis (joint disorder), muscle spasm and cardiovascular, psychotropic, and neuroleptic medication administration. Approach (approach) bed in lowest position, call light in easy reach. Remind resident to call for staff assist when needed and answer call promptly. Check on resident at routine intervals to assess needs, monitor safety issues and offer assist as needed. Intervene with resident to minimize or reduce fall occurrences. Provide adequate staff assistance and support for tasks. <BR/>During an observation on 03/29/2025 at 4:42 PM revealed Resident #1 engaged the call light system in his room and began to situate himself on the side of his bed. CNA A entered Resident #1's room and turned off the call light and asked Resident #1 what he needed. Resident #1 stated he needed to utilize the restroom. Upon initial observation there was observable left sided deficit on both Resident #1's left leg and left arm. CNA A proceeded to retrieve Resident #1's wheelchair and secured it on Resident #1's left side. CNA A then proceeded to assist Resident #1 to stand while she simultaneously grabbed Resident #1's left arm and with strength assisted him into the wheelchair. During Resident #1's transfer, Resident #1 pivoted to the wheelchair, and was observed to struggle while he staggered when pivoting from bed to wheelchair. Resident #1 was observed to have compromising balance as he was observed to be struggling while transferring to the wheelchair. Resident #1 was successful in transferring to the wheelchair while CNA A utilized his left arm to assist him. Throughout the transfer CNA A did not utilize a gait belt . <BR/>During an interview on 03/29/2025 at 5:17 PM, CNA A stated she should have used a gait belt to assist Resident #1 to transfer onto his wheelchair. CNA A stated she should not have used Resident #1's left arm to transfer and should have used a gait belt . CNA A stated she was unaware Resident #1 had a left arm deficit however during this bed to wheelchair transfer, Resident #1 struggled to transfer into the wheelchair. CNA A was asked if she utilized a gait belt when transferring Resident #1, CNA A gave no definitive answer. CNA A stated she left her gait belt in her locker and did usually keep it on her person. CNA A stated she did not use a gait belt because she had left the gait belt in her locker. CNA A stated she was supposed to use a gait belt for transfers but did not have access to it as it was in a destination that was not near Resident #1's room. CNA A stated by not using a gait belt Resident #1 could have fallen and was fortunate that he did not fall. CNA A stated going forward she would ensure to always keep a gait belt with her and would utilize the gait belt when she transferred any resident. CNA A stated she could not recall when she was last in-serviced about resident transfers. <BR/>During an interview on 03/29/2025 at 5:43 PM, the DON stated she was made aware of the observation by CNA A. The DON stated CNA A should have used a gait belt when transferring Resident #1 from the bed to the wheelchair as not only a safety precaution but also to maintain Resident #1's wellbeing. The DON stated CNA A may have compromised Resident #1's well-being as Resident #1 may have fallen. The DON stated all CNAs were supposed to keep a gait belt on their persons. The DON stated going forward she would conduct an impromptu in-service regarding gait belt transfers. <BR/>During an interview on 03/30/2025 at 11:47 AM, ADON B stated Resident #1 was independent during transfers. ADON B stated as she pointed out while reviewing Resident #1's care plan, Resident #1 was independent with transfers, however when asked about the edited date of 03/30/2025, ADON B did not give a definitive answer. ADON B while reviewing Resident #1's MDS stated it appeared Resident #1 was coded for needing assistance with transfer from bed to chair. ADON B stated CNA A could have compromised Resident #1's well-being by not using a gait belt as he could have fallen. ADON B stated CNA A should have used a gait belt while transferring Resident #1 given he was coded for hemiparesis (paralysis) and hemiplegia (weakness). ADON B stated she facilitated an impromptu in-service regarding transfer with gait belts on 03/29/2025. <BR/>Record review of CNA A's 03/08/2025 Lifting, Moving, Positioning, and Transferring competency revealed CNA A completed Transfer Resident from Bed to Chair/Wheelchair or Chair/Wheelchair to bed: <BR/>A. <BR/>(1) Person *Use of Gait Belt.<BR/>B. <BR/>(2) Person *Use of Gait Belt. <BR/>Record review of the facility's gait belt usage in-service, dated 03/29/2025, documented CNA A in attendance.<BR/>Record review of the facility's, undated, One Person Transfer with Gait Belt-Check Off reflected ,<BR/> .4. Position and secure belt properly.<BR/>5. Grasp belt on either side of resident, assist resident to move toward edge of bed. <BR/>6. Place feet firmly on floor under resident. <BR/>8. Face resident, squat with knees bent and your waist at resident's waist level, with back straight use leg muscles to lift to standing position.<BR/>Record review of the facility's, undated, Safe Lifting and Movement of Residents reflected, <BR/>1.Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of resident. <BR/>2.Manual lifting of resident shall be eliminated when feasible.<BR/>4.Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. All manual lifting devices will be made available for use, when necessary, in resident transfer with staff training on usage implement. <BR/>5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving resident when necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that two residents with an indwelling urinary catheter received appropriate treatment and services for two (R #1 and R #2) of six residents reviewed for urinary catheters, in that:<BR/>1.) CNA A and CNA B did not ensure Resident #1's indwelling catheter tubing, was allowed to flow freely via gravity drainage, as indicated in Resident #1's physician's orders. R #1's catheter bag was incorrectly positioned on top of the resident's bed, which situated above the resident's bladder for an undetermined amount of time, during the whole duration of perineal catheter cleaning. Back-flow of urine was observed during the catheter cleaning. <BR/>2.) CNA C and CNA D did not ensure Resident #2's indwelling catheter tubing, was allowed to flow freely via gravity drainage, as indicated in Resident 2's physician's orders. R 2's catheter bag was incorrectly positioned on top of the resident's bed, which situated above the resident's bladder for an undetermined amount of time, during the whole duration of perineal catheter cleaning, with observable back-flow of urine.<BR/>This deficient practice affected two residents who had indwelling urinary catheters and placed them at risk for infection.<BR/>The findings include:<BR/>1.) Resident #1 <BR/>Record review of Resident #1's Face Sheet dated 01/17/2023 documented a [AGE] year-old female admitted [DATE], with readmission date 05/26/2022, with the diagnoses of: Hemiplegia (paralysis of one side of the body), Neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), Atrophy (muscle wasting), Generalized muscle weakness, Hypertensive (high blood pressure).<BR/>R #65's Nursing admission Data Collection dated 02/07/18 revealed R #65 had an indwelling urinary catheter.<BR/>Record review of Resident #1's Annual Minimum Data Set, dated [DATE] revealed Resident #1 had a brief interview of mental status score of 9 -moderately impaired cognitive skills for decision making. Resident #1 required extensive assistance with two-person physical assist for bed mobility, transfers, dressing, and personal hygiene. Resident #1 was incontinent of bladder and bowel. Resident #1 pressure ulcer/injury was noted upon admission and maintains risk of ulcer progression. <BR/>R #1's Comprehensive Care Plan dated 03/02/2021 documented:<BR/>-Problem: Resident has neuromuscular dysfunction of bladder requiring indwelling foley catheter. [Resident #1] has uninhibited bowel. Potential for UTI. Potential for constipation. Goal: Resident will have neuromuscular dysfunction of bladder effectively managed without complications related to indwelling foley catheter, will be clean/dry/ odor free, will be from signs and symptoms of UTI and will have regular bowel movement patterns through next review. Approach: 18 French/ 5 CC foley catheter to gravity drainage as ordered. Change 18FR 5CC Foley catheter and drainage bag Q Months and PRN; Check on resident at routine intervals to assess needs and offer assist with toileting tasks. Resident is dependent x1 staff for toileting tasks/ incontinent care. Encourage physical activity within limits of physical ability, endurance, activity tolerance. Ensure cloths and linen are clean, and dry; change PRN. Provide incontinent care promptly when found wet or soiled. Foley catheter care Q shift and PRN. Monitor for s/s of UTI. <BR/>Observation and interview of Resident #1 on 03/06/2023 at 10:19AM revealed Resident #1 lying in bed, on their back, with head of bed elevated. Upon observation foley catheter anchored in place, with foley catheter situated below bladder, hanging on fixed metal part of bed. Resident #1 was unable to correctly state their name, location, and was not aware of the date/day. Attempted further interview Resident #1 and was unsuccessful. During perineal catheter care, CNA B, removed foley catheter bag from fixed metal part of bed, and placed it on top of the bed during the entire perineal catheter cleaning. During perineal catheter care there was observed urine back-flow. <BR/>Interview with CNA B on 03/06/2023 at 10:31AM, when asked about the correct positioning of foley catheter bag, CNA B responded they position the foley catheter on the bed all the time to eliminate pulling catheter from insertion placement. Inquired about reasons why foley catheters are positioned on fixed portions of bed, below bladder, CNA B responded with no definitive answer and reiterated they position foley catheter bags on the bed to eliminate pulling catheter from insertion placement. Inquired why resident #1 utilized on anchor on leg, CNA B declined to respond and continued with daily work. <BR/>Interview with CNA A on 03/06/2023 at 10:50 AM Inquired about position of foley catheter placements during perineal care, CNA A stated it was on the bed. When asked for the reason as to why the foley catheter bag is positioned on top of the bed, CNA A did not give definitive answer. Inquired what could happen if the foley catheter bag is positioned above the bladder, CNA A stated, they did not know. Inquired about any education provided about catheter care, CNA A responded upon hire. <BR/>Interview with ADON, which is also the Infection Preventionist on 03/06/2023 at 3:39PM, Inquired about the proper positioning of a foley catheter bag. ADON responded, below the bladder. Inquired about reasons why the foley catheter bag must be positioned below the bladder, ADON responded, to prevent urine back-flow which could cause infections. Inquired about the positioning of foley catheter bags during perineal care, ADON stated again, foley bags are to be positioned below the bladder, and not to be placed on top the bed, due to risk of urine back- flow that would put the resident at risk of infection. <BR/>2.) Resident #2<BR/>Record review of Resident #2's Face Sheet dated 01/17/2023 documented a [AGE] year-old female admitted [DATE], readmitted [DATE] with the following diagnoses: Paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) Epigastric pain (pain in the upper abdomen), Urinary tract infection (An infection in any part of the urinary system, the kidneys, bladder, or urethra), Diabetes mellitus (a group of diseases that affect how the body uses blood sugar), Nausea (the feeling of being sick to your stomach)<BR/>Record review of Resident #2's admission Minimum Data Set, dated [DATE] revealed, Brief Interview Mental Status (BIMS) Summary Score of 13 and is cognitively intact. was totally dependent on staff for bed mobility, transfers, dressing, bathing, toileting, and personal hygiene. Resident #2 was always incontinent of bladder and bowel. Resident #2 was at risk of pressure ulcer/injury development due to paraplegia. Resident #2 did not have any pressure ulcers/injuries upon admission.<BR/>Review of Resident #2's Care Plan revealed Problem start date: 04/11/2016 and was edited on 10/12/2022; revealed Resident has uninhibited bowel and is dependent on indwelling foley catheter due to neuromuscular dysfunction of bladder, retention of urine, obstructive uropathy. Has history of and is at risk for UTIs. Potential for constipation. Recently required antibiotic treatment for bacterial diarrhea. Goal: Resident will be clean/dry/odor free, will be free from complications related to indwelling foley catheter use, will have bladder dysfunction/ obstructive uropathy effectively managed, will be free rom s/s of UTI and will have regular bowel movements through next review. Approach: Check on resident at routine intervals to assess needs and offer assist with toileting tasks. Resident is dependent x1 staff for toileting tasks/ incontinent care/ foley catheter management. Encourage completion of meals and beverages served with meals. Encourage physical activity within limits of physical ability, endurance activity tolerance. Ensure cloths and linen are clean and dry; change PRN. Provide incontinent care promptly when found wet or soiled. Monitor for S/S of UTI. Foley catheter care Q shift and PRN. Change foley catheter 18FR/ 10CC and bag Q month and PRN. <BR/>Observation on 03/06/2023 at 3:03PM; While walking with CNA D through hallway, was notified that Resident #2 had an indwelling catheter. We knocked on Resident #2's door, opened door, were granted permission to observe their perineal catheter care. Upon knocking on door and opening door, direct sight of CNA C performing catheter care, curtains were not being utilized, catheter bag was on bed and stayed throughout catheter care. While observing catheter care, visible back-flow of urine was observed traveling back up the catheter tubing. Foley catheter bag on bed for undetermined amount of time and stayed throughout the remainder of perineal catheter care. <BR/>Interview on 03/06/2023 at 3:19PM with CNA C; Inquired about any in services attended that educated on steps and protocols to perfom perineal care, CNA C stated yes, they have to go through checkoffs. Asked if the position of the foley catheter bag was on top the bed, CNA C responded, yes. Inquired if the foley bag was to remain to be on top the bed, CNA C responded, no. and continued with the reason, to prevent backflow of urine. CNA C continued response with, I shouldn't have put it on the bed. CNA C stated their last in-service regarding catheter catheter care was a couple of months ago maybe.<BR/>Interview on 03/06/2023 AT 3:29 PM with CNA D; Inquired, if catheter bag on top of the bed upon arrival to Resident #2's bedside, which CNA D responded, yes. CNA D stated I don't think so when asked about acceptability of positioning foley bag on top of bed. CNA D, continued response stating, we put the bag on the bed, to keep it from pulling on resident, during changing and cleaning the resident. When questioned about the purpose of hanging catheter bag below bladder, CNA D responded with, I can't remember. <BR/>Interview on 03/06/2023 at 11:46 AM with DON; Inquired about the expectation of catheter care regarding positioning of catheter bag, DON responded, to be below the bladder, and empty. DON stated that staff must be mindful and not compromise and pull catheter. Inquired about the usage of leg anchors, and the utilization to minimize chance of pulling catheter out, which DON stated, To be honest I don't know. DON stated they were just hired in October 2022 and is catching up with competencies. DON stated that drainage bags are to be positioned below the bladder. DON stated, when caring or positioning resident, the expectation is to quickly move bag to perform procedure and place immediately back down. Is it okay to keep the foley catheter bag on the resident's bed during perineal care? Absolutely not. DON stated they do in-services for CNAs and Nurses,<BR/>The facility's Catheter Care, Urinary Policy and Procedure dated revision September 2014, documented The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. <BR/>The facility's Medicare and Medicaid Services Form 672 dated 03/06/23 identified six residents with indwelling catheters or external catheters.

Based on interviews, and record review, the facility failed to designate a person to serve as director of food and nutrition services who is a certified dietary manager 1 of 1 facility staff in that:<BR/>The facility has been without a certified dietary manager since October 2020.<BR/>This failure could result in the dietary needs of all residents served by the kitchen not being met. <BR/>Findings included:<BR/>Interview with Dietary Manager (DM) on 5/7/2023 at 9:30am revealed, DM does not currently have a Certified Dietary Manger certification (CDM) but is enrolled currently in the program with the University of Florida. DM stated she has about five months left to complete the program. DM stated, she has been working as the Dietary Manager as of 10/12/2020, with this facility and was hired for the position of Dietary Manger. DM was enrolled in the Certified Dietary Manger course upon hire but did not complete it in time and did not receive her certification. <BR/>A Personnel file review on 5/10/2023 revealed that the facility's current Dietary Manager was hired on 10/12/2020. The file contained documentation that the Dietary Manager had enrolled in the CDM (Certified Dietary Manager) program (Nutrition and Foodservice Professional Training-Pathway III B section 1400073741) on 12/11/2020 with the University of Florida but did not complete the course during the allotted timeframe (15 months). Dietary Manger re-enrolled for the CDM program in November of 2022 and is not CDM certified as of date. <BR/>Interview with Dietary Manger (DM) on 05/09/23 at 03:00 PM revealed DM was working every day because the facility had lost five dietary workers and just did not have the time to complete the course. DM did provide me a copy of her Food Manager Permit issued by the local City of County Public Health District. <BR/>Phone Interview with the local County Public Health District on 05/09/23 at 03:12PM revealed the local Public Health District requires all individuals who are food/dietary managers to obtain a Food Manager Permit. The local County Public Health District stated that the Food Manger Permit is very different than the CDM course and does not replace having to go through the CDM course as required by State for Nursing Facilities. The Food Manager Permit is a basic course for food handling and proper hygiene while handling food in a restaurant, or any establishment where the individual is handling and preparing food. <BR/>Interview with Administrator on 05/08/23 at 01:20 PM. Facility does not currently have a certified Dietary Manager, but DM is enrolled in the CDM program as of March of this year (2023). A certified Dietician does come in once a week to oversight kitchen and manage the dietary needs of the residents. Administrator presented this surveyor with a printout from CMS Manual System for F801 dated 9/30/2022 with a highlighted portion 483.60 (a)(2) stating; If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services. Line (E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operation including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. <BR/>Facility Policy on Food and Nutrition Services dated 11/28/2017 states; The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy during care, for one (Residents #1) of five Residents reviewed for privacy issues, in that:<BR/>1. CNA A and B did not provide complete privacy when providing Resident #1 with perineal catheter care.<BR/>This failure could place residents at risk for embarrassment, poor self-esteem, and unmet needs.<BR/>Findings included: <BR/>Record review of Resident #1's Face Sheet dated 01/17/2023 documented a [AGE] year-old female admitted [DATE], with readmission date 05/26/2022, with the diagnoses of: Hemiplegia (paralysis of one side of the body), Neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), Atrophy (muscle wasting), Generalized muscle weakness, Hypertensive (high blood pressure). <BR/>Record review of Resident #1's Annual Minimum Data Set, dated [DATE] revealed a BIMS score of 9 -moderately impaired cognitive skills for decision making. Resident #1 required extensive assistance with two-person physical assist for bed mobility, transfers, dressing, and personal hygiene. Resident #1 was always incontinent of bladder and bowel. Resident #1 pressure ulcer/injury was noted upon admission and maintains risk of ulcer progression. <BR/>Record review of Resident #1's comprehensive care plan dated 06/04/2021 documented:<BR/>[Resident #1] requires assistance for all ADL and mobility tasks due to weakness impaired balance, poor endurance/activities tolerance. [Resident #1] often refuses to be out of bed. Potential for unavoidable decline with progressive weakness second to [Resident #1] preferences. <BR/>Observation of Resident #1 on 03/06/2023 at 10:19 AM revealed [Resident #1] lying in bed, on their back, with head of bed elevated. Resident #1 was unable to correctly state their name, location, and was not aware of the date/day. Attempted further interview Resident #1 and was unsuccessful.<BR/>Observation of Resident #1 on 03/06/2023 at 10:31 AM, revealed Resident #1 receiving perineal catheter care. Resident #1 was exposed while provided personal care with their door remaining open, as well as curtain open. Resident incontinent care visible to staff and visitors walking by, with a clear view of their perineal area. <BR/>In an interview with CNA B on 03/06/2023 at10:42 AM, CNA B stated, the door is not open, it is ajar, but yes the door needs to be closed for privacy and for the resident's dignity. <BR/>Interview with CNA A on 03/06/2023 at 10:50 AM, CNA A during inquiry about the doors position stated, it was open. Inquired if the door was to be open during resident care, CNA stated No. Asked about the reason about the door remaining closed during care, CNA A stated, the door needed to be closed to give resident right to privacy.<BR/>Interviewed DON on 03/06/2023 at 3:39PM, Inquired about measures taken to promote resident's right to privacy during care, DON stated closing the door and curtains. DON provided Perineal Care Checkoff used by facility as their competency form states, Provide for privacy (closed door, pulled curtain, closed blinds). DON stated the vitality to promote resident's right to dignity and privacy. <BR/>Record review of the facility's policy dated 11/28/2017 Titled: Resident Rights, documented A facility must treat each resident with respect and dignity and care for each resident in a manner and in environment that promotes maintenance or enhancement of his or her quality of life .The facility must protect and promote the rights of the resident. <BR/>Record review of the facility's Perineal Care Checkoff, undated, Titled Perineal Care Checkoff, documented Provide for privacy (closed door, pulled curtain, closed blinds).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents were treated in a respectful manner that maintained or enhanced each resident's dignity for 1 (Resident #3) of 6 residents reviewed for dignity.<BR/>The facility failed to treat Resident #3 with dignity and respect during a post-fall assessment by RN D in Resident #3's room on 05/16/25. RN D asked Resident #3 in a stern tone What is wrong with you and Do you want to break something while Resident #3 was still on the floor post-fall. <BR/>This failure could place residents who require assistance from nurses at risk of feeling disrespected. <BR/>Findings included:<BR/>Record review of Resident #3's face sheet dated 06/19/25 revealed a [AGE] year-old female with an initial admission date of 04/18/25 and a discharge date of 06/19/25. Pertinent diagnosis included Depression. <BR/>Record review of Resident #3's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 13 (cognition intact).<BR/>Record review of Resident #3's comprehensive care plan reviewed with no related information.<BR/>During an observation of a surveillance video at 8:30 AM on 06/25/25 from Resident #3's room with a timestamp dated 05/16/25, RN D was observed speaking loudly at Resident #3 while she was on the floor next to her bed after an apparent unwitnessed fall. RN D was heard on the video stating What is wrong with you? and Do you want to break something? while Resident #3 lay on the floor next to her bed. <BR/>In an interview with ADON-A at 5:38 PM on 06/25/25, ADON-A stated it was important to treat a resident with respect and dignity so they feel like the facility can be their home. ADON A stated Resident #3 was not treated with dignity, respect, consideration, or courtesy after her fall on 05/16/25. ADON-A stated it was important to always treat residents with patience and kindness, otherwise they could experience emotional harm. <BR/>In an interview with the ADM at 4:51 PM on 06/26/25, the ADM stated it was important to treat the residents the same way you would want to be treated. The ADM stated the residents have the rights to be treated with dignity and respect. The ADM stated berating a resident after a fall was not treating them with consideration or courtesy. The ADM stated he was not aware of the video until it was brought to his attention by this state surveyor. The ADM stated RN D was fired not long after the incident in the video for her behavior, mannerisms, and lack of tact. The ADM stated residents could experience mental anguish leading to physical symptoms if they were not treated properly. <BR/>In an interview with the DON at 5:06 PM on 06/26/25, the DON stated it was important to always treat residents with respect, dignity, consideration, and courtesy. The DON stated nurses should treat others as they would like to be treated. The DON stated a resident could get depressed and experience mental anguish if they were treated inappropriately by staff. <BR/>Record review of the Facility admission Packet last updated 07/20/15 stated You have the right to be treated with dignity, courtesy, consideration, and respect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one (R #1) of three residents that were reviewed for infection control and transmission-based precautions policies and practices, in that:<BR/>LVN A did not remove her contaminated gloves after touching multiple surfaces prior to commencement of PEG tube cleansing as well as maintained usage of same contaminated gloves during care of PEG tube. <BR/>These failures could place residents at risk for infection through cross contamination of pathogens. <BR/>The findings included: <BR/>Record review of R #1's Face Sheet undated, admitted [DATE], documented a [AGE] year-old male with the following diagnoses of: COPD (airflow blockage and breathing-related problems), GERD (acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus)), multiple rib fractures, HIV (virus that attacks the body's immune system), Hepatitis C (infection caused by a virus that attacks the liver and leads to inflammation). <BR/>Record review of R #1's MDS was not conducted due to being unavailable due to the resident being admitted [DATE]<BR/>Record review of R #1's Comprehensive Care Plan unavailable due to being admitted [DATE]<BR/>Observation on 04/12/2023 at 9:58AM, LVN A was permitted by Resident #1 to perform PEG site care. LVN A began PEG tube care by performing hand hygiene with Alcohol Based Hand Rub prior to entry into Resident #1's room. LVN A continued by placing supplies on bedside table and applied clean gloves. While at bedside, LVN A proceeded to touch the pause/hold button on kangaroo pump with the same pair of initial gloves to pause the enteral feed. LVN A continued with same pair of initial gloves to lift resident gown up, remove dirty gauze from PEG tube insertion, clamped tube, and disengaged feeding tube from PEG tube. LVN A proceeded to exit Resident #1's room, retrieved clean 4x4 gauze from treatment cart located by doorway, opened drawer with same pair of gloves, and re-entered Resident #1's room. LVN A proceeded to open clean gauze packet with same initial pair of dirty gloves, saturate gauze with normal saline and performed cleansing of PEG tube insertion. LVN A continued by removal of dirty gloves, performed hand hygiene, and without applying new gloves, retrieved another clean gauze with bare hands, removed gauze from package and applied normal saline to clean gauze. LVN A proceeded to take the saturated normal saline gauze and clean insertion area with bare hand.<BR/>During an interview on 04/12/2023 at 10:23AM LVN A stated, she was unknowledgeable on how to perform site care on the newly admitted Resident #1. LVN A continued by stating it is the duty of night shift nurses to perform all resident cleansing care which included PEG tube site care. LVN A continued by stating she only performs administration of medications and feedings, and was nervous throughout procedure which, per LVN A, kept her from following procedure. LVN A proceeded to state that she should have removed dirty gloves and performed hand hygiene after touching the Kangaroo feeding pump, after removal of dirty gauze, and before PEG tube insertion site cleansing care to promote infection control and prevent potential infection contraction. LVN A stated she had a competency check off two weeks prior to 4/12/2023, which contained written material about g-tubes dressing changes but could not recall what the written education entailed. LVN A stated she was given an education sheet about caring for g-tubes to look over by facility, but not how to care for PEG tube. LVN A continued by stating she only does medication administration via PEG tube.<BR/>During an interview on 04/12/2023 at10:46AM, the DON stated that the expectation of the facility is to follow a specific step by step procedure when performing clean dressing change to eliminate chance of infection contraction. The DON continued by stating it is in the nurse's scope of practice to perform PEG tube site care, and nurses must be competent in performing dressing changes. The DON stated that hand hygiene as well as glove changes must be performed prior, during, and after providing gastric tube site care to promote infection control. The DON continued by stating the procedure was: 1. verify orders 2. knock and provide privacy and explain procedure 3. Wash hands 4. set up clean and dirty areas 5. Put on clean gloves 6. Remove soiled dressing and discard 7. Wash hands and put on clean gloves. The DON continued by stating she provides all nursing staff competency check offs upon hire with educational literature prior to gaining independent admittance onto floor. The DON proceeded to state she also conducts infection control in-services monthly, annually, and as needed for skills maintenance. The DON stated that in no way is it ever acceptable to perform any resident care without the use of gloves. <BR/> Record Review of facility's Clean Dressing Change Check off, undated, stated: <BR/>3. Wash hands<BR/>4. set up clean and dirty areas<BR/>5. Put on clean gloves<BR/>6. Remove soiled dressing and discard<BR/>7. Wash hands and put on clean gloves<BR/>8. Clean wound using circular motion starting from the inside working outward<BR/>9. Remove gloves and sanitize hands<BR/>10. Put on clean gloves to continue with the dressing change.<BR/>Record Review of facility's Infection Control-Prevention and Control Program dated 03/2012 stated, <BR/>2) Prevent and control outbreaks and cross contamination using transmission-based precautions in addition to standard precautions. <BR/>1) Policies, procedures, and practices which promote consistent adherence to evident-based infection control practices.<BR/>10) Implementing measures to prevent the transmission of infectious agents and to reduce risks for device and procedure-related infections. <BR/>Record Review of facility's Hand hygiene Policy dated August 2019 stated, use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, so (antimicrobial or non-antimicrobial) and water for the following situations:<BR/>d. Before performing any non-surgical invasive procedures<BR/>e. Before handling an invasive device.<BR/>g. Before handling clean or soiled dressings, gauze pads etc.<BR/>k. After handling used dressings, contaminated equipment etc.<BR/>m. After removing gloves. <BR/>Record Review of the CDC Guidelines regarding Hand Hygiene in Healthcare Settings, dated January 30, 2020, stated Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, contaminated surfaces, and immediately after glove removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that two residents with an indwelling urinary catheter received appropriate treatment and services for two (R #1 and R #2) of six residents reviewed for urinary catheters, in that:<BR/>1.) CNA A and CNA B did not ensure Resident #1's indwelling catheter tubing, was allowed to flow freely via gravity drainage, as indicated in Resident #1's physician's orders. R #1's catheter bag was incorrectly positioned on top of the resident's bed, which situated above the resident's bladder for an undetermined amount of time, during the whole duration of perineal catheter cleaning. Back-flow of urine was observed during the catheter cleaning. <BR/>2.) CNA C and CNA D did not ensure Resident #2's indwelling catheter tubing, was allowed to flow freely via gravity drainage, as indicated in Resident 2's physician's orders. R 2's catheter bag was incorrectly positioned on top of the resident's bed, which situated above the resident's bladder for an undetermined amount of time, during the whole duration of perineal catheter cleaning, with observable back-flow of urine.<BR/>This deficient practice affected two residents who had indwelling urinary catheters and placed them at risk for infection.<BR/>The findings include:<BR/>1.) Resident #1 <BR/>Record review of Resident #1's Face Sheet dated 01/17/2023 documented a [AGE] year-old female admitted [DATE], with readmission date 05/26/2022, with the diagnoses of: Hemiplegia (paralysis of one side of the body), Neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), Atrophy (muscle wasting), Generalized muscle weakness, Hypertensive (high blood pressure).<BR/>R #65's Nursing admission Data Collection dated 02/07/18 revealed R #65 had an indwelling urinary catheter.<BR/>Record review of Resident #1's Annual Minimum Data Set, dated [DATE] revealed Resident #1 had a brief interview of mental status score of 9 -moderately impaired cognitive skills for decision making. Resident #1 required extensive assistance with two-person physical assist for bed mobility, transfers, dressing, and personal hygiene. Resident #1 was incontinent of bladder and bowel. Resident #1 pressure ulcer/injury was noted upon admission and maintains risk of ulcer progression. <BR/>R #1's Comprehensive Care Plan dated 03/02/2021 documented:<BR/>-Problem: Resident has neuromuscular dysfunction of bladder requiring indwelling foley catheter. [Resident #1] has uninhibited bowel. Potential for UTI. Potential for constipation. Goal: Resident will have neuromuscular dysfunction of bladder effectively managed without complications related to indwelling foley catheter, will be clean/dry/ odor free, will be from signs and symptoms of UTI and will have regular bowel movement patterns through next review. Approach: 18 French/ 5 CC foley catheter to gravity drainage as ordered. Change 18FR 5CC Foley catheter and drainage bag Q Months and PRN; Check on resident at routine intervals to assess needs and offer assist with toileting tasks. Resident is dependent x1 staff for toileting tasks/ incontinent care. Encourage physical activity within limits of physical ability, endurance, activity tolerance. Ensure cloths and linen are clean, and dry; change PRN. Provide incontinent care promptly when found wet or soiled. Foley catheter care Q shift and PRN. Monitor for s/s of UTI. <BR/>Observation and interview of Resident #1 on 03/06/2023 at 10:19AM revealed Resident #1 lying in bed, on their back, with head of bed elevated. Upon observation foley catheter anchored in place, with foley catheter situated below bladder, hanging on fixed metal part of bed. Resident #1 was unable to correctly state their name, location, and was not aware of the date/day. Attempted further interview Resident #1 and was unsuccessful. During perineal catheter care, CNA B, removed foley catheter bag from fixed metal part of bed, and placed it on top of the bed during the entire perineal catheter cleaning. During perineal catheter care there was observed urine back-flow. <BR/>Interview with CNA B on 03/06/2023 at 10:31AM, when asked about the correct positioning of foley catheter bag, CNA B responded they position the foley catheter on the bed all the time to eliminate pulling catheter from insertion placement. Inquired about reasons why foley catheters are positioned on fixed portions of bed, below bladder, CNA B responded with no definitive answer and reiterated they position foley catheter bags on the bed to eliminate pulling catheter from insertion placement. Inquired why resident #1 utilized on anchor on leg, CNA B declined to respond and continued with daily work. <BR/>Interview with CNA A on 03/06/2023 at 10:50 AM Inquired about position of foley catheter placements during perineal care, CNA A stated it was on the bed. When asked for the reason as to why the foley catheter bag is positioned on top of the bed, CNA A did not give definitive answer. Inquired what could happen if the foley catheter bag is positioned above the bladder, CNA A stated, they did not know. Inquired about any education provided about catheter care, CNA A responded upon hire. <BR/>Interview with ADON, which is also the Infection Preventionist on 03/06/2023 at 3:39PM, Inquired about the proper positioning of a foley catheter bag. ADON responded, below the bladder. Inquired about reasons why the foley catheter bag must be positioned below the bladder, ADON responded, to prevent urine back-flow which could cause infections. Inquired about the positioning of foley catheter bags during perineal care, ADON stated again, foley bags are to be positioned below the bladder, and not to be placed on top the bed, due to risk of urine back- flow that would put the resident at risk of infection. <BR/>2.) Resident #2<BR/>Record review of Resident #2's Face Sheet dated 01/17/2023 documented a [AGE] year-old female admitted [DATE], readmitted [DATE] with the following diagnoses: Paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) Epigastric pain (pain in the upper abdomen), Urinary tract infection (An infection in any part of the urinary system, the kidneys, bladder, or urethra), Diabetes mellitus (a group of diseases that affect how the body uses blood sugar), Nausea (the feeling of being sick to your stomach)<BR/>Record review of Resident #2's admission Minimum Data Set, dated [DATE] revealed, Brief Interview Mental Status (BIMS) Summary Score of 13 and is cognitively intact. was totally dependent on staff for bed mobility, transfers, dressing, bathing, toileting, and personal hygiene. Resident #2 was always incontinent of bladder and bowel. Resident #2 was at risk of pressure ulcer/injury development due to paraplegia. Resident #2 did not have any pressure ulcers/injuries upon admission.<BR/>Review of Resident #2's Care Plan revealed Problem start date: 04/11/2016 and was edited on 10/12/2022; revealed Resident has uninhibited bowel and is dependent on indwelling foley catheter due to neuromuscular dysfunction of bladder, retention of urine, obstructive uropathy. Has history of and is at risk for UTIs. Potential for constipation. Recently required antibiotic treatment for bacterial diarrhea. Goal: Resident will be clean/dry/odor free, will be free from complications related to indwelling foley catheter use, will have bladder dysfunction/ obstructive uropathy effectively managed, will be free rom s/s of UTI and will have regular bowel movements through next review. Approach: Check on resident at routine intervals to assess needs and offer assist with toileting tasks. Resident is dependent x1 staff for toileting tasks/ incontinent care/ foley catheter management. Encourage completion of meals and beverages served with meals. Encourage physical activity within limits of physical ability, endurance activity tolerance. Ensure cloths and linen are clean and dry; change PRN. Provide incontinent care promptly when found wet or soiled. Monitor for S/S of UTI. Foley catheter care Q shift and PRN. Change foley catheter 18FR/ 10CC and bag Q month and PRN. <BR/>Observation on 03/06/2023 at 3:03PM; While walking with CNA D through hallway, was notified that Resident #2 had an indwelling catheter. We knocked on Resident #2's door, opened door, were granted permission to observe their perineal catheter care. Upon knocking on door and opening door, direct sight of CNA C performing catheter care, curtains were not being utilized, catheter bag was on bed and stayed throughout catheter care. While observing catheter care, visible back-flow of urine was observed traveling back up the catheter tubing. Foley catheter bag on bed for undetermined amount of time and stayed throughout the remainder of perineal catheter care. <BR/>Interview on 03/06/2023 at 3:19PM with CNA C; Inquired about any in services attended that educated on steps and protocols to perfom perineal care, CNA C stated yes, they have to go through checkoffs. Asked if the position of the foley catheter bag was on top the bed, CNA C responded, yes. Inquired if the foley bag was to remain to be on top the bed, CNA C responded, no. and continued with the reason, to prevent backflow of urine. CNA C continued response with, I shouldn't have put it on the bed. CNA C stated their last in-service regarding catheter catheter care was a couple of months ago maybe.<BR/>Interview on 03/06/2023 AT 3:29 PM with CNA D; Inquired, if catheter bag on top of the bed upon arrival to Resident #2's bedside, which CNA D responded, yes. CNA D stated I don't think so when asked about acceptability of positioning foley bag on top of bed. CNA D, continued response stating, we put the bag on the bed, to keep it from pulling on resident, during changing and cleaning the resident. When questioned about the purpose of hanging catheter bag below bladder, CNA D responded with, I can't remember. <BR/>Interview on 03/06/2023 at 11:46 AM with DON; Inquired about the expectation of catheter care regarding positioning of catheter bag, DON responded, to be below the bladder, and empty. DON stated that staff must be mindful and not compromise and pull catheter. Inquired about the usage of leg anchors, and the utilization to minimize chance of pulling catheter out, which DON stated, To be honest I don't know. DON stated they were just hired in October 2022 and is catching up with competencies. DON stated that drainage bags are to be positioned below the bladder. DON stated, when caring or positioning resident, the expectation is to quickly move bag to perform procedure and place immediately back down. Is it okay to keep the foley catheter bag on the resident's bed during perineal care? Absolutely not. DON stated they do in-services for CNAs and Nurses,<BR/>The facility's Catheter Care, Urinary Policy and Procedure dated revision September 2014, documented The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. <BR/>The facility's Medicare and Medicaid Services Form 672 dated 03/06/23 identified six residents with indwelling catheters or external catheters.

Based on interview and record review, the facility failed to ensure a qualified professional directed the activities program for the facility for one of 19 (Activity Director) employees reviewed for compliance.<BR/>The current facility Activity Director was not a qualified therapeutic recreation specialist or an activities professional who met state licensure requirements. <BR/>This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interest/preferences of each resident.<BR/>The findings were:<BR/>Record review of the current Activity Director's (AD) employee file revealed the AD had been employed at the facility as a CNA on 04/07/22. There was no documentation in the AD's employee file the AD had an Activity Director's Certification. <BR/>In an interview on 05/10/23 at 8:24 AM, the HR said the Activity Director has not finished her program. She enrolled but had not begun the classes. The HR said the current AD was hired on 04/07/23.<BR/>In an interview on 05/10/23 at 10:02 AM, the current AD said she has not started the approved course to be certified as an Activity Director. The course will begin in July 2023. The program was 4 weeks.<BR/>In an interview on 05/10/23 at 01:01 PM, the Administrator said his Licensed Activity Director quit a month ago and they needed to fill the position. The Administrator said the current AD was a CNA and she had been assisting with activities when the previous AD left, so he offered her the position. The Administrator said the AD was not certified but she has already enrolled in the course and will begin soon.<BR/>Record review of registration order dated 05/01/23 receipt for the AD revealed the AD registered for Activity Director online classes on 05/01/23 at 3:41 PM. The classes to begin on 07/05/23. <BR/>Record review of the facility's, Job Description for Activity Director, revised on 06/01/2011, revealed the following qualifications for the AD position: <BR/>-Incumbents are required to have current, valid licensure (by the state in which practicing) as a qualified therapeutic recreation specialist, or eligibility for certification as a therapeutic recreation specialist recognized accrediting body, or<BR/>-Two years of experience in a social or recreational program with the last five years, one of which was full-time in a patient (resident) activity program in a health care setting, or<BR/>-Qualification as an occupational therapist or occupational therapist assistant or completed a state-approved training course withing six months of employment.<BR/>-Specifically related experience in a long-term care setting.<BR/>-Effective interpersonal and communications skills are required.<BR/>-Functional literacy in English is necessary.

Based on interview and record review, the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 5 of 5 residents (Resident #1, Resident #2, Resident #5, Resident #6, and Resident #7) reviewed for accuracy of records. <BR/>The facility failed to ensure Resident #1, Resident #2, Resident #5, Resident #6, and Resident #7 had documented Quarterly Elopement Assessments since January 2025. <BR/>This failure could place residents at risk for improper care due to inaccurate or incomplete assessments and records. <BR/>Findings included: <BR/>Record review of Quarterly Assessments for sampled residents (Resident #1, Resident #2, Resident #5, Resident #6, and Resident #7) revealed no quarterly assessments had been completed since 01/16/2025. <BR/>In an interview with ADON-A on 06/26/2025 at 10:00 AM she stated the Quarterly Elopement Assessments were typically completed either by the charge nurse or one of the ADONs. She stated the previous MDS nurse would create a calendar for when the Quarterly Elopement Assessments were due on each resident, but the previous MDS nurse was fired. She stated the new MDS nurse started in January 2025 and refused to create the calendar for the nurses because it was not her job. She stated the charge nurses and ADONs did not have time to create this calendar, so it was never created, and the elopement assessments were never completed. ADON-A also stated they were looking to hire a new MDS nurse and had discussed this situation with the quarterly assessment calendar and incomplete elopement assessments with the Administrator, so he was aware of the situation. She stated she realized this puts the residents at risk for elopement if they were not being evaluated and assessed properly. <BR/>In an interview with the MDS nurse on 06/26/2025 at 2:50 PM she stated she started working at the facility in January 2025. She stated she had not created the calendar for the Quarterly Elopement Assessments for the nurses because it was not her job. She stated the nurses on the floor were the ones who did the assessments, so they should be creating their own calendars for the assessments since it was considered a nursing task. She stated the residents were probably not being assessed any longer for elopement since the nurses were not keeping up with when the quarterly assessments were due. <BR/>In an interview with the DON on 06/26/2025 at 2:54 PM she stated the MDS nurse no longer created the Quarterly Elopement Assessment calendar. She stated nursing was supposed to be doing this since it was a nursing task, but she also stated she found out today nursing had not been doing this, so these assessments had not been completed. The DON stated this placed the residents at risk for elopement and inaccurate or inadequate care or treatment. <BR/>Facility policy regarding Quarterly Elopement Assessments or Elopement Assessments requested on 06/26/2025 at 12:05 PM. Per the Administrator, the facility did not have a specific policy regarding Quarterly Elopement Assessments.

Based on interviews and record reviews the facility failed to refer for a PASRR level II screening who had newly evident or possible serious mental disorder, intellectual disability, or a related condition for review upon a significant change in condition for 1 of 3 residents (Resident #37) reviewed for PASRR.<BR/>The facility failed to refer Resident #37 for a PASRR level II review after resident received diagnoses of Anxiety, Bipolar with Severe Psychotic Features, Adjustment Disorder, Suicidal Ideations, Depression, Personality Disorder, Mood Disorder. <BR/>This deficient practice could affect residents who received new mental illness diagnoses by not receiving additional evaluations and needed services.<BR/>The findings included: <BR/>Record review of Resident #37's Face Sheet revealed an admission date of 9/1/23 with a readmission date of 2/9/24. Diagnoses included Insomnia, Anxiety, Bipolar with Severe Psychotic Features, Adjustment Disorder, Suicidal Ideations, Depression, Personality Disorder, Mood Disorder. <BR/>Review of Resident #37's PASRR evaluation dated 9/1/23 revealed the mental illness assessment, Section C, showed no evidence or indicator this individual had a primary diagnosis of dementia, a mental illness or intellectual disability. <BR/>Record review of Resident #37's physician orders revealed the resident was ordered antianxiety and antipsychotic medication and a Senior Psych Care Consult on 02/09/24.<BR/>Interview on 8/27/24 at 03:57 PM with the MDS coordinator, she stated that if resident already had a PASRR screening, then a new one is not completed. MDS coordinator also stated that she only completes the 1012 follow-up form if the individual had a diagnosis of dementia or if there is an evaluation done while resident is admitted to a psychiatric hospital. She stated that she was not aware that the PASRR needed to be completed or updated for change of status or new mental health diagnoses or she would have completed one for him.<BR/>In an interview with the MDS coordinator and the DON on 08/29/24 at 10:15 a.m., the DON stated the nurse managers followed up and updated the orders and care plans, as well as the MDS, DON and the ADON. The DON stated the system to ensure the PASRR was being done and correct was those that were already done, she and the nurse managers would be checking for accuracy, and they were now helping. She said she had not put anything in place in the 3 months she had been employed at the facility. She stated they needed to make an improvement to their system to make sure the data of the patient is accurate. She said the MDS and care plans were used for the aides and nurses to know what the focus on the resident was. She said they needed to improve documentation and focus on the needs of the patients. She said she would be involved in this training. She said she reviewed care plans only when there was a concern, and she had not reviewed all of them. She said she saw a failure in care planning and PASRR, and they needed to improve that. The MDS nurse said all the nurses were responsible for checking for mental illness correctness, and it's a hit or miss because they come from home, hospital, etc.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 1 kitchen reviewed for pests.<BR/>The facility failed to maintain an effective pest control program for gnats flying in the dish room of the kitchen, and there was a foul odor in the dish room. <BR/>The facility failed to ensure there was not a method for rodents to enter the kitchen due to a gaping hole in the baseboard.<BR/>These failures could put residents who consumed food from the kitchen at risk for infection and/or food contamination.<BR/>The findings included:<BR/>Observation and initial tour of the kitchen on 08/25/24 at 11:15 a.m., revealed multiple gnats flying in the dish room and there was a foul odor in the dish room of the kitchen. There was a gaping hole approximately 6x6 inches in the base of a wall, adjacent to the floor under the 3-compartment sink. There were what appeared to be rat droppings along the same baseboard near the hole. <BR/>An interview with the FSM on 08/25/24 at 11:45 a.m., she said she was unaware of the hole in the baseboard by the 3-compartment sink. She said the gnats in the dish room had been an on-going problem. Pest control invoices were requested.<BR/>An interview with the ADM (and the FSM present) on 08/28/24 at 1:04 PM, the ADM revealed he was not aware of the state of the dish room. He said the facility received regular and as needed pest control. He said could not recall the last time the facility had been treated, but the MS should have the receipts.<BR/>An interview with the MS on 08/29/24 at 11:00 a.m., revealed the process of him knowing what needed to be fixed was that they (kitchen staff) contacted him verbally via the FSM and she told him by phone. He said there was a handwritten maintenance log at the nurse's station, but anything related to the kitchen he considered a priority. He said pest control came out whenever they need them and monthly. He said the pest control company had sprayed for gnats before, but would not say how often or when the last treatment was done. The Maintenance log and pest control log/invoices were requested.<BR/>Record review of the facility pest sighting log indicated gnats in the dish room was addressed and initialed by the MS on 01/06/24, 07/13/24 and 07/30/24. Rat droppings were addressed and initialed by the MS on 05/05/24, 07/12/24, and 08/09/24. The Pest control invoices were not received.<BR/>The Maintenance log and pest control log/invoices were not received .<BR/>Record review of the facility kitchen policy titled, Sanitation and Infection Control-insect and rodent control revised 05/2016 revealed It is the policy of this home to prevent and control insect and rodent infestations within the dietary services department to prevent food borne illness. Under Procedure, 2. The home will maintain .properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents. 3. The sanitation of the kitchen will be maintained to prevent food sources, breeding places, etc. for insects or rodents. 8. The pest control company will leave a copy of treatments made in the kitchen at the end of each service call.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 1 kitchen reviewed for pests.<BR/>The facility failed to maintain an effective pest control program for gnats flying in the dish room of the kitchen, and there was a foul odor in the dish room. <BR/>The facility failed to ensure there was not a method for rodents to enter the kitchen due to a gaping hole in the baseboard.<BR/>These failures could put residents who consumed food from the kitchen at risk for infection and/or food contamination.<BR/>The findings included:<BR/>Observation and initial tour of the kitchen on 08/25/24 at 11:15 a.m., revealed multiple gnats flying in the dish room and there was a foul odor in the dish room of the kitchen. There was a gaping hole approximately 6x6 inches in the base of a wall, adjacent to the floor under the 3-compartment sink. There were what appeared to be rat droppings along the same baseboard near the hole. <BR/>An interview with the FSM on 08/25/24 at 11:45 a.m., she said she was unaware of the hole in the baseboard by the 3-compartment sink. She said the gnats in the dish room had been an on-going problem. Pest control invoices were requested.<BR/>An interview with the ADM (and the FSM present) on 08/28/24 at 1:04 PM, the ADM revealed he was not aware of the state of the dish room. He said the facility received regular and as needed pest control. He said could not recall the last time the facility had been treated, but the MS should have the receipts.<BR/>An interview with the MS on 08/29/24 at 11:00 a.m., revealed the process of him knowing what needed to be fixed was that they (kitchen staff) contacted him verbally via the FSM and she told him by phone. He said there was a handwritten maintenance log at the nurse's station, but anything related to the kitchen he considered a priority. He said pest control came out whenever they need them and monthly. He said the pest control company had sprayed for gnats before, but would not say how often or when the last treatment was done. The Maintenance log and pest control log/invoices were requested.<BR/>Record review of the facility pest sighting log indicated gnats in the dish room was addressed and initialed by the MS on 01/06/24, 07/13/24 and 07/30/24. Rat droppings were addressed and initialed by the MS on 05/05/24, 07/12/24, and 08/09/24. The Pest control invoices were not received.<BR/>The Maintenance log and pest control log/invoices were not received .<BR/>Record review of the facility kitchen policy titled, Sanitation and Infection Control-insect and rodent control revised 05/2016 revealed It is the policy of this home to prevent and control insect and rodent infestations within the dietary services department to prevent food borne illness. Under Procedure, 2. The home will maintain .properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents. 3. The sanitation of the kitchen will be maintained to prevent food sources, breeding places, etc. for insects or rodents. 8. The pest control company will leave a copy of treatments made in the kitchen at the end of each service call.

**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 the resident's medical, nursing, mental, and psychosocial needs, for one Residents (R#1) of 14 residents reviewed for care plans.<BR/>The facility did not implement the comprehensive person-centered care plan set forth for R #1. <BR/>These failures place residents at risk for not being provided necessary care and services. <BR/>The findings included:<BR/>Upon review of R#1's Face sheet, dated 12/21/2021, documented a [AGE] year-old female admitted on [DATE] and readmitted [DATE] with the diagnosis of vascular dementia (memory loss), psychotic disorder with hallucinations (where a person hears, sees and, in some cases, feels, smells or tastes things that do not exist outside their mind but can feel very real to the person affected by them) , psychotic disorder with delusions (unshakeable belief in something implausible, bizarre, or obviously untrue), Mood disorder (general emotional state or mood is distorted or inconsistent with the circumstances and interferes with ones' ability to function.), Paranoid schizophrenia (predominantly positive symptoms of schizophrenia, including delusions and hallucinations), Major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Impulse disorder (chronic problems in which people lack the ability to maintain self-control).<BR/>Record Review of R#1's Care Plan dated 12/23/2022 documented:<BR/>Resident has physical behavioral symptoms toward others pulling hair, hitting, kicking, pushing, scratching, abusing others. Incident occurred 12/14/22, resident threw apple sauce container at other resident back. Resident has history of verbal altercations with other residents. Altercation with another resident 12/20/22. Goals, Resident will not harm others secondary to physically abusive behavior. Approach, Provide 1:1(staff/personnel with resident always) sessions with resident, obtain a psych consult/psychosocial therapy, transfer out to Geri psych per MD order. Avoid Power struggles with resident. Convey an attitude of acceptance toward resident Maintain a calm environment and approach to the resident, offer one step verbal directions for tasks. Allow for extra time to process the information. <BR/>Record Review of R#1's Minimum Data Set (MDS) dated [DATE] documented:<BR/>Behaviors not exhibited for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others.<BR/>Brief Interview for Mental Status (BIMS) Summary Score: 99. Enter 99 if the resident was unable to complete the interview. <BR/>During an observation of R #1 on 01/19/2023@1:10 PM: Observed R #1 in their room unattended. According to R#1's care plan, R#1 requires 1:1 (staff/personnel with resident always) session with resident. R #1 in wheelchair with food tray placed in front of resident, on bed side table. R #1 is unable to be seen and monitored from nurse's station.<BR/>During a second observation of R #1 01/19/2023@3:37 PM Observed R #1 in room, in wheelchair, no personnel/nurse/staff with resident. <BR/>During an interview with the Director of Nursing (DON), on 01/19/2023@2:35 PM, revealed that the facility no longer required R#1 to have a 1:1 (staff/personnel with resident always). Inquired for clarification and justification as to why the 1:1 status remained on care plan. DON stated 1:1 should not be on care plan and isn't being practiced. DON stated they are doing q15min (every 15 minutes) rounding but currently the intervention has not been added nor updated to R#1's care plan. Inquired as to why the updates had not been completed on R#1's care plan, was not given a definitive answer. <BR/>During an interview with MDS Coordinator, on 01/19/2023@4:03 PM, revealed that the care plan for R#1 still read, Provide 1:1 session with resident. Inquired for the reasoning as to why Provide 1:1 session with resident was still on the care plan if the facility no longer requires R#1 to have a 1:1? The MDS Coordinator stated that they had not updated the care plan to reflect R#1's care plan change. Per the MDS Coordinator, R#1 was transferred many times throughout December 2022, and did not update the care plan for this reason. Per MDS Coordinator, R #1 was transferred to local hospital from [DATE]-[DATE] Geri Psych,/22 as well as 12/30/2022-01/09/2023. residentUpon return of R#1, on 01/09/2023, care plan hadn'thas not been updated to reflect recent interventional changes of removal of 1:1 session with resident, and insertion of q15min rounding upon return MDS Coordinator stated they didn't want to lie and hadn't updated care plan since resident return on 01/09/2023.<BR/>Record Review of the facility's undated Care Plans, Comprehensive Person-Centered policy states:<BR/>12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of required comprehensive assessment (MDS).<BR/>13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.<BR/>14. The interdisciplinary team must review and update the care plan:<BR/>a. when there has been a significant change in the resident's condition. <BR/>c. when the resident has been readmitted to the facility from a hospital stay;.

Based on interview and record review, the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 5 of 5 residents (Resident #1, Resident #2, Resident #5, Resident #6, and Resident #7) reviewed for accuracy of records. <BR/>The facility failed to ensure Resident #1, Resident #2, Resident #5, Resident #6, and Resident #7 had documented Quarterly Elopement Assessments since January 2025. <BR/>This failure could place residents at risk for improper care due to inaccurate or incomplete assessments and records. <BR/>Findings included: <BR/>Record review of Quarterly Assessments for sampled residents (Resident #1, Resident #2, Resident #5, Resident #6, and Resident #7) revealed no quarterly assessments had been completed since 01/16/2025. <BR/>In an interview with ADON-A on 06/26/2025 at 10:00 AM she stated the Quarterly Elopement Assessments were typically completed either by the charge nurse or one of the ADONs. She stated the previous MDS nurse would create a calendar for when the Quarterly Elopement Assessments were due on each resident, but the previous MDS nurse was fired. She stated the new MDS nurse started in January 2025 and refused to create the calendar for the nurses because it was not her job. She stated the charge nurses and ADONs did not have time to create this calendar, so it was never created, and the elopement assessments were never completed. ADON-A also stated they were looking to hire a new MDS nurse and had discussed this situation with the quarterly assessment calendar and incomplete elopement assessments with the Administrator, so he was aware of the situation. She stated she realized this puts the residents at risk for elopement if they were not being evaluated and assessed properly. <BR/>In an interview with the MDS nurse on 06/26/2025 at 2:50 PM she stated she started working at the facility in January 2025. She stated she had not created the calendar for the Quarterly Elopement Assessments for the nurses because it was not her job. She stated the nurses on the floor were the ones who did the assessments, so they should be creating their own calendars for the assessments since it was considered a nursing task. She stated the residents were probably not being assessed any longer for elopement since the nurses were not keeping up with when the quarterly assessments were due. <BR/>In an interview with the DON on 06/26/2025 at 2:54 PM she stated the MDS nurse no longer created the Quarterly Elopement Assessment calendar. She stated nursing was supposed to be doing this since it was a nursing task, but she also stated she found out today nursing had not been doing this, so these assessments had not been completed. The DON stated this placed the residents at risk for elopement and inaccurate or inadequate care or treatment. <BR/>Facility policy regarding Quarterly Elopement Assessments or Elopement Assessments requested on 06/26/2025 at 12:05 PM. Per the Administrator, the facility did not have a specific policy regarding Quarterly Elopement Assessments.

Based on interviews and record reviews the facility failed to refer for a PASRR level II screening who had newly evident or possible serious mental disorder, intellectual disability, or a related condition for review upon a significant change in condition for 1 of 3 residents (Resident #37) reviewed for PASRR.<BR/>The facility failed to refer Resident #37 for a PASRR level II review after resident received diagnoses of Anxiety, Bipolar with Severe Psychotic Features, Adjustment Disorder, Suicidal Ideations, Depression, Personality Disorder, Mood Disorder. <BR/>This deficient practice could affect residents who received new mental illness diagnoses by not receiving additional evaluations and needed services.<BR/>The findings included: <BR/>Record review of Resident #37's Face Sheet revealed an admission date of 9/1/23 with a readmission date of 2/9/24. Diagnoses included Insomnia, Anxiety, Bipolar with Severe Psychotic Features, Adjustment Disorder, Suicidal Ideations, Depression, Personality Disorder, Mood Disorder. <BR/>Review of Resident #37's PASRR evaluation dated 9/1/23 revealed the mental illness assessment, Section C, showed no evidence or indicator this individual had a primary diagnosis of dementia, a mental illness or intellectual disability. <BR/>Record review of Resident #37's physician orders revealed the resident was ordered antianxiety and antipsychotic medication and a Senior Psych Care Consult on 02/09/24.<BR/>Interview on 8/27/24 at 03:57 PM with the MDS coordinator, she stated that if resident already had a PASRR screening, then a new one is not completed. MDS coordinator also stated that she only completes the 1012 follow-up form if the individual had a diagnosis of dementia or if there is an evaluation done while resident is admitted to a psychiatric hospital. She stated that she was not aware that the PASRR needed to be completed or updated for change of status or new mental health diagnoses or she would have completed one for him.<BR/>In an interview with the MDS coordinator and the DON on 08/29/24 at 10:15 a.m., the DON stated the nurse managers followed up and updated the orders and care plans, as well as the MDS, DON and the ADON. The DON stated the system to ensure the PASRR was being done and correct was those that were already done, she and the nurse managers would be checking for accuracy, and they were now helping. She said she had not put anything in place in the 3 months she had been employed at the facility. She stated they needed to make an improvement to their system to make sure the data of the patient is accurate. She said the MDS and care plans were used for the aides and nurses to know what the focus on the resident was. She said they needed to improve documentation and focus on the needs of the patients. She said she would be involved in this training. She said she reviewed care plans only when there was a concern, and she had not reviewed all of them. She said she saw a failure in care planning and PASRR, and they needed to improve that. The MDS nurse said all the nurses were responsible for checking for mental illness correctness, and it's a hit or miss because they come from home, hospital, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 3 residents personal refrigerators reviewed for food safety (Resident #114) in that: Resident #114's personal refrigerator located in her room was observed to have 2 slices of pie that were not dated or labeled. This failure could place residents at risk for food-borne illnesses.The findings included: Record review of Resident #114's Resident Face Sheet dated 09/17/25 reflected a [AGE] year-old female with a re-admission date of 08/08/25. Resident #114 had diagnoses which included Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (Primary Admission), Essential (primary) hypertension, Schizophrenia, unspecified. Record review of Resident #114's BIMS score quarterly MDS, dated [DATE], revealed a BIMS score of 0, which indicated severe cognitive impairment. An observation on 09/16/25 at 3:40 p.m. of Resident #114's personal refrigerator revealed 2 slices of pie covered in plastic wrap and were not dated or labeled. In an interview on 09/16/25 at 3:42 p.m. the RP stated he had not brought in those pies and he didn't know when they were brought in. In an interview on 09/16/25 at 3:59 p.m. CNA R stated she doesn't check residents' refrigerators, she said the night nurses check them. She said they check them for temperature and dates. CNA R said she didn't check Resident #114's refrigerator and said she'd check it and remove any food not dated. In an interview on 09/16/25 at 3:59 p.m. LVN T said she checks residents' personal refrigerators. She said she checked the temperature but did not check the label or dates of food. She said she checks them every day on her shift. When asked why she didn't check the food dates or labels, she did not answer. Record review of the facility policy, titled Foods Brought by Family/Visitors not dated documented, Policy StatementFood brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 (Resident #47) residents reviewed for respiratory care. The facility failed to ensure Resident #47's oxygen tubing was changed and documented every night shift on Sunday as ordered. This failure could place residents at an increased risk of infection leading to a decline in health.The findings included: Record review of Resident #47's face sheet dated 09/17/25 revealed a [AGE] year-old male with an admission date of 04/05/24. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (COPD) (group of diseases that cause chronic inflammation and narrowing of the airways, making it difficult to breathe), and dependence on supplemental oxygen. Record review of Resident #47's Quarterly MDS assessment dated [DATE] revealed a BIMS of 15 (cognition intact). Further review revealed Resident #47 had not received oxygen within 14 days of the assessment. Record review of Resident #47's comprehensive care plan dated 09/17/25 revealed the problem Resident is at risk for respiratory distress [related to] chronic hypoxia (low oxygen)/COPD. Oxygen dependent initiated on 04/24/24 and revised on 08/06/24. Approaches listed for the problem included:Administer oxygen at 2-3 LPM via NC. Observe oxygen precautions revised on 08/06/24.Provide medications as ordered. Explain medication regimen, actions, and side effects revised on 08/06/24. Record review of Resident #47's order summary revealed an active order for Change updraft tubing, and humidifier bottle once a day on Sun[day] nights initiated on 04/05/24. Further review revealed an active order for Oxygen via NC at 2-5 Lpm to maintain saturation above 90% every shift initiated on 04/05/25. Record review of Resident #47's MAR revealed the last time staff documented Resident #47's oxygen tubing was changed was on 08/24/25. During an observation of Resident #47's room at 10:22 AM on 09/16/25, Resident #47 was resting in bed. Oxygen tubing attached to the oxygen concentrator was dated 4/27. In an interview with RN E at 10:24 AM on 09/16/25, RN E stated Resident #47's oxygen tubing was not dated correctly. RN E stated based on the date written on the oxygen tubing, she was unable to tell the last time it was changed. RN E stated the oxygen tubing was supposed to be changed out weekly to help prevent possible infections. In an interview with the DON at 9:30 AM on 09/18/25, the DON stated the oxygen tubing was supposed to be changed out weekly on Sundays as ordered by the physician. The DON stated the oxygen tubing should be dated whenever it was changed out. The DON stated it was important to change out the oxygen tubing weekly to help prevent infection.Record review of the undated facility policy Oxygen Administration revealed the following policy: .10. Label oxygen tubing with date and initials and change per facility standard.