ALAMEDA OAKS NURSING CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident. Consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in comprehensive assessment for 1 (Resident #70) of 6 residents reviewed for care plans. The facility failed to ensure Resident #70's care plan was implemented by not having the resident's call light within reach on 08/04/25 at 2:10 PM. This failure could place residents at an increased risk of needs going unmet or harm.The findings included:Record review of Resident #70's face sheet dated 08/04/25 revealed a [AGE] year-old male with an admission date of 02/10/21. Resident #70's Pertinent diagnoses included hemiplegia and hemiparesis affecting the right dominant side (complete paralysis to right side of body), aphasia (unable to speak), and dementia (decline in mental ability that interferes with daily life). Record review of Resident #70's quarterly MDS assessment dated [DATE] revealed a BIMS score could not be obtained because the resident was rarely or never understood. Record review of Resident #70's comprehensive care plan revealed the focus [Resident #70] is at risk for falls r/t right-sided hemiplegia and hemiparesis, impaired condition initiated on 02/10/21 and revised on 07/15/25. An Intervention for this focus included Call light within reach initiated on 02/10/21. During an observation on 08/04/25 at 2:10 PM, Resident #70's call light cord and button were coiled up on the floor approximately 3 feet away from the head of the bed on Resident #70's right side. In an interview with Resident #70 on 08/04/25 at 2:10 PM, Resident #70 was unable to answer questions due to his inability to speak. Resident #70 was able to nod his head up and down or side to side to indicate yes or no answers. Resident #70 was asked if he knew how long his call light had been on the floor out of reach and he shrugged his shoulders. Resident #70 was asked if his call light was on the floor out of reach very often and he shook his head side to side. Resident #70 was asked if he was able to communicate with nursing staff in the halls with any means other than the call light and he shook his head side to side. In an interview with CNA B on 08/04/25 at 2:15 PM, CNA B stated residents' call lights were supposed to be clipped to the side of the bed within reach of the resident. CNA B stated he did not know how Resident #70's call light fell on the floor out of reach. CNA B stated it was important for residents to be able to access their call lights so they could notify the nursing staff if they had any problems. In an interview with LVN A on 08/04/25 at 2:20 PM, LVN A stated residents' call lights were supposed to be clipped to the side of the bed within reach of the resident. LVN A stated he was in Resident #70's room sometime after lunch and thought the call light was on Resident #70's bed. LVN A stated it was important for any resident to be able to access their call light so they could contact the nursing staff if they had any problems. LVN A stated it was especially important for Resident #70 to have his call light because he was unable to speak or yell to get attention. LVN A stated if a resident could not access their call light, they could accidentally injure themselves and not be able to get the nurses attention for help. In an interview with the DON on 08/06/25 at 2:50 PM, the DON stated it was important for all residents to have access to their call lights so all their needs could be met by the nursing staff. The DON stated if residents could not reach their call light, then they could have trouble informing the CNA's and nurses on the floor of any problems they had. The DON stated this issue could lead to a resident experiencing harm and then receiving a delayed response by the staff. Record review of the facility's policy Person Centered Care Planning last reviewed 09/05/2024 revealed the following: . The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights. that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -i. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 3 residents (Residents #1, #2, and #3), reviewed for pharmaceutical services, in that: 1. LVN A failed to administer Resident #1's Morphine at his scheduled time on 10/09/25.2. LVN A failed to administer Resident #3's Tramadol at her scheduled time on 10/09/25.3. LVN B administered Resident #2's Tramadol without an order in place.The findings included: 1. Record review of Resident #1's face sheet, dated 10/10/25, revealed the resident was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses that included: other chronic pain (pain that last more than 3 months), peripheral vascular disease (circulation disorder caused by narrowing, blockage or spasms in blood vessels), secondary osteoarthritis (joint degeneration caused by another medical condition), right ankle and foot, hemiplegia (paralysis of one side of body) and hemiparesis (one side weakness) following cerebral infarction (a stroke - death of brain tissue due to lack of blood flow) affecting left dominant side. Record review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 indicating no cognitive impairment. Record review of Resident #1's care plan, with an initiation date of 06/17/24 had a focus that stated Resident #1 was on pain medication therapy related to chronic pain with an initiation date of 03/08/25 with interventions that included to administer analgesic medication as ordered by physician with an initiation date of 03/08/25. Record review of Resident #1's active physician's orders, retrieved on 10/10/25, revealed an order for Morphine Sulfate ER Tablet Extended Release 15mg with a start date of 10/02/25 and an indefinite end date stated it was to be administered two times a day, at 9:00 am and 5:00 pm. Record review of Resident #1's narcotic sheet revealed LVN A had signed that she administered Resident #1's morphine at 7:57 pm on 10/09/25. During an interview with Resident #1 on 10/09/25 at around 8:05 pm, he stated he had just gotten his morphine not too long ago. He stated he did not have any pain between 5:00 pm and the time of interview. Resident #1 stated he had a meeting after dinner, but stated he had not asked to hold his medication. During an interview with LVN A on 10/09/25 at 8:28 pm, she stated Resident #1 had morphine scheduled at 5:00 pm, and stated she administered it at 7:57 pm. LVN A stated she did not know Resident #1 had morphine scheduled at 5:00 pm and stated it was not given on time because she was busy and stated it was her first time doing med pass and she did not know there were so many scheduled narcotics. LVN A also stated Resident #1 had a lot of family in his room and they were having a meeting and she did not want to interrupt. LVN A stated Resident #1 never complained of pain from the time his morphine was scheduled at 5:00 pm to the time it was administered at 7:57 pm. LVN A stated it was important to provide medication at the time it was scheduled so that residents' pain would not get out of control. LVN A stated she had been trained over medication administration and following physician orders when she was hired in September of 2025. LVN A stated the facility policy for medication administration stated medications were due at the time they were ordered. LVN A stated she did not follow the facility policy. LVN A stated not administering medication such as morphine on time could negatively impact residents because they could have pain. During an interview with the DON on 10/10/25 at 6:48 pm, she stated Resident #1 had orders for Morphine 2 times a day, once at 9:00am and 5:00pm. The DON stated Resident #1 received his morphine late on 10/09/25 at 7:57pm. The DON stated LVN A was responsible for administering the medication to Resident #1 at the time it was late and stated it was late because Resident #1 had stuff going on with a family member trying to get power of attorney. The DON stated Resident #1 did not have any negative outcome due to receiving his medication late and did not verbalize any pain to her. The DON stated it was important that residents got their medications for the continuity of care and stated that residents with chronic pain were used to having medication at a certain time, and it was their duty to make sure they were free of pain and their pain was at a certain level to where they were comfortable. The DON stated LVN A had been trained upon hire by the SDC over medication administration and following the scheduled times. The DON stated as per their facility policy medication had to be given in a timely manner, and stated they had a 1-hour window to administer. The DON stated LVN A did her best to follow the policy in this situation, and did not state if she did or did not follow the policy. The DON stated not providing medication at the scheduled time could negatively impact residents because they could start to withdraw or start having behaviors and yelling out, or they could get anxiety. 2. Record review of Resident #3's face sheet, dated 10/10/25, revealed the resident was a [AGE] year old female who initially admitted to the facility on [DATE] with diagnoses that included: pain in left shoulder, type 2 diabetes (high blood sugar) without complications, hemiplegia (paralysis of one side of body) and hemiparesis (one side weakness) following cerebral infarction (a stroke - death of brain tissue due to lack of blood flow) affecting left non-dominant side, vascular dementia (changes in memory, thinking and behavior caused by impaired supply of blood to the brain), severe with agitation and psychotic disturbance. Record review of Resident #3's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #3 had a BIMS score of 04 indicating severe cognitive impairment. Record review of Resident #3's care plan, with an initiation date of 03/25/25 had a focus that stated Resident #3 was on as needed pain medication therapy related to limited mobility, terminal prognosis, and occasional complaint of pain with a created date of 04/02/25 with interventions that included to administer analgesic medication as ordered by physician with an initiation date of 04/02/25. Record review of Resident #3's active physician's orders, retrieved on 10/10/25, revealed an order started on 06/23/25 for tramadol 50mg to be administered 2 times a day at 9:00 am and 5:00 pm. Record review of Resident #3's narcotic sheet revealed LVN A had signed that she administered Resident #3's tramadol at 8:00 pm on 10/09/25. LVN A was attempted to be reached for interview via telephone on 10/10/25 at 4:56 pm, 4:57 pm, 5:16 pm, 5:19 pm and 5:53 pm with no calls successfully answered or returned. During an interview with Resident #3 on 10/10/25 at 5:45 pm, she required re-direction to questions and stated she had no pain yesterday and she was good. Resident #3 was unable to answer any other questions coherently. During an interview with the DON on 10/10/25 at 6:48 pm, she stated she did not know Resident #3's scheduled time to receive her tramadol, but knew it was 2 times a day. The DON stated Resident #3 received her tramadol on 10/09/25 at 8:00 pm. The DON stated she was not in front of Resident #3 from their scheduled time of 5:00 pm until she received her medication at 8:00 pm, and could not tell me if she was in any pain. The DON stated LVN A was responsible for administering the medication to Resident #3 on 10/09/25. The DON stated it was late because they did not have a med aide and LVN A was the one passing the medication. The DON stated Resident #3 did not have any negative outcome due to receiving her medication late. The DON stated it was important that residents got their medications for the continuity of care. She stated that residents with chronic pain were used to having medication at a certain time, and it was their duty to make sure they were free of pain and their pain was at a certain level to where they are comfortable. The DON stated LVN A had been trained upon hire by the SDC over medication administration and following the scheduled times. The DON stated, as per their facility policy, medication had to be given in a timely manner, and they had a 1-hour window to administer. The DON stated LVN A did her best to follow the policy in this situation, but did not state if she did or did not follow the policy. The DON stated not providing medication at the scheduled time could negatively impact residents because they could start to withdraw, start having behaviors and yelling out, or they could get anxiety. 3. Record review of Resident #2's face sheet, dated 10/10/25, revealed the resident was a [AGE] year old female who initially admitted to the facility on [DATE] with diagnoses that included: heart failure (when the heart muscle does not pump blood as well as it should), chronic kidney disease, stage 5 (when kidneys have almost completely stopped filter waste from the blood), orthostatic hypotension (sudden drop in blood pressure when going to a standing position from sitting or lying), type 1 diabetes with neuropathic arthropathy (nerve and joint damage from long term diabetes) Record review of Resident #2's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #2 had a BIMS score of 15 indicating no cognitive impairment. Record review of Resident #2's care plan, with an initiation date of 07/18/24 had a focus that stated Resident #2 was on pain medication therapy with a created date of 04/27/25 with interventions that included to administer analgesic medication as ordered by physician with an initiation date of 04/27/25. Record review of Resident #2's active physician's orders, retrieved on 10/10/25, revealed Resident #2 did not have an order for tramadol on 09/20/25. Resident #2's tramadol order was started on 09/22/25.Record review of Resident #2's narcotic sheet revealed LVN B had signed that he administered Resident #2 with tramadol on 09/20/25 at 2:00 pm. During an interview with LVN B on 10/10/25 at 3:06 pm, LVN B confirmed that he provided Resident #2 with tramadol on 09/20/25. LVN B stated Resident #2 had an order for tramadol for a long time, and she had gone to the hospital, and when she came back, the order was not put back in. LVN B stated Resident #2 asked for a tramadol and he administered it because he thought she still had the order, and after he administered it, he saw she did not have an order for tramadol. LVN B stated before administering medication, he should review the residents' charts to ensure they had orders for the medication. LVN B stated he did not review Resident #2's orders prior to providing her with tramadol. LVN B stated he should have reached out to the physician to request an order, but , he did not get a chance to. LVN B stated he should not have provided Resident #2 with the tramadol if she did not have an order. LVN B stated he had been trained over mediation administration and ensuring residents had orders in place prior to providing medication. LVN B stated he was trained about a month prior by the DON. LVN B stated the facility policy stated they could not administer a medication without an order. LVN B stated he did not follow the facility policy. LVN B stated administering medications without orders in place could cause an accidental overdose. LVN B stated Resident#2 had no negative impacts due to being administered tramadol. During an interview with Resident #2 on 10/10/25 at 4:00 pm, she stated she recalled getting tramadol on 09/20/25 after she requested it from LVN B. Resident #2 stated she did not have any negative side effects by receiving tramadol. During an interview with the DON on 10/10/25 at 5:45 pm, she stated she did not have any directly related in-services or trainings prior to the identified failures. During an interview with the DON on 10/10/25 at 6:48 pm, she stated staff should review residents charts to ensure they had orders for medication and stated the order should match the blister pack and the narcotic sheet. The DON confirmed that LVN B administered tramadol to Resident #2 on 09/20/25 at 2:00pm. The DON stated Resident #2 had gone to the hospital and when she came back the medication list they provided did not include the tramadol. The DON stated Resident #2 got orders for tramadol on 09/22/25. The DON stated she did not know if LVN B was aware the Resident #2 did not have orders for tramadol on 09/20/25 and did not know if he reviewed her orders before administering tramadol. The DON stated she was not aware of LVN B reaching out the physician to request an order for tramadol before providing it but stated LVN B should have done that. The DON stated LVN B should not have administered tramadol without an order. The DON stated when LVN B had orientation in July of 2025 he was trained over medication administration and ensuring residents had orders prior to administering medication. The DON stated, per their facility policy, medication could not be administered without an order. The DON stated LVN B did not follow this policy. The DON stated administrating medication without an order could negatively impact residents because it could be contraindicated. The DON stated Resident #3 did not have any negative outcome due to being administered tramadol on 09/20/25. Record review of an in-service completed 10/09/25 covering Administering of Medications revealed that LVN A had received the training. Record review of the facility's policy titled, Administration of Medications with a reviewed date of 09/09/25 revealed, 1. Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medication in a skilled nursing facility. 2. Staff who are responsible for medication administration will adhere to the 10 rights of Medication administration.e. Right Time and Frequency. Check the order for when it would be given and when was the last time it was given.3. A physician order that includes dosage, route, frequency, duration, and other required consideration including the purpose, diagnoses or indication for use is required for administration of medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview, and record review the facility failed ensure, in accordance with accepted professional standards and practices, to maintain medical records on each resident that was complete and accurately documented for one resident 1 of 7(Resident #00) residents reviewed for medical records. The facility failed to ensure Resident #00's MARS was revised to reflect the accuracy of times the resident took hydrocodone-Acetaminophen Tablet 10-325 milligrams taken as needed for pain control on 04/09/2025.This failure could place residents at risk for not receiving appropriate and timely pain care relief to meet their current needs.The findings included:Record review on 08/06/25 of Resident #00's facesheet documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident # 00 had diagnoses which included diabetes(a group of diseases that result in too much sugar in the blood), necrotizing fasciitis (a serious bacterial infection that destroys the tissue under your skin called fascia) , pressure ulcers(injury to skin and underlying tissue resulting from prolonged pressure on the skin) of heel unstageable, pressure ulcer of sacral region(the anatomical area located at the base of the spine, where the lower back meet the pelvis) stage 4 cutaneous(skin) of limb, skin transplant, encounter of sepsis aftercare.Record review of Resident #00's Minimum Data Set, dated )03/03/25 documented Resident #00 had a BIMS of 14, which indicated the resident's cognitive function was intact. Resident #00 required assist with one-person physical assist for transfers, dressing, toileting, and personal hygiene. Resident #00 had 2 stage 4 pressure ulcers and 2 unstageable pressure ulcers due to coverage of wound bed by slough (dead tissue that accumulates on the surface of a wound, often appearing as a moist, yellow, tan or white layer)or eschar(dead tissue that eventually sloughs off healthy skin after an injury). Resident #00 was receiving insulin injections and IV medications. Record review of resident #00's Care Plan dated 03/22/25 revealed Resident expresses chronic pain related to immobility, limited range of motion to joints, wounds and neuropathy. The Resident is on pain Medication therapy related to wounds and neuropathy. Administer ANALGESIC medications as ordered by physician. Observe for side effects and effectiveness every shift. Record review of Resident's #00's March 2025 Physician's Orders revealed Resident's #00 was prescribed hydrocodone-Acetaminophen tablet 10-325 MG give1 tablet by mouth every 4 hours as needed for pain. The MARS and the Narc Sheet did not match as the Narc sheet showed dates the medication was removed from blister pack. The blister pack did have medication missing and matched the Narc sheet. Record review of the MARs is did not have dates documented on the days the Narc sheet documented medication administered. Record review of the of the narcotic sheet reveal that on 04/09/25 the time of 7:20 pm a pill was documented to be administered to Resident #00 and was signed out by the [NAME] LVN at 7:20 shift ended at 7:00pm.In an interview on 08/06/2025 at 1:30 pm, the Administrator stated the MARs and Narcotic sheet were to match up when compared. The Administrator said the nurse or med aid were to document in these days areas when a narcotic was dispensed to the resident in order to keep accurate account of the amount and the time the resident received their narcotic medication. The Admin stated if the two forms of documentation did not match it could cause an error in dispensing the medication that could put the resident at risk of overdosing and possibly death. In an interview on 08/06/2025 at 2:47 PM with the ADON she stated keeping the narcotic sheet and the resident's MAR accurate kept the resident safe and free of medication mistakes. The ADON stated the nurses were to document in both records as the medication was given to the resident. The ADON stated correctly documented dates and times of resident receiving medication help track drug diversion.The ADON stated she would recheck and match the both records themselves randomly this incident occurred between the time she checked them twice a month In an interview on 08/07/25 the DON stated it was of great importance to maintain accuracy in all aspects of the resident's records but more with the correct documentation of the Narcotic sheet and MAR. The DON stated inconsistencies in the documentation of date and times could keep the resident from getting their medications or getting their medication too early that could cause the resident to have an overdose which could result in hospitalization or death. The DON stated surprise audits of residents records with narcotics were done to prevent such errors from occurring. Record review of the facility policy stated It is the policy of this facility that reports allegations of drug diversion are promptly and thoroughly investigated. Residents have the right to live at ease in a safe environment. Complaints and grievances will be investigated and will be reported as required by law if the investigation reveals any alleged violations and /or misappropriation of resident property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all alleged violations involving the reasonable suspicion of a crime were reported immediately to a law enforcement entity for its political subdivision, within two hours if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, for 1 (Resident #1 ) of 5 residents reviewed for abuse/neglect.<BR/>The facility failed to report to the local law enforcement agency within the allotted time frame of 24 hours on 11/24/2024 around 2 PM when Resident #1 notified LVN A that LVN B allegedly had thrown her into a wheel chair. <BR/>This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse.<BR/>The findings included:<BR/>Record review of Resident #1's admission record dated 04/26/2025 revealed Resident #1 was a [AGE] year-old-female who was admitted on [DATE]. Additionally, Resident #1 was admitted with diagnoses Parkinson's disease (neurological disease that affected movement), and dysphagia (swallowing problem). <BR/>Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 15 which meant she was cognitively aware and needed setup or clean-up assistance for her ADLs. <BR/>Record review of Resident #1's care plan Date Initiated: 06/28/2024, The resident has an ADL self-care performance deficit r/t Confusion, impaired balance touch pad needed/ in place due to unable to press call bell. Observe and report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Praise all efforts at self-care. PT/OT evaluation and treatment as per MD orders .<BR/>Record review of the written statement by LVN A dated 11/24/24 revealed during an interview, Resident #1 stated [LVN B] grabbed her by her arm and leg and threw her into a wheelchair . <BR/>During a phone interview on 04/29/2025 at 2:23 PM the DON stated she had been employed with the facility for roughly 1 week. The DON stated once an allegation of abuse was made, the facility would activate their abuse protocols which would consist of protecting the resident, calling the police if needed, and reporting the allegation to state agencies. The DON stated she would assume any form of abuse would be a criminal offense and if proven true the person could get into a lot of trouble. The DON stated she could not speak to the actions or lack of actions regarding the previous DON, but in her professional opinion if there was an allegation of physical abuse, she would notify local law enforcement. The DON did not definitively state what could transpire if the local law enforcement were not notified of the allegation of abuse. <BR/>During an interview on 04/29/2025 at 2:41PM the Administrator stated when she was made aware of the allegation on 11/24/2024, she enacted the facility abuse protocol. The Administrator stated she treated the allegation as a physical abuse allegation. The Administrator stated she ensured the LVN B who was the alleged perpetrator was removed from the facility and the facility schedule, pending the investigation results. The Administrator stated she notified Health and Human Services Commission of the allegation of physical abuse. The Administrator stated she directed her clinical staff to ensure the safety of Resident #1 and ensured the nursing staff performed a head-to-toe assessment. The Administrator stated Resident #1 stated the allegation of abuse transpired in June 2024 and therefore focused their record review for June 2024 to ensure there were no skin irregularities noted. The Administrator stated Resident #1 notified LVN A on 11/24/24 that LVN B threw her in a geriatric chair roughly in June 2024. The Administrator stated she did not contact the local law enforcement on 11/24/2024 regarding the allegation of physical abuse due to the allegation transpiring in June 2024. The Administrator stated her reason for not calling local law enforcement was due to the allegation timeframe of June 2024. The Administrator stated LVN B was allowed to return to the facility as there was no evidence of any physical abuse. The Administrator stated Resident #1 no longer resided within the facility. The Administrator did not verbalize a definitive answer when asked as to what could potentially happen if local law enforcement were not notified of an allegation of physical abuse. The Administrator stated once the investigation into Resident #1's allegation concluded there was no evidence of the physical abuse. The Administrator verbally clarified, going forward any allegation of abuse would be notified to the proper authorities and state agencies . <BR/>Record review of the facility's Abuse-Protection of Residents policy and procedure issued:10/04/2022; Reviewed: 06/17/2024 documented, Procedure: The following methods to ensure the protection of residents during an investigation may include but are not limited to; 5. Notification of the alleged violation to other agencies or law enforcement authorities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care.<BR/>The facility failed to have a nurse evaluate Resident #1 after an unwitnessed fall. Resident #1 sustained a left distal femoral shaft fracture and a right tibia and fibula fracture.<BR/>The noncompliance was identified as PNC. The PNC began on 08/29/24 and ended on 09/05/24. The facility had corrected the noncompliance before the investigation began.<BR/>The failure could affect residents, 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 #1's face sheet dated 03/04/25 revealed an [AGE] year-old female with an initial admission date of 02/29/24 and a current admission date of 09/16/24. Pertinent diagnoses included acquired absence of left leg above knee, unspecified dementia, and depression.<BR/>Record review of Resident #1's discharge MDS assessment dated [DATE] section C, cognitive patterns, revealed a BIMS score of 2 (severe impairment).<BR/>Record review of Resident #1's care plan dated 11/05/24 revealed the focus Resident is at risk for falls r/t impaired mobility, weakness, impaired cognition, and pain initiated on 09/17/24 and revised on 11/06/24. Interventions listed for the focus included:<BR/>Anticipate and meet the resident's needs initiated on 05/29/24 and revised on 11/06/24.<BR/>Assist with ADL's as needed initiated on 03/02/24 and revised on 11/06/24.<BR/>Call light within reach initiated on 03/02/24 and revised ono 11/06/24.<BR/>Complete fall risk assessment initiated on 03/02/24 and revised on 11/06/24.<BR/>Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs initiated on 06/04/24 and revised on 11/06/24.<BR/>May have [non-slip mats] to wheelchair initiated on 08/07/24 and revised on 11/06/24.<BR/>May have floor mats next to bed initiated on 06/04/24 and revised on 11/06/24.<BR/>Orient resident to room initiated on 03/02/24 and revised on 11/06/24.<BR/>Therapy evaluate and treat as ordered or PRN fall 05/28/24 resident currently on PT, therapy informed of fall resident DC'd off OT due to refusals initiated on 05/29/24 and revised on 11/06/24.<BR/>Will review medications for adverse reactions initiated on 06/04/24 and revised on 11/06/24.<BR/>Record review of the provider investigation report dated 09/05/24 revealed the following witness timeline:<BR/>Timeline - 8.29.24 [Resident#1]<BR/>Approximately 5:50 AM:<BR/>[CNA A], rounding on 400 hall and she hears resident saying help me help me.<BR/>[CNA A] attempts to get resident up. Resident states she cannot stand. [CNA A] leaves room to go get help.<BR/>[CNA A] gets other [CNA B] and asks her to help get [Resident #1] up off floor.<BR/>[CNA A] and [CNA B] enter [Resident #1's] room. Both get resident up from floor and assist her into wheelchair. Both aides then transfer her into bed and tuck her back into bed. <BR/>Both aides leave room and continue with final rounds. Neither report fall to nurse or other aides on their shift or oncoming shift.<BR/>Approximately 7:00 AM:<BR/>[CNA C] is rounding on 400 hall and goes to check [Resident #1].<BR/>[Resident #1] reports pain in her leg and wanting to see the Dr.<BR/>[CNA C] reports this to her nurse [RN D].<BR/>[RN D] calls doctor and Dr. order Xrays.<BR/>Xray results come in and [Resident #1] is transferred to hospital with acute left femur fracture.<BR/>Incident is reported to HHSC<BR/>All staff interviewed from night before, no one reports [Resident #1] having a fall.<BR/>[CNA B] and [CNA A] state they rounded on [Resident #1] was having increased weakness, however, was a self transfer and only required assistance to transfer into bed.<BR/>Staff inserviced on: Abuse/Neglect/Exploitation, Falls, and Transfers<BR/>Tuesday, September 2nd, 2024<BR/>Interview with aides [CNA A] and [CNA B] reveals that resident sometimes needed more assistance with transferring and toileting at night. [CNA B] states she asked [Resident #1] to pivot on transfer into bed but that there was no sign of pain [or] grimacing. [CNA A] agreed with interview.<BR/>Wednesday, September 3rd, 2024<BR/>Aides [CNA A] and [CNA B] interview along with Nurses [RN E] and [RN D]<BR/>[Resident #1] readmits to facility.<BR/>Interview of resident by [ADM] and DON. Resident revealed that she fell in door way when ambulating back to bed after having gone to restroom. She states she does not remember who came to help her but a nurse came to help her. When the resident stated she could not stand the nurse went to get another nurse and they both picked her up off the floor and transferred her to bed. Resident stated at the time she felt nothing and went back to sleep. Later, around 7a she felt pain and requested from a different nurse to see the doctor.<BR/>Aides interviewed again and statement of [CNA A] changes.<BR/>Aides [CNA A] and [CNA B] suspended pending investigation.<BR/>[CNA A] and [CNA B] terminated based off of investigation findings.<BR/>Record review of the provider investigation revealed the following interviews:<BR/>Resident #1 on 09/04/24<BR/>Around 7a I got up from bed to go to the restroom. I was going back to bed when I heard a pop and my leg gave out. I fell in my doorway. A nurse came right away and tried to help me off the floor but I could not stand. She left and came back with a second nurse. Both nurses helped get me off the floor and sat me in my wheelchair. They then wheeled me closer to my bed and transferred me into bed. I do not remember their names. I didn't feel any pain then. Later, another nurse came to check on me and I told her my leg was turned the wrong way and hurt and I needed to see the doctor. She said okay that she would tell someone. Another Nurse called the doctor and they did xrays on my leg and it was broken.<BR/>CNA A on 09/04/24<BR/>I was walking down 400 hall when I heard a resident saying help me help me. I entered [Resident #1's] room and found her on the floor in the doorway of the bathroom. I went to get the other [CNA B]. [CNA B] and I got her up. We put her in her wheelchair and then put her in bed. I asked [Resident #1] if she was okay and she said she was. We then kept rounding. We never told the nurse.<BR/>Record review of x-ray of Resident #1 dated 08/29/24 revealed a fracture through the left distal femoral shaft at the level tip of the intramedullary femoral stem, minimally comminuted (fracture that extends into the knee and up through the femur). Further review revealed a fracture of the right tibia and fibula.<BR/>Record review of a local hospital's patient records for Resident #1 dated 08/30/24 revealed the following plan: Regarding patient's left distal femur fracture, this fracture is not fixable and unfortunately is not convertible either. At this time [Doctor] has recommended a left above-knee amputation.<BR/>Interview was attempted with CNA A at 10:58 AM on 03/05/25, but CNA A could not be reached so a message was left. <BR/>Interview was attempted with CNA B at 11:00 AM on 03/05/25, but CNA B could not be reached so a message was left. <BR/>In an interview with the ADM at 11:22 AM on 03/05/25, the ADM stated they did not know Resident #1 had fallen from the incident on 08/29/24 until they interviewed her on 09/04/24. The ADM stated before they were able to interview Resident #1 they thought the breaks were from brittle bones. The ADM stated they originally thought the fractures caused the fall, and not the fall caused the fractures. The ADM stated Resident #1 had problems with her left knee, and she had several surgeries on it in the past few years. The ADM stated she believe the ultimate outcome of left leg above knee amputation of Resident #1 would not have changed even if the CNA's A and B had acted appropriately. The ADM stated CNA A and CNA B should have found a nurse to evaluate the resident on the floor before moving her at all. The ADM stated no employee had ever come to her to report another employee for possible abuse of a resident. The ADM stated the two CNA's involved in this incident had always been good CNA's. The ADM stated they conducted safe surveys after the incident and all residents reported they felt safe. The ADM stated they inserviced all employees on abuse, neglect, falls, and alerting staff if there was a fall. The ADM stated they made cards that all employees carried on their badges to inform them of the proper steps in case a resident fell.<BR/>In an interview with Witness #1 at 1:40 PM on 03/05/25, Witness #1 stated she was a good friend of Resident #1. Witness #1 stated she visited Resident #1 when she was in the hospital after her fall on 08/29/24. Witness #1 stated Resident #1 told her she went to the bathroom and fell. Witness #1 stated Resident #1 told her the CNA's tried to move her several times while she was in the bathroom, but her legs kept hurting more and more. Witness #1 stated the two CNA's had a tough time picking up Resident #1, but one of them bear hugged her and threw her in bed. Witness #1 stated Resident #1 told her she asked for the nurses to come back and check on her legs, but they left the room.<BR/>In an interview with the NP at 2:49 PM on 3/5/25, the NP stated Resident #1 had infective hardware with multiple revision surgeries (surgery to correct or modify the results of a previous surgery) on her left knee. The NP stated Resident #1 was on IV antibiotics for an extended period of time before the fall on 08/29/24. The NP stated she initially sent the resident out to the hospital for swelling and the fractures in her legs. The NP stated there was potential the CNA's could have caused more damage when they moved her. The NP stated in this condition Resident #1's leg was in, any fall or twist could have injured it. The NP stated she still had Resident #1 as her patient, and Resident #1 was doing much better with pain control after the amputation. <BR/>In an interview with Resident #1 at 10:48 AM on 03/06/25, Resident #1 stated she remembered the facility she was at when she had her fall at the end of August. Resident #1 stated she was leaving her bathroom when her feet came out from under her. Resident #1 stated she did not remember hearing a pop before falling. Resident #1 stated he hips faced one way while her legs faced the other. Resident #1 stated it was very painful. Resident #1 stated when she told the nurses about her pain they did not believe her. Resident #1 stated one of the nurses told her bite the bullet for a bit while she moved her back into bed. Resident #1 stated she told the first two nurses that she wanted to see the doctor but they laughed at her. Resident #1 stated once she was back in bed she positioned her legs so they did not hurt as bad. Resident #1 stated it was not until a 3rd nurse came in 30 minutes later that started helping her for the pain. <BR/>In an interview with CNA C at 1:59 PM on 03/06/25, CNA C stated when she entered Resident #1's room around 7:00 AM on 08/29/24 it looked like Resident #1 was in severe pain and very uncomfortable. CNA C stated Resident #1 told her she was in pain. CNA C stated she went and got the nurse as soon as she realized the condition Resident #1 was in. <BR/>Record review of the facility policy titled Incident and Reportable Event Management issues 07/19/21, revised 08/15/23 and reviewed 09/25/24 revealed the following:<BR/>Incident/Injury<BR/>1. The licensed nurse should evaluate the resident and render first aide if needed<BR/>a. The nurses evaluation should be completed prior to moving a resident who has fallen, to determine presence of injury.<BR/>2. The licensed nurse should create an event note and include the following details;<BR/>a. The assessment details of the resident (including location details of the resident)<BR/>b. Presence or absence of injury, and any treatments rendered<BR/>c. If resident is able to report what occurred, this should be included in the notes<BR/>d. Notification of family or responsible party<BR/>e. Notification of physician and any orders received<BR/>3. The licensed nurse should create a risk report in the electronic system and identify the most appropriate type of event from the available options in the system. <BR/>4. The licensed nurse should also notify the following in accordance with state and federal requirements<BR/>a. Supervisor on duty and/or DON<BR/>In interviews beginning at 2:12 PM on 03/04/25 with staff from multiple shifts, the DON, ADM, CNA C, CNA F, LVN G, CNA H, CNA I, CNA J, LVN K, LVN L, MA M, CNA N, CNA O, CNA P, and RN Q were able to identify the proper procedures to follow when responding to a witnesses or unwitnessed fall. All staff knew not to move the resident before getting the nurse and referenced the card attached to their name badges to demonstrate the proper protocol. All staff were familiar with different types of abuse and neglect.<BR/>Record review and verification of the corrective action implemented by the facility beginning on 08/29/25:<BR/>The facility terminated the employment of CNA A and CNA B effective 09/05/24 verified by record review of the provider investigation, staff roster, and interview with the ADM.<BR/>Resident #1 was discharged to another nursing facility on 11/05/24 verified through record review of Resident #1's face sheet and interview with the ADM.<BR/>teams<BR/>Re-educated and in-services staff beginning on 08/29/25 verified through interviews with carious staff members and record review of in-services.<BR/>Abuse and Neglect<BR/>Exploitation<BR/>Falls<BR/>Transfers<BR/>Ad-Hoc QAPI conducted on 09/05/24 regarding incidents/accidents verified by interview with the ADM.<BR/>Reviewed all policies regarding falls on 09/05/24 verified by interview with the ADM.<BR/>Badge cards created on 09/05/24 for all staff to be worn at all times detailing proper step-by-step procedures for what to do if a resident fell or was found on the ground verified by interviews with various staff.<BR/>The noncompliance was identified as PNC. The PNC began on 08/29/24 and ended on 09/05/24. The facility had corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received adequate supervision for one Resident (Resident #2) of three residents reviewed for supervision.<BR/>The facility failed to ensure Resident #2 received adequate supervision and did not exit the facility through the front door.<BR/>This failure could place residents requiring supervision at risk for injury and accidents. <BR/>The findings include:<BR/>Record review of Resident #2's face sheet dated 03/05/35 reflected a [AGE] year-old male with an original admission date of 12/08/23. Diagnoses included heart failure, type two diabetes (insufficient insulin production in the body), Alzheimer's disease (disease that destroys memory and thinking skills), and Dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life). Resident #2 was discharged on 11/12/24.<BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 1 (severe cognitive impairment).<BR/>Record review of Resident #2's care plan dated 11/11/24 reflected Resident #2 was at risk for elopement related to confusion/disorientation to place, impaired safety awareness, and aimless wandering. Interventions included frequent monitoring and wandering behavior at times. The plan did not indicate any previous elopement attempts.<BR/>In an interview on 3/5/25 at 9:26am the Central Supply staff member stated on 11/09/24 she was going to do a transport and was parking the facility bus upfront in the driveway when she saw Resident #2 sitting on the bench by the front door with no attempt to get up and walk. The Central Supply staff member stated she parked the facility bus and redirected Resident #2 back inside without incident. The Central Supply staff member stated Resident #2 stated he was just enjoying the fresh air. The Central Supply staff member stated a former maintenance assistant was outside at the time and stated Resident #2 was sitting outside for about 3-5 minutes according to a previous maintenance assistant who was outside at the time working. The Central Supply staff member said the former maintenance assistant said Resident #2 did not attempt to go anywhere or was not in any danger and if so, he would have intervened and called for assistance.<BR/>In an interview on 3/5/25 at 9:38 am LVN G stated there was a new receptionist who went on break and did not set the door alarm correctly (no wander guard system in use at facility). LVN G stated Resident #2 was found sitting on the bench near front door by a Central Supply staff member and stated Resident #2 was brought back into the facility. LVN G stated a head-to-toe assessment was conducted with no noted injuries. LVN G said at the time of the assessment, Resident #2 stated he was just sitting outside getting some fresh air. LVN G stated Resident #2 was placed on one-to-one monitoring. LVN G stated the facility elopement protocols were conducted, and all other residents were accounted for. LVN G stated Resident #2 did not display any exit seeking behaviors prior but was discharged to a secured unit at another facility. <BR/>Through interviews and record review, no residents were exit seeking and only had risks for elopement.<BR/>In an interview on 3/5/25 at 2:12 pm the ADM stated Resident #2 was at the back station and the receptionist who was new was trying to leave for lunch and locked the door but did not realize the door only locks on the outside and not the inside. The ADM stated Resident #2 was outside for about 3-5 minutes the Maintenance Assistant (no longer employed with facility) saw Resident #2 sitting on the bench and watching him work. The ADM stated that a Central Supply staff member pulled up to the facility moments after and realized Resident #2 was not supposed to be outside and brought him back in immediately and notified the nurse. The ADM stated Resident #2 was found right by the front door sitting on the bench approximately 6-7 feet. The ADM stated Resident #2 was not trying to leave the facility and was simply sitting outside with no immediate danger noted at the time. The ADM stated Resident #2 was assessed with no injuries and was transferred to another facility with a secured unit. The ADM stated all staff were in-serviced on elopement and drills were conducted beginning on 11/09/24 with all staff on all shifts.<BR/>In an interview on 3/5/25 at 2:45 pm the ADON stated Resident #2 would wander about the facility but was not exit seeking. The ADON stated she heard Resident #2 had exited the facility and was found sitting on the bench by the front door. The ADON stated Resident #2 was allowed to go outside but with supervision and usually goes outside in the courtyard area. The ADON stated staff were in-serviced on elopement, exit seeking behaviors, and elopement drills conducted beginning on 11/09/24 (verified through record review). <BR/>In a phone interview on 3/5/25 at 4:40pm the previous Receptionist stated she was going to lunch and normally someone relieves her but, on that day, there was no one to relieve her at that moment and waited for someone to relieve her. The receptionist stated she spoke to a charge nurse who said she could leave but lock the front door. The Receptionist stated she locked the door but was fairly new and thought she locked it correctly but guess she didn't. The Receptionist stated when she returned after lunch, that was when she learned Resident #2 had exited through the front door. The Receptionist stated she was shown how to lock the door but guess she did not alarm it correctly.<BR/>Record review of the facility's Elopement policy dated 01/03/2022 and revised on 11/19/2024 reflected:<BR/>Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. <BR/>&sect;483.25(d) Accidents.<BR/>The facility must ensure that -<BR/>&sect;483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and<BR/>&sect;483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

**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. Consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in comprehensive assessment for 1 (Resident #70) of 6 residents reviewed for care plans. The facility failed to ensure Resident #70's care plan was implemented by not having the resident's call light within reach on 08/04/25 at 2:10 PM. This failure could place residents at an increased risk of needs going unmet or harm.The findings included:Record review of Resident #70's face sheet dated 08/04/25 revealed a [AGE] year-old male with an admission date of 02/10/21. Resident #70's Pertinent diagnoses included hemiplegia and hemiparesis affecting the right dominant side (complete paralysis to right side of body), aphasia (unable to speak), and dementia (decline in mental ability that interferes with daily life). Record review of Resident #70's quarterly MDS assessment dated [DATE] revealed a BIMS score could not be obtained because the resident was rarely or never understood. Record review of Resident #70's comprehensive care plan revealed the focus [Resident #70] is at risk for falls r/t right-sided hemiplegia and hemiparesis, impaired condition initiated on 02/10/21 and revised on 07/15/25. An Intervention for this focus included Call light within reach initiated on 02/10/21. During an observation on 08/04/25 at 2:10 PM, Resident #70's call light cord and button were coiled up on the floor approximately 3 feet away from the head of the bed on Resident #70's right side. In an interview with Resident #70 on 08/04/25 at 2:10 PM, Resident #70 was unable to answer questions due to his inability to speak. Resident #70 was able to nod his head up and down or side to side to indicate yes or no answers. Resident #70 was asked if he knew how long his call light had been on the floor out of reach and he shrugged his shoulders. Resident #70 was asked if his call light was on the floor out of reach very often and he shook his head side to side. Resident #70 was asked if he was able to communicate with nursing staff in the halls with any means other than the call light and he shook his head side to side. In an interview with CNA B on 08/04/25 at 2:15 PM, CNA B stated residents' call lights were supposed to be clipped to the side of the bed within reach of the resident. CNA B stated he did not know how Resident #70's call light fell on the floor out of reach. CNA B stated it was important for residents to be able to access their call lights so they could notify the nursing staff if they had any problems. In an interview with LVN A on 08/04/25 at 2:20 PM, LVN A stated residents' call lights were supposed to be clipped to the side of the bed within reach of the resident. LVN A stated he was in Resident #70's room sometime after lunch and thought the call light was on Resident #70's bed. LVN A stated it was important for any resident to be able to access their call light so they could contact the nursing staff if they had any problems. LVN A stated it was especially important for Resident #70 to have his call light because he was unable to speak or yell to get attention. LVN A stated if a resident could not access their call light, they could accidentally injure themselves and not be able to get the nurses attention for help. In an interview with the DON on 08/06/25 at 2:50 PM, the DON stated it was important for all residents to have access to their call lights so all their needs could be met by the nursing staff. The DON stated if residents could not reach their call light, then they could have trouble informing the CNA's and nurses on the floor of any problems they had. The DON stated this issue could lead to a resident experiencing harm and then receiving a delayed response by the staff. Record review of the facility's policy Person Centered Care Planning last reviewed 09/05/2024 revealed the following: . The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights. that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -i. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation.<BR/>1. <BR/>The facility failed to ensure the ice machine was clean.<BR/>2. <BR/>The facility failed to ensure drinking glasses were clean.<BR/>3. <BR/>The facility failed to ensure non-stick pans were not eroded.<BR/>4. <BR/>The facility failed to ensure pots and pans were not dented.<BR/>5. <BR/>The facility failed to ensure pest control was effective.<BR/>6. <BR/>The facility failed to ensure personal items were not on prep carts or in walk-ins.<BR/>7. <BR/>The facility failed to ensure proper cleaning was done according to their daily <BR/>kitchen cleaning log.<BR/>8. <BR/>The facility failed to ensure the walk-in freezer was in good operating condition.<BR/>9. <BR/>The facility failed to ensure the lights in the walk-in refrigerator, freezer, and vent <BR/>hood were in good operating condition.<BR/>10. <BR/>The facility failed to maintain cleanliness of the ovens, floor, and air vents on the <BR/>ceiling.<BR/>These failures could place residents at risk of foodborne illnesses.<BR/>Findings included:<BR/>Observation and initial tour of the kitchen beginning on 07/01/24 at 9:05 am revealed the ice machine had a removable reddish substance along the entire edge of the ice chute. 25 of 25 drinking glasses had a heavily coated whitish yellow substance on the insides. There were 2 non-stick pans the finish was eroded from, one completely gone except the sides. The other non-stick pan was on the stove and had deep scratches throughout the center of the finish. There was one large pot that was heavily dented, and 5 small holding pans that had deep dents with crevices in the inside corners and scratches on the inside bottoms. There were ants on the prep table next to the stove. The ants were on and around the can opener attached to the prep table. The ants were crawling across the top of the prep table to the other side as well as up the back wall and into a moderate crack in the wall. There was a 25-pound container of powdered beef base on the lower shelf of the prep table (that had the ants on it) with the lid askew. There was a large block of ice build-up in the walk-in freezer that was so heavy, the ceiling of the walk-in freezer was drooping. There were 2 open, partially full 16-ounce sodas on the shelf of the walk-in refrigerator. There was a purse on the lower shelf of a prep cart. The walk-ins were dimly lit and there were no lights under the vent hood. The ovens were dirty with build-up inside and outside. There was a dark brown-black substance along the floor where it met the walls behind the stove and prep tables. There was an approximate 1-inch hole in the corner of the wall where it met the floor, with what appeared to be possible rodent droppings. The air vent and return air on the ceiling had thick layers of a dark brown/black substance covering them.<BR/>In an interview with the Assistant DM, on 07/01/24 at 9:15 am she stated she did not know what the stuff on the ice chute was and it looked dirty. She stated they were having issues with their water softener, and that caused the haziness in the drinking glasses. She stated the drinking glasses were on the clean rack for use. She stated she would not want to drink from any of the 25 glasses. She stated the residents could get sick from whatever was inside the drinking glasses. She stated the kitchen staff did not really use the large, damaged non-stick pan and said it should have been removed from the pot rack it was on long ago because that rack was for the pans they used. She would not say why she did not remove it or what the risk was to residents from using a non-stick pan with an eroded finish. She stated the other damaged non-stick pan on the stove was not that bad. She stated the large, dented pot on the pot rack was used for boiling water that was used for food such as potatoes. She stated the dented holding pans were not being used right now because of the low census. She stated she did not know bacteria could grow in crevice's the dents made, and she guessed the residents could get sick from that. Regarding the 25-pound container of powdered beef base on the lower shelf of the prep table (that had the ants on it) with the lid askew, she stated there was probably not ants in there. (She did not check the contents of the container prior to replacing the lid) She stated the kitchen staff followed a daily cleaning schedule for the floors, prep tables, the stove and microwaves. She stated she could not remember what else was on the daily cleaning schedule. She stated she did not know where or how the large block of ice came from in the walk-in freezer, and that it was maintenance's job to fix it. She stated she did not know what they were doing about the ice build-up in the walk-in freezer, but it had been there a while. She stated the lights in the walk-ins had always been very dim and it was difficult to see anything in the walk-ins because if food went bad, it was not noticeable. She stated the lights in the vent hood just went out one day. She stated she never reported any of the lights because she assumed the DM and maintenance already knew. She stated the air vents on the ceiling could use some cleaning. She stated kitchen staff were not allowed to have personal items in the walk-in refrigerator because it could cause cross contamination and make residents sick. She stated the purse on the prep cart was hers because she was in a hurry this morning and just tossed it there. She stated she was going to move it. She stated she would tell maintenance about the ants.<BR/>In an interview with the ADM on 07/03/24 at 5:20 pm, she stated she was aware the kitchen needed a lot. She stated she had been in the facility since 06/13/24 and was trying to get things done. She stated she was not aware of the extent of repairs the kitchen needed. She stated the MS had not made her aware of the condition of the walk-in freezer.<BR/>Record review of the kitchen daily cleaning log dated 04/2024-06/29/24 revealed there was no section for the ice machine. The section for stove top and grill was blank for 04/26/24, 06/19/24, and 06/26/24 and 06/28/24. The section for floors was blank for 05/04/24, 06/28/24. <BR/>Record review of kitchen in-services revealed no significant ongoing training on infection control and the prevention of food contamination, as stated in the facility's policy. <BR/>Record review of the facility policy titled Prevention of Cross Contamination revised 04/26/23 documented under Policy, All food and nutrition services associates are trained in infections control techniques to prevent the contamination of food and the spread of infection to ensure that food is stored, prepared, distributed, and served in accordance with professional standards for safety, and per federal, state, and local requirements. Under Procedure, 1. The director of food and nutrition or designee provides training to departmental new hires on infection control techniques. Categories of infection control training will include a minimum of a. Biological contamination, b. Chemical contamination, c. physical contamination, f. equipment. 2. The director of food and nutrition services and registered dietician provide ongoing training on infection control and the prevention of food contamination. 3. The director of food and nutrition or designee will check food storage, food preparation, and food service areas daily to ensure proper steps are being followed. 4. Foodservice associates may drink from a closed beverage container if handled to prevent contamination of a. The associates' hands, b. the container, c. exposed food, clean equipment, utensils, linens, and unwrapped items. 5. The following assists in preventing contamination of food and spread of infection. G. All equipment, utensils, counters, workstations, and cutting boards are cleaned and sanitized per department guidelines. 6. Ice used in connection with food or drink will be obtained from a sanitary source and handled and dispensed in a sanitary manner. F. Inside of bin will be cleaned according to facility cleaning schedule. Routine Housekeeping 7. Rodent and pest control must be provided on an established schedule, and as needed. <BR/>Record review of the facility policy titled, Cleaning Schedule revised 12/17/21 documented under Policy, The director of food and nutrition services develops a cleaning schedule, with assistance from the registered dietician, to ensure that the food and nutrition services department remains clean and sanitary at all times. Equipment and Utensil Cleaning and Sanitization, A potential cause of foodborne outbreaks is improper cleaning (washing and sanitizing) of equipment and protecting equipment from contamination via splash, dust, grease, etc., Procedure 1. The director of food and nutrition services develops a cleaning schedule to include all equipment and areas to be cleaned. 4. The director of food and nutrition services monitors the cleaning schedule to ensure the tasks are completed timely and appropriately.<BR/>The facility policy on Food Storage was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview, and record review the facility failed ensure, in accordance with accepted professional standards and practices, to maintain medical records on each resident that was complete and accurately documented for one resident 1 of 7(Resident #00) residents reviewed for medical records. The facility failed to ensure Resident #00's MARS was revised to reflect the accuracy of times the resident took hydrocodone-Acetaminophen Tablet 10-325 milligrams taken as needed for pain control on 04/09/2025.This failure could place residents at risk for not receiving appropriate and timely pain care relief to meet their current needs.The findings included:Record review on 08/06/25 of Resident #00's facesheet documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident # 00 had diagnoses which included diabetes(a group of diseases that result in too much sugar in the blood), necrotizing fasciitis (a serious bacterial infection that destroys the tissue under your skin called fascia) , pressure ulcers(injury to skin and underlying tissue resulting from prolonged pressure on the skin) of heel unstageable, pressure ulcer of sacral region(the anatomical area located at the base of the spine, where the lower back meet the pelvis) stage 4 cutaneous(skin) of limb, skin transplant, encounter of sepsis aftercare.Record review of Resident #00's Minimum Data Set, dated )03/03/25 documented Resident #00 had a BIMS of 14, which indicated the resident's cognitive function was intact. Resident #00 required assist with one-person physical assist for transfers, dressing, toileting, and personal hygiene. Resident #00 had 2 stage 4 pressure ulcers and 2 unstageable pressure ulcers due to coverage of wound bed by slough (dead tissue that accumulates on the surface of a wound, often appearing as a moist, yellow, tan or white layer)or eschar(dead tissue that eventually sloughs off healthy skin after an injury). Resident #00 was receiving insulin injections and IV medications. Record review of resident #00's Care Plan dated 03/22/25 revealed Resident expresses chronic pain related to immobility, limited range of motion to joints, wounds and neuropathy. The Resident is on pain Medication therapy related to wounds and neuropathy. Administer ANALGESIC medications as ordered by physician. Observe for side effects and effectiveness every shift. Record review of Resident's #00's March 2025 Physician's Orders revealed Resident's #00 was prescribed hydrocodone-Acetaminophen tablet 10-325 MG give1 tablet by mouth every 4 hours as needed for pain. The MARS and the Narc Sheet did not match as the Narc sheet showed dates the medication was removed from blister pack. The blister pack did have medication missing and matched the Narc sheet. Record review of the MARs is did not have dates documented on the days the Narc sheet documented medication administered. Record review of the of the narcotic sheet reveal that on 04/09/25 the time of 7:20 pm a pill was documented to be administered to Resident #00 and was signed out by the [NAME] LVN at 7:20 shift ended at 7:00pm.In an interview on 08/06/2025 at 1:30 pm, the Administrator stated the MARs and Narcotic sheet were to match up when compared. The Administrator said the nurse or med aid were to document in these days areas when a narcotic was dispensed to the resident in order to keep accurate account of the amount and the time the resident received their narcotic medication. The Admin stated if the two forms of documentation did not match it could cause an error in dispensing the medication that could put the resident at risk of overdosing and possibly death. In an interview on 08/06/2025 at 2:47 PM with the ADON she stated keeping the narcotic sheet and the resident's MAR accurate kept the resident safe and free of medication mistakes. The ADON stated the nurses were to document in both records as the medication was given to the resident. The ADON stated correctly documented dates and times of resident receiving medication help track drug diversion.The ADON stated she would recheck and match the both records themselves randomly this incident occurred between the time she checked them twice a month In an interview on 08/07/25 the DON stated it was of great importance to maintain accuracy in all aspects of the resident's records but more with the correct documentation of the Narcotic sheet and MAR. The DON stated inconsistencies in the documentation of date and times could keep the resident from getting their medications or getting their medication too early that could cause the resident to have an overdose which could result in hospitalization or death. The DON stated surprise audits of residents records with narcotics were done to prevent such errors from occurring. Record review of the facility policy stated It is the policy of this facility that reports allegations of drug diversion are promptly and thoroughly investigated. Residents have the right to live at ease in a safe environment. Complaints and grievances will be investigated and will be reported as required by law if the investigation reveals any alleged violations and /or misappropriation of resident property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #54) reviewed for infection control practices. 1.The facility failed to ensure the ADON (who was also the ICP) knew the proper technique for cleansing the wound and keeping it clean during wound care. 2. The facility failed to ensure CNA-C performed hand hygiene between providing Resident #54 incontinent care and applying a clean brief. These fails could place residents at risk for cross contamination and infection. The findings include: Record review of Resident #54's face sheet, dated 08/05/25 revealed an [AGE] year-old-female with an admission date of 07/24/25. Resident #54's Pertinent diagnoses included Displaced Intertrochanteric Fracture of Right Femur with Subsequent Encounter for Closed Fracture with Routine Healing (a common type of hip fracture which typically required surgical intervention for proper healing) and Type 2 Diabetes (a chronic condition which affects the way your body metabolizes sugar). Record review of Resident #54's admission MDS assessment dated [DATE] revealed a BIMS score of 03, which indicated severely impaired cognition. The MDS also revealed Resident #54 had a surgical incision or wound. Record review of Resident #54's physician orders with a start date of 07/28/25, revealed an order for wound care to the right hip surgical incision, cleanse with normal saline, pat dry with gauze, and cover with a dry dressing daily (the order was not clear and did not specify to perform wound care to all four surgical incision areas). The Physician orders did not reveal an order for EBP. Record review of Resident #54's care plan, initiated 07/24/25 and revised 07/28/25 revealed Resident #54 had a break in skin integrity related to right hip surgical incision with interventions to include treatment as ordered and weekly skin checks. In an observation on 08/04/25 at 11:33 AM revealed Resident #54's room had no EBP sign and no PPE supplies. In an observation on 08/05/25 at 9:40 AM of Resident #54's incontinent care and wound care revealed CNA-C provided incontinent care without cleaning or sanitizing her hands in between cleaning Resident #54 and removing the old brief and applying the new, clean brief, then assisting with positioning Resident #54 for wound care. CNA-C was observed placing her dirty, gloved hand over the uncovered 4th surgical wound on Resident #54. CNA-C kept her dirty gloved hand over the surgical site with sutures throughout the entire wound care process. The ADON was observed cleansing and covering 3 of the 4 open surgical wounds. The 4th surgical wound to the lateral aspect of Resident #54's right leg was observed to have gone without wound care. In an interview on 08/04/25 at 10:52 AM, the ADON stated she was also the ICP, and she was the one who typically obtained the order for EBP and placed the EBP signs outside of the residents' doors. She stated the floor nurses did it sometimes upon admission, but if it was not ordered upon admission, she typically obtained the order, hung the signs and placed the PPE outside the residents' rooms. In an interview on 08/05/25 at 10:45 AM, CNA-C stated she should have used hand sanitizer and changed her gloves after cleaning and removing Resident #54's dirty brief. She stated she got nervous and forgot to do it. She stated she did not see the wound on Resident #54's leg or she would not have put her dirty hand over the top of the wound while she assisted to hold Resident #54 in position for wound care. She stated touching the wound with her dirty glove could cause cross contamination and cause the resident to have an infection. In an interview on 08/05/25 at 3:05 PM, the ADON stated CNA-C should have used hand sanitizer and changed her gloves after cleaning and removing Resident #54's dirty brief, and she should have reminded her about hand hygiene and clean gloves as well as reminded her not to touch Resident #54's open wound. The ADON stated she was not sure why the 4th surgical area was not previously covered, and why it was not listed in the orders, so she had the order clarified, and went back and performed wound care on the area. She stated touching Resident #54's surgical wound with a dirty glove could have caused cross contamination and caused an infection. She stated she started an in-service with all staff regarding proper hand hygiene and proper incontinent care. The ADON stated Resident #54 should have previously been placed on EBP precautions, and she must have just overlooked it. Record review of the facility's EBP policy, revised 04/22/25, revealed The facility should use Enhanced Barrier Precautions (EBP) as an additional MDRO mitigation strategy for residents that meet the following criteria, during high-contact resident activities; 2. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. (A) Wounds generally include chronic wounds, to include pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Record review of the facility's Skin Management policy, issued 01/03/22 and revised 11/21/24 revealed 8. Wound care is provided utilizing a clean technique, while practicing Enhanced Barrier Precautions (EBP) when indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services with reasonable accommodation of resident needs and preferences, for 1 of 5 residents (Resident #300) reviewed for accommodation of needs. <BR/>The facility did not provide Resident #300 an accessible call light that she could physically use.<BR/>This failure could place residents who utilized call lights at risk for not having his/her needs met, help in event of an emergency or place residents with a history of falls at risk for additional falls and injuries. <BR/>Findings included:<BR/>Record review of the admission record for Resident #300 reflected Resident #300 was admitted to the facility on [DATE], was a [AGE] year-old female with diagnoses that included Parkinson's disease (chronic and progressive movement disorder that causes tremors, stiffness or slowing of movement), neuralgia (nerve pain) and neuritis (inflammation of the peripheral nervous system), lack of coordination, muscle weakness, anemia, muscle spasm, disorientation, and history of falling. <BR/>Record review of Resident #300's Care Plan revised on 06/28/24 reflected a focus on the resident has an ADL self-care performance deficit r/t confusion, impaired balance with interventions/task, encourage the resident to use bell to call for assistance and observe and report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. <BR/>Record review of Resident #300's Skilled Nursing Documentation dated 06/30/24 noted primary reason for admission #2 as neurologic, section 6, musculoskeletal, abnormal. Section 6b. Muscle tone is mixed with Parkinson tremors. <BR/>Record review of Resident #300's Incomplete MDS assessment dated for 07/05/24 reflected Section GG Functional Abilities and Goals was blank. MDS Section O 400, listed 70 minutes of Occupational Therapy given for 2 days started on 06/27/2024 and 61 minutes of Physical Therapy given for 2 days started on 06/27/2024. Section O 0500 Restorative Nursing Programs was blank. <BR/>Observation on 07/03/24 at 08:43 AM Resident #300 was observed in bed, with the call light wrapped on the right-side rail. <BR/>Observation on 07/03/2024 at 08:50 AM., LVN D administered medications to Resident #300. The call light was wrapped on the right-side rail.<BR/>Observation on 07/03/24 at 09:03 AM, Resident #300 observed unable to get or use her call light that was on the right bedrail. <BR/>Interview and observation on 07/03/24 at 09:28 AM DON observed Resident #300 in the room. DON asked resident to press call light, and resident attempted again to get the call light and was able to get the call light cord but was unable to grasp the portion of the call light and press for assistance. DON stated they would get Resident #300 a touch pad call light. DON stated that the resident would not get the help they need and could result in harm if they were unable to use the call light. She replied that the resident had two falls. DON stated that mobility issues or limited range of motion should be documented in the comprehensive assessment and MDS assessments, by admitting nurse or MDS nurse. <BR/>Interview on 07/03/24 at 10:02 AM Resident #300 stated she has had not been able to push the button on the call light since she came into the facility but still tried to use it. She stated she would call out and the staff sometimes heard her and came or sometimes another resident heard her and called the staff. <BR/>Interview on 07/03/24 at 10:14 AM CNA A stated that Resident #300 would call out or they would ask the resident during rounds if she needed anything prior to the resident getting the touch pad call light.<BR/>Interview on 07/03/24 at 03:35 PM Administrator stated Resident # 300 was able to utilize the call light when she was first admitted , but that she has had seizures almost daily so that may be why she cannot now. She stated that when a resident has a change in condition, there is an assessment done in general where vitals are documented, and the physician notified but not specifically for the use of the call light. ADM stated that if a resident is unable to use the call light, they would be assisted during rounds, and what can happen is it may take a little longer than normal. <BR/>Interview on 07/03/24 at 03:48 PM DON stated that in-service on call lights and rounds is done at least once a month, with last in-service done in June or end of May 2024. <BR/>Interview on 07/03/24 at 05:10 PM Administrator stated that comprehensive assessments, change in condition assessments and MDS assessments are completed but that there is no specific item to assess a resident's ability to use the call light. Although assessment dated [DATE] documented Resident # 300 required assistance to eat, it is not the same losing fine motor skills to losing gross motor skills and Resident # 300 had her call light withing reach. <BR/>Interview on 07/03/24 at 05:17 PM RN C stated she only had Resident #300 yesterday, and today. As far as she can tell Resident #300 was not able to use a call light. She does frequent checks to make sure Resident #300 is ok, every 30 minutes, besides the 2 hour rounds that CNAs do, but this is her self-practice. RN C said there is no procedure or policy for ensuring a resident can use the call light. The times she has had Resident #300, she has not seen her able to use the call light due to both cognitive and physical changes. RN C said most of the time in her shift Resident # 300 is asleep and has minimal communication.<BR/>Interview on 07/03/24 at 05:22 PM LVN B stated Resident #300 would press her call light prior to today, and that today with the touch pad, she called about four times.<BR/>Record review of the facility policy titled Resident Call System revised 01/04/23 and reviewed 01/15/24 reflected, the facility must be adequately equipped to allow residents to call for assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident beside. Procedure: Facility associates should always be aware of call lights; associates should answer call lights whether they are assigned to provide care to that resident. The call light should be positioned within reach of the resident. Return demonstration may be used when educating the resident about call light use. If the resident is unable to demonstrate appropriate call light use, the nurse must be notified to determine an adequate alternative. The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care.<BR/>The facility failed to have a nurse evaluate Resident #1 after an unwitnessed fall. Resident #1 sustained a left distal femoral shaft fracture and a right tibia and fibula fracture.<BR/>The noncompliance was identified as PNC. The PNC began on 08/29/24 and ended on 09/05/24. The facility had corrected the noncompliance before the investigation began.<BR/>The failure could affect residents, 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 #1's face sheet dated 03/04/25 revealed an [AGE] year-old female with an initial admission date of 02/29/24 and a current admission date of 09/16/24. Pertinent diagnoses included acquired absence of left leg above knee, unspecified dementia, and depression.<BR/>Record review of Resident #1's discharge MDS assessment dated [DATE] section C, cognitive patterns, revealed a BIMS score of 2 (severe impairment).<BR/>Record review of Resident #1's care plan dated 11/05/24 revealed the focus Resident is at risk for falls r/t impaired mobility, weakness, impaired cognition, and pain initiated on 09/17/24 and revised on 11/06/24. Interventions listed for the focus included:<BR/>Anticipate and meet the resident's needs initiated on 05/29/24 and revised on 11/06/24.<BR/>Assist with ADL's as needed initiated on 03/02/24 and revised on 11/06/24.<BR/>Call light within reach initiated on 03/02/24 and revised ono 11/06/24.<BR/>Complete fall risk assessment initiated on 03/02/24 and revised on 11/06/24.<BR/>Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs initiated on 06/04/24 and revised on 11/06/24.<BR/>May have [non-slip mats] to wheelchair initiated on 08/07/24 and revised on 11/06/24.<BR/>May have floor mats next to bed initiated on 06/04/24 and revised on 11/06/24.<BR/>Orient resident to room initiated on 03/02/24 and revised on 11/06/24.<BR/>Therapy evaluate and treat as ordered or PRN fall 05/28/24 resident currently on PT, therapy informed of fall resident DC'd off OT due to refusals initiated on 05/29/24 and revised on 11/06/24.<BR/>Will review medications for adverse reactions initiated on 06/04/24 and revised on 11/06/24.<BR/>Record review of the provider investigation report dated 09/05/24 revealed the following witness timeline:<BR/>Timeline - 8.29.24 [Resident#1]<BR/>Approximately 5:50 AM:<BR/>[CNA A], rounding on 400 hall and she hears resident saying help me help me.<BR/>[CNA A] attempts to get resident up. Resident states she cannot stand. [CNA A] leaves room to go get help.<BR/>[CNA A] gets other [CNA B] and asks her to help get [Resident #1] up off floor.<BR/>[CNA A] and [CNA B] enter [Resident #1's] room. Both get resident up from floor and assist her into wheelchair. Both aides then transfer her into bed and tuck her back into bed. <BR/>Both aides leave room and continue with final rounds. Neither report fall to nurse or other aides on their shift or oncoming shift.<BR/>Approximately 7:00 AM:<BR/>[CNA C] is rounding on 400 hall and goes to check [Resident #1].<BR/>[Resident #1] reports pain in her leg and wanting to see the Dr.<BR/>[CNA C] reports this to her nurse [RN D].<BR/>[RN D] calls doctor and Dr. order Xrays.<BR/>Xray results come in and [Resident #1] is transferred to hospital with acute left femur fracture.<BR/>Incident is reported to HHSC<BR/>All staff interviewed from night before, no one reports [Resident #1] having a fall.<BR/>[CNA B] and [CNA A] state they rounded on [Resident #1] was having increased weakness, however, was a self transfer and only required assistance to transfer into bed.<BR/>Staff inserviced on: Abuse/Neglect/Exploitation, Falls, and Transfers<BR/>Tuesday, September 2nd, 2024<BR/>Interview with aides [CNA A] and [CNA B] reveals that resident sometimes needed more assistance with transferring and toileting at night. [CNA B] states she asked [Resident #1] to pivot on transfer into bed but that there was no sign of pain [or] grimacing. [CNA A] agreed with interview.<BR/>Wednesday, September 3rd, 2024<BR/>Aides [CNA A] and [CNA B] interview along with Nurses [RN E] and [RN D]<BR/>[Resident #1] readmits to facility.<BR/>Interview of resident by [ADM] and DON. Resident revealed that she fell in door way when ambulating back to bed after having gone to restroom. She states she does not remember who came to help her but a nurse came to help her. When the resident stated she could not stand the nurse went to get another nurse and they both picked her up off the floor and transferred her to bed. Resident stated at the time she felt nothing and went back to sleep. Later, around 7a she felt pain and requested from a different nurse to see the doctor.<BR/>Aides interviewed again and statement of [CNA A] changes.<BR/>Aides [CNA A] and [CNA B] suspended pending investigation.<BR/>[CNA A] and [CNA B] terminated based off of investigation findings.<BR/>Record review of the provider investigation revealed the following interviews:<BR/>Resident #1 on 09/04/24<BR/>Around 7a I got up from bed to go to the restroom. I was going back to bed when I heard a pop and my leg gave out. I fell in my doorway. A nurse came right away and tried to help me off the floor but I could not stand. She left and came back with a second nurse. Both nurses helped get me off the floor and sat me in my wheelchair. They then wheeled me closer to my bed and transferred me into bed. I do not remember their names. I didn't feel any pain then. Later, another nurse came to check on me and I told her my leg was turned the wrong way and hurt and I needed to see the doctor. She said okay that she would tell someone. Another Nurse called the doctor and they did xrays on my leg and it was broken.<BR/>CNA A on 09/04/24<BR/>I was walking down 400 hall when I heard a resident saying help me help me. I entered [Resident #1's] room and found her on the floor in the doorway of the bathroom. I went to get the other [CNA B]. [CNA B] and I got her up. We put her in her wheelchair and then put her in bed. I asked [Resident #1] if she was okay and she said she was. We then kept rounding. We never told the nurse.<BR/>Record review of x-ray of Resident #1 dated 08/29/24 revealed a fracture through the left distal femoral shaft at the level tip of the intramedullary femoral stem, minimally comminuted (fracture that extends into the knee and up through the femur). Further review revealed a fracture of the right tibia and fibula.<BR/>Record review of a local hospital's patient records for Resident #1 dated 08/30/24 revealed the following plan: Regarding patient's left distal femur fracture, this fracture is not fixable and unfortunately is not convertible either. At this time [Doctor] has recommended a left above-knee amputation.<BR/>Interview was attempted with CNA A at 10:58 AM on 03/05/25, but CNA A could not be reached so a message was left. <BR/>Interview was attempted with CNA B at 11:00 AM on 03/05/25, but CNA B could not be reached so a message was left. <BR/>In an interview with the ADM at 11:22 AM on 03/05/25, the ADM stated they did not know Resident #1 had fallen from the incident on 08/29/24 until they interviewed her on 09/04/24. The ADM stated before they were able to interview Resident #1 they thought the breaks were from brittle bones. The ADM stated they originally thought the fractures caused the fall, and not the fall caused the fractures. The ADM stated Resident #1 had problems with her left knee, and she had several surgeries on it in the past few years. The ADM stated she believe the ultimate outcome of left leg above knee amputation of Resident #1 would not have changed even if the CNA's A and B had acted appropriately. The ADM stated CNA A and CNA B should have found a nurse to evaluate the resident on the floor before moving her at all. The ADM stated no employee had ever come to her to report another employee for possible abuse of a resident. The ADM stated the two CNA's involved in this incident had always been good CNA's. The ADM stated they conducted safe surveys after the incident and all residents reported they felt safe. The ADM stated they inserviced all employees on abuse, neglect, falls, and alerting staff if there was a fall. The ADM stated they made cards that all employees carried on their badges to inform them of the proper steps in case a resident fell.<BR/>In an interview with Witness #1 at 1:40 PM on 03/05/25, Witness #1 stated she was a good friend of Resident #1. Witness #1 stated she visited Resident #1 when she was in the hospital after her fall on 08/29/24. Witness #1 stated Resident #1 told her she went to the bathroom and fell. Witness #1 stated Resident #1 told her the CNA's tried to move her several times while she was in the bathroom, but her legs kept hurting more and more. Witness #1 stated the two CNA's had a tough time picking up Resident #1, but one of them bear hugged her and threw her in bed. Witness #1 stated Resident #1 told her she asked for the nurses to come back and check on her legs, but they left the room.<BR/>In an interview with the NP at 2:49 PM on 3/5/25, the NP stated Resident #1 had infective hardware with multiple revision surgeries (surgery to correct or modify the results of a previous surgery) on her left knee. The NP stated Resident #1 was on IV antibiotics for an extended period of time before the fall on 08/29/24. The NP stated she initially sent the resident out to the hospital for swelling and the fractures in her legs. The NP stated there was potential the CNA's could have caused more damage when they moved her. The NP stated in this condition Resident #1's leg was in, any fall or twist could have injured it. The NP stated she still had Resident #1 as her patient, and Resident #1 was doing much better with pain control after the amputation. <BR/>In an interview with Resident #1 at 10:48 AM on 03/06/25, Resident #1 stated she remembered the facility she was at when she had her fall at the end of August. Resident #1 stated she was leaving her bathroom when her feet came out from under her. Resident #1 stated she did not remember hearing a pop before falling. Resident #1 stated he hips faced one way while her legs faced the other. Resident #1 stated it was very painful. Resident #1 stated when she told the nurses about her pain they did not believe her. Resident #1 stated one of the nurses told her bite the bullet for a bit while she moved her back into bed. Resident #1 stated she told the first two nurses that she wanted to see the doctor but they laughed at her. Resident #1 stated once she was back in bed she positioned her legs so they did not hurt as bad. Resident #1 stated it was not until a 3rd nurse came in 30 minutes later that started helping her for the pain. <BR/>In an interview with CNA C at 1:59 PM on 03/06/25, CNA C stated when she entered Resident #1's room around 7:00 AM on 08/29/24 it looked like Resident #1 was in severe pain and very uncomfortable. CNA C stated Resident #1 told her she was in pain. CNA C stated she went and got the nurse as soon as she realized the condition Resident #1 was in. <BR/>Record review of the facility policy titled Incident and Reportable Event Management issues 07/19/21, revised 08/15/23 and reviewed 09/25/24 revealed the following:<BR/>Incident/Injury<BR/>1. The licensed nurse should evaluate the resident and render first aide if needed<BR/>a. The nurses evaluation should be completed prior to moving a resident who has fallen, to determine presence of injury.<BR/>2. The licensed nurse should create an event note and include the following details;<BR/>a. The assessment details of the resident (including location details of the resident)<BR/>b. Presence or absence of injury, and any treatments rendered<BR/>c. If resident is able to report what occurred, this should be included in the notes<BR/>d. Notification of family or responsible party<BR/>e. Notification of physician and any orders received<BR/>3. The licensed nurse should create a risk report in the electronic system and identify the most appropriate type of event from the available options in the system. <BR/>4. The licensed nurse should also notify the following in accordance with state and federal requirements<BR/>a. Supervisor on duty and/or DON<BR/>In interviews beginning at 2:12 PM on 03/04/25 with staff from multiple shifts, the DON, ADM, CNA C, CNA F, LVN G, CNA H, CNA I, CNA J, LVN K, LVN L, MA M, CNA N, CNA O, CNA P, and RN Q were able to identify the proper procedures to follow when responding to a witnesses or unwitnessed fall. All staff knew not to move the resident before getting the nurse and referenced the card attached to their name badges to demonstrate the proper protocol. All staff were familiar with different types of abuse and neglect.<BR/>Record review and verification of the corrective action implemented by the facility beginning on 08/29/25:<BR/>The facility terminated the employment of CNA A and CNA B effective 09/05/24 verified by record review of the provider investigation, staff roster, and interview with the ADM.<BR/>Resident #1 was discharged to another nursing facility on 11/05/24 verified through record review of Resident #1's face sheet and interview with the ADM.<BR/>teams<BR/>Re-educated and in-services staff beginning on 08/29/25 verified through interviews with carious staff members and record review of in-services.<BR/>Abuse and Neglect<BR/>Exploitation<BR/>Falls<BR/>Transfers<BR/>Ad-Hoc QAPI conducted on 09/05/24 regarding incidents/accidents verified by interview with the ADM.<BR/>Reviewed all policies regarding falls on 09/05/24 verified by interview with the ADM.<BR/>Badge cards created on 09/05/24 for all staff to be worn at all times detailing proper step-by-step procedures for what to do if a resident fell or was found on the ground verified by interviews with various staff.<BR/>The noncompliance was identified as PNC. The PNC began on 08/29/24 and ended on 09/05/24. The facility had corrected the noncompliance before the investigation began.

**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, for 1 of 14 residents (Residents #38) reviewed for respiratory care, in that:<BR/>Resident #38's nebulizer mask was unbagged and resting on top of the resident's bedside table. <BR/>This failure could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in a decline in health.<BR/>The findings were:<BR/>Record review of Resident #38's face sheet, dated 04/04/2023, revealed the resident had an initial admission date of 07/06/2021 and was readmitted on [DATE] with diagnoses that included: tracheostomy status, malignant neoplasm of pharynx, dysphagia, speech disturbances and dementia.<BR/>Record review of Resident #38's Annual MDS, dated [DATE], revealed a BIMS score of 10, which indicated moderate cognitive impairment. <BR/>Record review of Resident #38's Care Plan, dated 03/22/2023, revealed a focus area, the resident has a tracheostomy r/t surgery (S/P Esophageal Cancer) with intervention administer nebs via trach collar PRN SOB/congestion initiated 02/16/2022.<BR/>Record review of Resident #38's electronic medical record Order Summary Report, Active Orders as of 04/04/2023, revealed an order dated 01/26/2023 for Budesonide Suspension 0.5 MG/2ML 2 ml inhale orally two times a day for COPD Lung sounds with no end date. Further review revealed an additional order dated 02/07/2023 for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally via nebulizer every 6 hours as needed for Shortness of breath lung sounds with no end date.<BR/>During an observation and interview with Resident #38 on 04/03/2023 at 4:10 pm, revealed Resident #38's nebulizer mask lying on the resident's bedside table unbagged. Resident #38 was asked if nursing staff assist with nebulizer treatments and Resident #38 nodded and in an airy voice d/t his trach attempted an answer however speech was too difficult to understand.<BR/>During an interview with LVN A on 04/03/2023 at 4:18 pm, LVN A stated the nebulizer mask should have been bagged and the bag dated. LVN A stated Resident #38 has scheduled nebulizer treatments twice a day. LVN A added that the last scheduled treatment would have been early this morning prior to this shift. LVN A stated, any pathogen could enter the tubing and then cause an upper respiratory infection if the mask was left unbagged.<BR/>During an interview with the DON on 04/05/2023 at 9:12 a.m., the DON stated a nebulizer mask should always be in a bag that was dated when not in use to protect it from the environment and to prevent infection.<BR/>Record review of the facility's policy titled, Small Volume Nebulizer Therapy, effective 11/10/2022, revealed, The facility will provide Small Volume Nebulizer Therapy in accordance with professional standards of practice. Review of an additional procedure provided by the DON titled, Nebulizer therapy, small volume, revised May 20, 2022, revealed, Critical Notes! [Corporate name] has approved the following information as an addendum to the Lippincott procedure. Nebulizer circuit should be stored in a patient-care set-up bag, labeled with the patient's name, and dated.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation.<BR/>1. <BR/>The facility failed to ensure the ice machine was clean.<BR/>2. <BR/>The facility failed to ensure drinking glasses were clean.<BR/>3. <BR/>The facility failed to ensure non-stick pans were not eroded.<BR/>4. <BR/>The facility failed to ensure pots and pans were not dented.<BR/>5. <BR/>The facility failed to ensure pest control was effective.<BR/>6. <BR/>The facility failed to ensure personal items were not on prep carts or in walk-ins.<BR/>7. <BR/>The facility failed to ensure proper cleaning was done according to their daily <BR/>kitchen cleaning log.<BR/>8. <BR/>The facility failed to ensure the walk-in freezer was in good operating condition.<BR/>9. <BR/>The facility failed to ensure the lights in the walk-in refrigerator, freezer, and vent <BR/>hood were in good operating condition.<BR/>10. <BR/>The facility failed to maintain cleanliness of the ovens, floor, and air vents on the <BR/>ceiling.<BR/>These failures could place residents at risk of foodborne illnesses.<BR/>Findings included:<BR/>Observation and initial tour of the kitchen beginning on 07/01/24 at 9:05 am revealed the ice machine had a removable reddish substance along the entire edge of the ice chute. 25 of 25 drinking glasses had a heavily coated whitish yellow substance on the insides. There were 2 non-stick pans the finish was eroded from, one completely gone except the sides. The other non-stick pan was on the stove and had deep scratches throughout the center of the finish. There was one large pot that was heavily dented, and 5 small holding pans that had deep dents with crevices in the inside corners and scratches on the inside bottoms. There were ants on the prep table next to the stove. The ants were on and around the can opener attached to the prep table. The ants were crawling across the top of the prep table to the other side as well as up the back wall and into a moderate crack in the wall. There was a 25-pound container of powdered beef base on the lower shelf of the prep table (that had the ants on it) with the lid askew. There was a large block of ice build-up in the walk-in freezer that was so heavy, the ceiling of the walk-in freezer was drooping. There were 2 open, partially full 16-ounce sodas on the shelf of the walk-in refrigerator. There was a purse on the lower shelf of a prep cart. The walk-ins were dimly lit and there were no lights under the vent hood. The ovens were dirty with build-up inside and outside. There was a dark brown-black substance along the floor where it met the walls behind the stove and prep tables. There was an approximate 1-inch hole in the corner of the wall where it met the floor, with what appeared to be possible rodent droppings. The air vent and return air on the ceiling had thick layers of a dark brown/black substance covering them.<BR/>In an interview with the Assistant DM, on 07/01/24 at 9:15 am she stated she did not know what the stuff on the ice chute was and it looked dirty. She stated they were having issues with their water softener, and that caused the haziness in the drinking glasses. She stated the drinking glasses were on the clean rack for use. She stated she would not want to drink from any of the 25 glasses. She stated the residents could get sick from whatever was inside the drinking glasses. She stated the kitchen staff did not really use the large, damaged non-stick pan and said it should have been removed from the pot rack it was on long ago because that rack was for the pans they used. She would not say why she did not remove it or what the risk was to residents from using a non-stick pan with an eroded finish. She stated the other damaged non-stick pan on the stove was not that bad. She stated the large, dented pot on the pot rack was used for boiling water that was used for food such as potatoes. She stated the dented holding pans were not being used right now because of the low census. She stated she did not know bacteria could grow in crevice's the dents made, and she guessed the residents could get sick from that. Regarding the 25-pound container of powdered beef base on the lower shelf of the prep table (that had the ants on it) with the lid askew, she stated there was probably not ants in there. (She did not check the contents of the container prior to replacing the lid) She stated the kitchen staff followed a daily cleaning schedule for the floors, prep tables, the stove and microwaves. She stated she could not remember what else was on the daily cleaning schedule. She stated she did not know where or how the large block of ice came from in the walk-in freezer, and that it was maintenance's job to fix it. She stated she did not know what they were doing about the ice build-up in the walk-in freezer, but it had been there a while. She stated the lights in the walk-ins had always been very dim and it was difficult to see anything in the walk-ins because if food went bad, it was not noticeable. She stated the lights in the vent hood just went out one day. She stated she never reported any of the lights because she assumed the DM and maintenance already knew. She stated the air vents on the ceiling could use some cleaning. She stated kitchen staff were not allowed to have personal items in the walk-in refrigerator because it could cause cross contamination and make residents sick. She stated the purse on the prep cart was hers because she was in a hurry this morning and just tossed it there. She stated she was going to move it. She stated she would tell maintenance about the ants.<BR/>In an interview with the ADM on 07/03/24 at 5:20 pm, she stated she was aware the kitchen needed a lot. She stated she had been in the facility since 06/13/24 and was trying to get things done. She stated she was not aware of the extent of repairs the kitchen needed. She stated the MS had not made her aware of the condition of the walk-in freezer.<BR/>Record review of the kitchen daily cleaning log dated 04/2024-06/29/24 revealed there was no section for the ice machine. The section for stove top and grill was blank for 04/26/24, 06/19/24, and 06/26/24 and 06/28/24. The section for floors was blank for 05/04/24, 06/28/24. <BR/>Record review of kitchen in-services revealed no significant ongoing training on infection control and the prevention of food contamination, as stated in the facility's policy. <BR/>Record review of the facility policy titled Prevention of Cross Contamination revised 04/26/23 documented under Policy, All food and nutrition services associates are trained in infections control techniques to prevent the contamination of food and the spread of infection to ensure that food is stored, prepared, distributed, and served in accordance with professional standards for safety, and per federal, state, and local requirements. Under Procedure, 1. The director of food and nutrition or designee provides training to departmental new hires on infection control techniques. Categories of infection control training will include a minimum of a. Biological contamination, b. Chemical contamination, c. physical contamination, f. equipment. 2. The director of food and nutrition services and registered dietician provide ongoing training on infection control and the prevention of food contamination. 3. The director of food and nutrition or designee will check food storage, food preparation, and food service areas daily to ensure proper steps are being followed. 4. Foodservice associates may drink from a closed beverage container if handled to prevent contamination of a. The associates' hands, b. the container, c. exposed food, clean equipment, utensils, linens, and unwrapped items. 5. The following assists in preventing contamination of food and spread of infection. G. All equipment, utensils, counters, workstations, and cutting boards are cleaned and sanitized per department guidelines. 6. Ice used in connection with food or drink will be obtained from a sanitary source and handled and dispensed in a sanitary manner. F. Inside of bin will be cleaned according to facility cleaning schedule. Routine Housekeeping 7. Rodent and pest control must be provided on an established schedule, and as needed. <BR/>Record review of the facility policy titled, Cleaning Schedule revised 12/17/21 documented under Policy, The director of food and nutrition services develops a cleaning schedule, with assistance from the registered dietician, to ensure that the food and nutrition services department remains clean and sanitary at all times. Equipment and Utensil Cleaning and Sanitization, A potential cause of foodborne outbreaks is improper cleaning (washing and sanitizing) of equipment and protecting equipment from contamination via splash, dust, grease, etc., Procedure 1. The director of food and nutrition services develops a cleaning schedule to include all equipment and areas to be cleaned. 4. The director of food and nutrition services monitors the cleaning schedule to ensure the tasks are completed timely and appropriately.<BR/>The facility policy on Food Storage was not received.

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 walk-in freezers, 1 of 1 walk-in refrigerators, 1 of 1 air intake vent, and 1 vent hood reviewed for essential equipment in the kitchen.<BR/>The facility failed to ensure the walk-in freezer was free of ice build-up, the door properly closed, and the inside light was bright enough.<BR/>The facility failed to ensure the light in the walk-in refrigerator was bright enough.<BR/>The facility failed to ensure the air intake and return air vent was clean. <BR/>The facility failed to ensure the vent hood lights and the exhaust fan worked.<BR/>These failures could place the residents at risk of potential fire hazards.<BR/>There findings were:<BR/>Initial observation of the kitchen on 07/01/24 at 9:05 am revealed a large block of ice build-up in the walk-in freezer appearing to be attached to the ceiling that was so heavy, the ceiling of the walk-in freezer was drooping. The door of the walk-in freezer did not close properly and there was a large gap between the door and the floor when shut. The walk-in refrigerator and the walk-in freezer were so dimly lit it was difficult to identify the contents. There were no lights under the vent hood. The air vent and return air on the ceiling had thick layers of a dark brown/black substance covering them. The air from the vents was directed at the center of the kitchen where the food holding table and plates were. <BR/>In an interview with the Assistant DM on 07/01/24 at 9:15 am she stated the lights in the walk-ins had always been very dim and it was difficult to identify what foods were in there. She stated the lights in the vent hood just went out one day. She stated the exhaust fan on the vent hood was making a screeching sound and she was not sure if the vent hood exhaust fan worked. She stated she never reported any of the lights because she assumed the DM and maintenance already knew. She stated the air vents on the ceiling could use some cleaning. She stated she did not know what they were doing about the ice build-up in the walk-in freezer, but it had been there a while. She stated the MS knew about the exhaust fan. She stated it was maintenance's job to fix things.<BR/>In an interview with the MS on 07/03/24 at 4:50 pm, he stated he did not know about the dim lighting in the walk-ins. He stated he spoke with an electrician about new fixtures for the vent hood lights and a new belt for the exhaust motor because it screeches. He could not say when he had spoken to an electrician, or the name of the electrician he spoke to. Regarding the air vent and return vent, the MS stated he started cleaning them 2 weeks ago but got pulled away to work on something else. He stated the ice build-up in the walk-in freezer had been like that since before he started working at the facility over 1 &frac12; years ago. He stated he spoke to regional (did not know the name) and was told by them to support the ceiling in the walk-in freezer by putting beams up to support the ceiling. The MS stated, The walk-in freezer was condemned by two restaurant supply companies a year ago. He stated, They wouldn't touch it. The MS stated the temperatures in the walk-ins were ok. He stated the ceiling in the walk-in freezer could collapse. He stated the walk-in freezer needed to be replaced.<BR/>In an interview with the DM on 07/03/24 at 5:10 pm, she stated she had not noticed the lights were dim in the walk-ins. She stated the walk-in freezer was a mess, meaning the door did not close properly and caused condensation. She stated the ice build-up in the walk-in freezer had been there 2-3 years. She stated the walk-in freezer could stop working at any time. The facility policy on food storage and maintaining equipment were requested.<BR/>In an interview with the ADM on 07/03/24 at 5:20 pm, she stated she was aware the kitchen needed a lot. She stated she had been in the facility since 06/13/24 and was trying to get things done. She stated she was not aware of the extent of repairs the kitchen needed. She stated the MS had not made her aware of the condition of the walk-in freezer.<BR/>Record review of the facility's paid kitchen invoices revealed the kitchen exhaust system was cleaned on 02/05/24 and 05/15/24. There were no invoices for the walk-in freezer, the walk-in cooler lights, or the vent hood. <BR/>Record review of the maintenance log reflected one entry dated 06/25 and was for a leaking sink in the kitchen.<BR/>The facility policy on Food Storage and maintaining equipment were not received.

Based on observations, interviews, and record reviews, the facility failed to maintain as effective pest control program for 1 of 1 kitchen reviewed for sanitation.<BR/>There were ants on a prep table on and around the can opener, all over the top of the prep table, and crawling up the wall into a crack.<BR/>There was evidence of rodent droppings on the kitchen floor adjacent to the wall.<BR/>There was a hole in the baseboard adjacent to the floor near the rodent droppings.<BR/>These failures could place residents at risk of living in an unsafe, unsanitary environment, and cross contamination of food. <BR/>Findings were:<BR/>Initial observation of the kitchen on 07/01/24 beginning at 9:05 am revealed there were ants on the prep table next to the stove. The ants were on and around the can opener attached to the prep table. The ants were crawling across the top of the prep table to the other side and up the back wall into a moderate crack in the wall. There was a 25-pound container of powdered beef base on the lower shelf of the prep table (that had the ants on it) with the lid askew. There was a dark brown-black substance along the floor where it met the walls behind the stove and prep tables. There was an approximate 1-inch hole in the corner of the wall where it met the floor, with what appeared to be possible rodent droppings.<BR/>In an interview with the Assistant DM on 07/01/24 at 9:15 am she stated she would tell maintenance about the ants. She would not answer regarding whether the ants were a problem, if they could get into any food type item, or what could happen to residents if the ants could get into any type of food type item. She did not answer as to whether she had ever seen mice or rodents in the kitchen. She stated she thought there were sticky traps in the kitchen, but she could not say where they were located, how long they had been there, or who was responsible for checking them. <BR/>In an interview with the MS on 07/03/24 at 4:50 pm, he stated the facility kept a pest control log he was responsible for. He stated the pest control company was at the facility on 07/02/24 to treat the ants and would be back in two weeks. He stated the pest control company sprayed for ants whenever they (they pest control company) were there. He stated he had not seen any mice for a while and could not determine what a while meant. He stated there were sticky traps usually by the bread and in the back room of the kitchen. He stated he did not know exactly where they were or if the sticky traps were even there. He stated the pest control company was responsible for them. He stated the maintenance logs were hand-written and the facility did not use an electronic work order system. He stated the maintenance logs were kept at the nurse's station. He stated he did not know how he knew when items were resolved because he did not keep the requests after he addressed the problem(s). The pest control log and maintenance log were requested.<BR/>In an interview with the DM on 07/03/24 at 5:10 pm, she stated the process of reporting problems in the kitchen was to go to maintenance. She stated there was a maintenance log specifically for the kitchen, separate from the other maintenance logs. She stated maintenance kept the kitchen maintenance log. She stated she had worked in the facility for 13 years. She said nothing when asked if she had ever seen mice, ants, or rodents in the kitchen.<BR/>In an interview with the ADM on 07/03/24 at 5:20 pm, she stated she was aware the kitchen needed a lot. She stated she had been in the facility since 06/13/24 and was trying to get things done. She stated she was not aware of the extent of repairs the kitchen needed. She stated the MS had not made her aware of the condition of the walk-in freezer.<BR/>Record review of the pest control service contract dated 07/14/16 included monthly interior and exterior service for insect control, rodent control, and fly control.<BR/>Record review of pest control services rendered dated 04/02/24, 05/07/24, and 06/04/24 reflected none of the invoices had detailed what kind of prevention the pest control company treated for. There was no invoice for 07/02/24. <BR/>Record review of the maintenance log reflected one entry dated 06/25 and regarded a leaking sink in the kitchen. <BR/>Facility policy regarding physical environment or pest control was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 2 of 4 residents (Resident #8 and #38) reviewed for advanced directives, in that:<BR/>1. Resident #8's DNR was executed incorrectly and was therefore invalid. <BR/>2. The facility failed to ensure Resident #38's OOH-DNR was reinstated by obtaining a DNR order upon readmission following a recent hospitalization.<BR/>This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.<BR/>The findings were:<BR/>1. Record review of Resident #8's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: Type 2 Diabetes Mellitus, Transient Cerebral Ischemic Attack, and Hypertensive Heart Disease with Heart Failure. <BR/>Record review of Resident #8's quarterly MDS, dated [DATE], revealed a BIMS score of 13 which indicated intact cognition. <BR/>Record review of Resident #8's care plan, revised [DATE], revealed, Resident [#8] has Advance Directives DNR - Do Not Resuscitate.<BR/>Record review of Resident #8's order summary report, dated [DATE], revealed a physician's order, Do Not Resuscitate dated [DATE]. <BR/>Record review of Resident #8's OOH-DNR form, dated [DATE], revealed the physician did not sign in the last section which read, All persons who have signed above must sign below, acknowledging that this document has been properly completed. <BR/>During an interview with the SSD on [DATE] at 10:18 a.m., the SSD stated Resident #8's OOH-DNR form had not been signed twice by the resident's physician. <BR/>During an interview with the DON on [DATE] at 10:05 a.m., the DON stated the SSD and Medical Records Director were responsible for ensuring the accuracy of residents' advanced directives and that OOH-DNR forms should be correctly executed. <BR/>2. Record review of Resident #38's face sheet, dated [DATE], revealed the resident had an initial admission date of [DATE] and was readmitted on [DATE] with diagnoses that included: tracheostomy status, malignant neoplasm of pharynx, dysphagia, speech disturbances and dementia. Further review of Resident #38's face sheet, revealed under the section ADVANCE DIRECTIVE: FULL CODE<BR/>Record review of Resident #38's Annual MDS, dated [DATE], revealed a BIMS score of 10, which indicated moderate cognitive impairment. <BR/>Record review of Resident #38's Care Plan, dated [DATE], revealed a focus area, Resident has Advance Directives DNR - Do Not Resuscitate and a goal Resident's Advance Directives will be honored. Further review revealed interventions code status will be reviewed on a quarterly basis and PRN and Resident has signed Do Not Resuscitate (DNR).<BR/>Record review of Resident #38's electronic medical record Order Summary Report, Active Orders as of [DATE], revealed an order dated [DATE] for FULL CODE. Further review of Resident #38's electronic medical record, main screen for resident information revealed a section, Code Status: FULL CODE.<BR/>Record review of Resident #38's clinical record at the nurse's station, revealed a red sheet of paper the front of the binder with the words DNR. Further review revealed an OOH-DNR signed by Resident #38's family member, physician and two witnesses.<BR/>In an interview with the SW on [DATE] at 1:05 p.m., the SW revealed Resident #38's OOH-DNR was completed prior to her starting at the facility. The SW stated sometimes the MDS Coordinator assisted residents at times with completing documents and may have information about Resident #38's OOH-DNR. <BR/>In an interview with the MDS Coordinator on [DATE] at 1:10 p.m., the MDS Coordinator revealed Resident #38 had been hospitalized from [DATE] to [DATE]. The MDS Coordinator stated that in the electronic record the resident had been noted as DNR up until [DATE] however when he returned on [DATE] an order for FULL CODE was entered by LVN B. <BR/>In an interview with LVN B on [DATE] at 1:18 p.m., LVN B revealed that he recalled a conversation with the hospital regarding code status at the time Resident #38 transferred to the hospital and the hospital staff told him regardless of the OOH-DNR, the resident would be considered FULL CODE at the hospital. LVN B stated when Resident #38 returned with hospital discharge orders that listed him as FULL CODE the order was not changed back at that time and was entered incorrectly. LVN B stated he would call the family right away to ensure Resident #38's DNR code status had not changed.<BR/>In an interview with the DON on [DATE] at 1:56 p.m., the DON stated Resident #38's code status should have been confirmed by the admitting nurse upon return from the hospital and the order would then correspond with all other areas in the resident's record. <BR/>Record review of the Texas Health and Safety Code Title 2 Health, Subtitle H Public Health Provisions, Chapter 166 Advance Directives, Section 166.083 Form of Out-Of-Hospital DNR order, effective [DATE], revealed, (a) A written out-of-hospital DNR order shall be in the standard form specified by department rule as recommended by the department. (b) The standard form of an out-of-hospital DNR order specified by department rule must, at a minimum, contain the following: . (13) a statement at the bottom of the document, with places for the signature of each person executing the document, that the document has been properly completed.<BR/>Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly. <BR/>Record review of the facility's policy titled, Area of Focus: Advance Directives, reviewed: [DATE], revealed, An advance directive is a written document prepared by the resident as to how he/she wants medical decisions to be made should he or she lose the ability to make decisions for him or herself. All residents or their responsible parties receive materials concerning their rights under applicable laws to make decisions regarding their medical care, including the right to accept or refuse medical care, the right to accept or refuse medical/surgical treatment, organ donation requests, and the formation of advance directives upon admission.

**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, for 1 of 14 residents (Residents #38) reviewed for respiratory care, in that:<BR/>Resident #38's nebulizer mask was unbagged and resting on top of the resident's bedside table. <BR/>This failure could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in a decline in health.<BR/>The findings were:<BR/>Record review of Resident #38's face sheet, dated 04/04/2023, revealed the resident had an initial admission date of 07/06/2021 and was readmitted on [DATE] with diagnoses that included: tracheostomy status, malignant neoplasm of pharynx, dysphagia, speech disturbances and dementia.<BR/>Record review of Resident #38's Annual MDS, dated [DATE], revealed a BIMS score of 10, which indicated moderate cognitive impairment. <BR/>Record review of Resident #38's Care Plan, dated 03/22/2023, revealed a focus area, the resident has a tracheostomy r/t surgery (S/P Esophageal Cancer) with intervention administer nebs via trach collar PRN SOB/congestion initiated 02/16/2022.<BR/>Record review of Resident #38's electronic medical record Order Summary Report, Active Orders as of 04/04/2023, revealed an order dated 01/26/2023 for Budesonide Suspension 0.5 MG/2ML 2 ml inhale orally two times a day for COPD Lung sounds with no end date. Further review revealed an additional order dated 02/07/2023 for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally via nebulizer every 6 hours as needed for Shortness of breath lung sounds with no end date.<BR/>During an observation and interview with Resident #38 on 04/03/2023 at 4:10 pm, revealed Resident #38's nebulizer mask lying on the resident's bedside table unbagged. Resident #38 was asked if nursing staff assist with nebulizer treatments and Resident #38 nodded and in an airy voice d/t his trach attempted an answer however speech was too difficult to understand.<BR/>During an interview with LVN A on 04/03/2023 at 4:18 pm, LVN A stated the nebulizer mask should have been bagged and the bag dated. LVN A stated Resident #38 has scheduled nebulizer treatments twice a day. LVN A added that the last scheduled treatment would have been early this morning prior to this shift. LVN A stated, any pathogen could enter the tubing and then cause an upper respiratory infection if the mask was left unbagged.<BR/>During an interview with the DON on 04/05/2023 at 9:12 a.m., the DON stated a nebulizer mask should always be in a bag that was dated when not in use to protect it from the environment and to prevent infection.<BR/>Record review of the facility's policy titled, Small Volume Nebulizer Therapy, effective 11/10/2022, revealed, The facility will provide Small Volume Nebulizer Therapy in accordance with professional standards of practice. Review of an additional procedure provided by the DON titled, Nebulizer therapy, small volume, revised May 20, 2022, revealed, Critical Notes! [Corporate name] has approved the following information as an addendum to the Lippincott procedure. Nebulizer circuit should be stored in a patient-care set-up bag, labeled with the patient's name, and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed, in that:<BR/>The facility, licensed for 146 beds, did not employ a full-time qualified social worker with a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and psychology and one year of supervised social work experience in a health care setting<BR/>working directly with individuals.<BR/>This failure could place residents at risk of social service and psychosocial needs not being met.<BR/>The findings were:<BR/>Record review of the Facility Summary Report, undated, revealed the facility had a total licensed capacity for 146 beds. <BR/>Record review of the staff roster, provided by the facility, dated [DATE]:46, revealed SSD was listed as Social Services Director. Further review revealed SSD was hired on 12/30/2022. <BR/>In an interview with the SSD on 04/06/2023 at 1:05 p.m., the SSD revealed she had completed her social work degree program in May of 2022, graduated in December of 2022 and was currently studying to take the Social Worker licensing exam. The SSD stated there was another SW at a sister facility that was available to support her if she had questions regarding any SW issues at the facility. <BR/>In an interview with the SW from the sister facility on 04/06/2023 at 1:09 p.m., the SW revealed she was available by telephone to answer questions from the SSD however did not come to this facility or supervise the SSD's work. The SW further revealed her SW license was due for renewal in February of 2023, and she had paid the renewal fee however was not aware she needed fingerprints this renewal period and therefore her renewal was listed as delinquent at this time.<BR/>In an interview with the Administrator on 04/06/2023 at 4:25 p.m., the Administrator revealed he was unaware the full-time social worker requirement was based on bed capacity and thought facilities with less than 120 residents did not require a full-time social worker as long as the designee was supervised by a licensed Social Worker. The Administrator further revealed the licensed SW was monitored by the sister facility HR department and he had not been informed her license had not completed the renewal process.<BR/>Record review of the Texas Administrative Code 554.703, transferred effective January 15, 2021, revealed in part .(a) the facility must provide medically-related social services to attain the highest practicable physical, mental, or psychosocial well-being of each resident. (1) A facility with more than 120 beds must employ a qualified social worker on a full-time basis. (b) A qualified social worker is an individual who is licensed, including a temporary or provisional license, by the Texas State Board of Social Worker Examiners as prescribed by Texas Occupations Code, Chapter 505, and who has at least: (1) a bachelor's degree in social work, or a bachelor's degree in a human services field, including sociology, gerontology, special education, rehabilitation counseling, and psychology; and (2) one year of supervised social work experience in a health care setting working directly with individuals.<BR/>Record review of facility's policy, Social Services Personnel, reviewed 09/30/2022, All facilities are required to provide medically related social services for each resident. Facilities must identify the need for medically related social service and ensure that these services are provided. It is not required that a qualified social worker necessarily provide all of these services, except as required by State law. Each facility has a Director responsible for the provision of social services. Each facility must abide by all state regulations in addition to Federal regulations. Any facility with more than 120 beds must employ a qualified social worker on a full-time basis. A qualified social worker is: An individual with a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field including, and one year supervised social work experience in a health care setting working directly with individuals.

Based on interviews and record reviews, the facility failed to provide and document sufficient preparation and orientation of resident representatives to ensure safe and orderly transfer or discharge from the facility.The facility failed to provide written transfer notices to residents, representatives, and the local ombudsman in a language and manner they understand.This failure could place residents at risk of not receiving information regarding their options, rights, and protection from inappropriate transfers or discharges. Findings included:In an interview with the ADM on 08/05/2025 at 10:41 am, she said the facility had not been sending out written transfer notifications. In an interview with the Ombudsman on 08/05/25 at 2:15 pm, she said she had not been getting written notifications of transfer from the facility. In an interview and record review with the ADM on 08/05/2025 at 4:30 pm, she said she developed and provided a performance improvement plan regarding written transfer policies at this time. In an interview with the ADM on 08/06/2025 at 10:41 am, She said the BOM would have been responsible for sending the letters to the resident, the resident representative, and the ombudsman. She said she did not know why they were not sending out transfer notifications.Record review of the facility's discharge report dated 05/01/25-08/04/25 revealed 55 discharges: 21 to an acute care hospital, 6 to funeral homes, 1 to hospice, 3 to nursing homes, 19 to private homes with home health services, and 5 to private homes without home health services. Record review of the facility's policy reviewed on 11/19/24 titled, Area of Focus: Discharge Process and Bed Holds revealed under Notice before transfer, before a facility transfers or discharges a resident, the facility must: (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they can understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the care plan was revised in a timely manner for 1 of 18 residents (Resident #15), in that: <BR/>Resident #15's care plan had not been revised to reflect the discontinuation of her hemodialysis treatment. <BR/>This failure could affect residents who receive care at the facility and could result in missed or inadequate care.<BR/>The findings were: <BR/>Record review of Resident #15's face sheet, dated 04/06/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Hyperkalemia, Chronic Kidney Disease, and Type 2 Diabetes Mellitus. <BR/>Record review of Resident #15's comprehensive MDS, dated [DATE], revealed a BIMS score of 99 which indicated the resident was unable to complete the interview. Further review revealed a staff assessment was completed and indicated the resident had short-term and long-term memory problems. <BR/>Record review of Resident #15's care plan, revised 02/07/2023, revealed, hemodialysis r/t chronic renal failure.<BR/>Record review of Resident #15's progress notes, dated 02/18/2023, revealed, Went to dialysis today, received call from [nephrologist] office .patient is to stop going to dialysis until further notice .<BR/>During an interview with the DON on 04/06/2023 at 12:12 p.m., the DON stated Resident #15 no longer received dialysis treatments due to an improvement in her condition. <BR/>During an interview with the MDS/Care Plan Coordinator on 04/06/2023 at 12:12 p.m., the MDS/Care Plan Coordinator stated Resident #15 has been discharged from dialysis on 02/17/2023 and the treatment had not been removed from her plan of care as of 04/06/2023. The MDS/Care Plan Coordinator stated the omission was an oversight and would be immediately rectified and stated that residents' plans of care should be revised in an accurate and timely manner to ensure the residents receive appropriate care. <BR/>Record review of the facility policy, Care Planning - Baseline, Comprehensive, and Routine Updates, reviewed 12/05/2022, revealed, Monitoring of Progress: Identify the individual's response to interventions and treatments .Define of refine prognosis, Define or refine when to stop or modify interventions, Identify when care objectives have been achieved sufficiently to allow for discharge, transfer, or change in level of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's a right to a dignified existence for 1 of 18 residents (Resident #51) reviewed for dignity, in that: <BR/>Resident #51's catheter bag did not have a privacy cover while the resident was in a common area of the facility. <BR/>This failure could lead to residents' loss of self-esteem and feelings of dignity. <BR/>The findings were: <BR/>Record review of Resident #51's face sheet, dated 04/05/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Cerebral Palsy, Epilepsy, and Hypotension. <BR/>Record review of Resident #51's comprehensive MDS, dated [DATE], revealed a BIMS score of 5 which indicated severe cognitive impairment. <BR/>Record review of Resident #51's of care plan, revised 02/28/2023, The resident has Indwelling Catheter .<BR/>Observation on 04/05/2023 at 10:46 a.m. revealed Resident #51 was sitting in a common area of the facility, near the nurses' station, and was greeted by several staff members and fellow residents. Further observation revealed Resident #51's catheter bag did not have a privacy cover and the urine which had collected in the bag was clearly visible. <BR/>The resident was not able to be interviewed due to cognitive deficit. <BR/>During an interview with LVN O on 04/05/2023 at 10:48 a.m., LVN O stated Resident #51's catheter bag did not have a privacy cover and the urine which had collected in the bag was clearly visible. LVN O further stated Resident #51's catheter bag should have a privacy cover to ensure the resident's privacy and dignity. <BR/>During an interview with the DON on 04/06/2023, the DON stated her expectation was that all residents with catheters have privacy covers to ensure their privacy and dignity. <BR/>Record review of the facility policy, Resident Rights, reviewed 11/21/2022, revealed, The resident has a right to a dignified existence .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy for 1 of 10 residents (Residents #22] reviewed for privacy.<BR/>The facility failed to ensure Resident #22's bedroom door was closed for privacy as she requested.<BR/>This failure could place residents at risk of having their bodies exposed to the public, resulting in emotional distress and a diminished quality of life.<BR/>The findings included: <BR/>Record review of Resident #22's face sheet dated 05/22/23 reflected an [AGE] year-old female with an original admission date of 03/07/23. Pertinent diagnoses included dementia, stroke, depression, anxiety, and limited range of motion. <BR/>Record review of Resident #22's quarterly MDS assessment dated [DATE] reflected a BIMS score of 13, indicating she was cognitively intact. She required moderate assistance with oral and personal hygiene, substantial assistance with dressing and positioning, and was dependent on staff with toileting, showering, and footwear. She was incontinent of bladder and bowel. Her active diagnosis was medically complex conditions.<BR/>Record review of Resident #22's care plan dated 06/06/2024 on page 1 reflected Resident #22 preferred that her door be kept closed with an initiation date of 03/16/23 and a revision date of 06/06/24. The goal documented resident will have her preference to keep door closed met with an initiation date of 03/16/23 and a revision date on 06/06/24. Interventions indicated close door after care, food delivery, any interactions with an initiation date of 03/16/23.<BR/>Observation of Resident #22's door beginning on 07/01/24 at 11:00 am through 07/03/24 throughout all days of the survey revealed her door was open wide. <BR/>In an interview with Resident #22 on 07/01/24 at 4:05 pm, Resident #22 stated she had requested her door be kept shut ever since she was admitted because she did not like the noise that came from the hallway. She stated the staff never shut her door and that made her angry.<BR/>In an interview with the DON on 07/03/2024 at 2:29 PM, the DON stated residents should have their preferences acknowledged. The DON stated that if resident's privacy was not protected, they could get embarrassed, ultimately leading to emotional distress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's a right to a dignified existence for 1 of 18 residents (Resident #51) reviewed for dignity, in that: <BR/>Resident #51's catheter bag did not have a privacy cover while the resident was in a common area of the facility. <BR/>This failure could lead to residents' loss of self-esteem and feelings of dignity. <BR/>The findings were: <BR/>Record review of Resident #51's face sheet, dated 04/05/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Cerebral Palsy, Epilepsy, and Hypotension. <BR/>Record review of Resident #51's comprehensive MDS, dated [DATE], revealed a BIMS score of 5 which indicated severe cognitive impairment. <BR/>Record review of Resident #51's of care plan, revised 02/28/2023, The resident has Indwelling Catheter .<BR/>Observation on 04/05/2023 at 10:46 a.m. revealed Resident #51 was sitting in a common area of the facility, near the nurses' station, and was greeted by several staff members and fellow residents. Further observation revealed Resident #51's catheter bag did not have a privacy cover and the urine which had collected in the bag was clearly visible. <BR/>The resident was not able to be interviewed due to cognitive deficit. <BR/>During an interview with LVN O on 04/05/2023 at 10:48 a.m., LVN O stated Resident #51's catheter bag did not have a privacy cover and the urine which had collected in the bag was clearly visible. LVN O further stated Resident #51's catheter bag should have a privacy cover to ensure the resident's privacy and dignity. <BR/>During an interview with the DON on 04/06/2023, the DON stated her expectation was that all residents with catheters have privacy covers to ensure their privacy and dignity. <BR/>Record review of the facility policy, Resident Rights, reviewed 11/21/2022, revealed, The resident has a right to a dignified existence .

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 supply room on the facility's 300 hall, in that: <BR/>The doorknob and locking mechanism on the supply room door on the facility's 300 hall was inoperable and as a result, the door was unable to be secured. The supply room contained potential hazardous materials. <BR/>This failure could place residents at risk of living in an unsafe environment.<BR/>The findings were: <BR/>Observation on 04/03/2023 at 2:16 p.m. revealed the supply room door on the facility's 300 hall was unlocked. Further observation revealed the supply room container razors, shampoo, body wash, and liquid cleaning agents. <BR/>During an interview with CNA I on 04/03/2023 at 2:18 p.m., CNA I stated the supply room door was unlocked, and further stated that the locking mechanism and doorknob were inoperable, and as a result, the door was unable to be secured. CNA I further stated the supply room contained materials which were potentially hazardous to residents including: razors, shampoo, body wash, and liquid cleaning agents. <BR/>During an interview with the DON on 04/06/2023 at 10:05 a.m., the DON stated a resident may be harmed by having access to items such as razors, shampoo, body wash, and liquid cleaning agents, and the supply room should have been secured. <BR/>During an interview with the Maintenance Director on 04/06/2023 at 11:57 a.m., the Maintenance Director stated the facility's procedure regarding needed repairs was to log such repairs in the Maintenance book which was found at the nurses' desk. The Maintenance Director also stated that facility staffshould notify him immediately of high priority repairs, such as the inoperable supply room locking mechanism. The Maintenance Director stated he had been immediately notified of the inoperable lock and the lock had been repaired. <BR/>Record review of the facility policy, Plant Operations - General Policy reviewed 07/28/2022, revealed, A safe, clean, and structurally sound environment shall be achieved in the facility .

Based on interview and record review the facility failed to develop and implement policies and procedures for screening through the employee misconduct registry to determine whether the individual is designated as unemployable for 14 of 19 staff (the DM, AD, LVN C, RN D, RN E, RN F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M and CNA N) reviewed for employment registry screenings, in that:<BR/>The DM, AD, LVN C, RN D, RN E, RN F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M and CNA N did not have current employment registry screenings. <BR/>This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.<BR/>The findings were:<BR/>Record review of the staff roster provided on 04/03/2023 by the facility for the DM revealed a hire date of 09/28/2011. Record review of the personnel file for the DM revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021. <BR/>Record review of the staff roster provided on 04/03/2023 by the facility for the AD revealed a hire date of 08/06/2018. Record review of the personnel file for the AD revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021. <BR/>Record review of the staff roster provided on 04/03/2023 by the facility for LVN C revealed a hire date of 12/20/2021. Record review of the personnel file for LVN C revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021. <BR/>Record review of the staff roster provided on 04/03/2023 by the facility for RN D revealed a hire date of 06/17/2011. Record review of the personnel file for RN D revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021. <BR/>Record review of the staff roster provided on 04/03/2023 by the facility for RN E revealed a hire date of 12/01/2016. Record review of the personnel file for RN E revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021. <BR/>Record review of the staff roster provided on 04/03/2023 by the facility for RN F revealed a hire date of 07/25/2006. Record review of the personnel file for RN F revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021. <BR/>Record review of the staff roster provided on 04/03/2023 by the facility for CNA G revealed a hire date of 01/17/2022. Record review of the personnel file for CNA G revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/13/2022. <BR/>Record review of the staff roster provided on 04/03/2023 by the facility for CNA H revealed an initial hire date of 11/14/1986 and a rehire date of 01/18/2022. Record review of the personnel file for CNA H revealed the most recent Employee Misconduct Registry (EMR) check was completed on 04/21/2021. <BR/>Record review of the staff roster provided on 04/03/2023 by the facility for CNA I revealed a hire date of 02/01/2021. Record review of the personnel file for CNA I revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021. <BR/>Record review of the staff roster provided on 04/03/2023 by the facility for CNA J revealed a hire date of 08/09/2019. Record review of the personnel file for CNA J revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021. <BR/>Record review of the staff roster provided on 04/03/2023 by the facility for CNA K revealed a hire date of 02/04/2019. Record review of the personnel file for CNA K revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021. <BR/>Record review of the staff roster provided on 04/03/2023 by the facility for CNA L revealed a hire date of 03/30/2005. Record review of the personnel file for CNA L revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021. <BR/>Record review of the staff roster provided on 04/03/2023 by the facility for CNA M revealed a hire date of 04/28/1988. Record review of the personnel file for CNA M revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021. <BR/>Record review of the staff roster provided on 04/03/2023 by the facility for CNA N revealed a hire date of 04/16/2020. Record review of the personnel file for CNA N revealed the annual Employee Misconduct Registry (EMR) check was completed on 04/21/2021. <BR/>In an interview with the HR Coordinator on 04/06/2023 at 12:45 p.m., the HR Coordinator revealed that in the past the facility staffing coordinator would complete background checks. The HR Coordinator stated employee screenings was a role she was recently assigned but the annual checks must have been missed during the transition.<BR/>In an interview with the Administrator on 04/06/2023 at 1:05 p.m., the Administrator stated the facility had been without a staffing coordinator but that he did not know the EMRs had been missed.<BR/>Record review of the facility's policy titled, Background Screening Policy: Associates, effective date 08/20/2018, revealed, [Facility name] shall conduct background investigations on the following, in accordance with the Department of Health and Human Services (DHHS) Centers for Medicare and Medicaid Services (CMS): * All candidates who have accepted a conditional offer of employment (i.e., full-time, part-time, PRN, temporary, and/or interim Associates). * Associates seeking a job change if the new position requires additional searches (e.g., professional license verification and/or motor vehicle search).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy for 1 of 10 residents (Residents #22] reviewed for privacy.<BR/>The facility failed to ensure Resident #22's bedroom door was closed for privacy as she requested.<BR/>This failure could place residents at risk of having their bodies exposed to the public, resulting in emotional distress and a diminished quality of life.<BR/>The findings included: <BR/>Record review of Resident #22's face sheet dated 05/22/23 reflected an [AGE] year-old female with an original admission date of 03/07/23. Pertinent diagnoses included dementia, stroke, depression, anxiety, and limited range of motion. <BR/>Record review of Resident #22's quarterly MDS assessment dated [DATE] reflected a BIMS score of 13, indicating she was cognitively intact. She required moderate assistance with oral and personal hygiene, substantial assistance with dressing and positioning, and was dependent on staff with toileting, showering, and footwear. She was incontinent of bladder and bowel. Her active diagnosis was medically complex conditions.<BR/>Record review of Resident #22's care plan dated 06/06/2024 on page 1 reflected Resident #22 preferred that her door be kept closed with an initiation date of 03/16/23 and a revision date of 06/06/24. The goal documented resident will have her preference to keep door closed met with an initiation date of 03/16/23 and a revision date on 06/06/24. Interventions indicated close door after care, food delivery, any interactions with an initiation date of 03/16/23.<BR/>Observation of Resident #22's door beginning on 07/01/24 at 11:00 am through 07/03/24 throughout all days of the survey revealed her door was open wide. <BR/>In an interview with Resident #22 on 07/01/24 at 4:05 pm, Resident #22 stated she had requested her door be kept shut ever since she was admitted because she did not like the noise that came from the hallway. She stated the staff never shut her door and that made her angry.<BR/>In an interview with the DON on 07/03/2024 at 2:29 PM, the DON stated residents should have their preferences acknowledged. The DON stated that if resident's privacy was not protected, they could get embarrassed, ultimately leading to emotional distress.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked treatment cart for 1 of 1 treatment cart reviewed for storage of drugs. <BR/>The facility's treatment/medication cart was left unlocked by the nurse's station (only one nurse's station) with the drawers facing outward.<BR/>This deficient practices could affect residents who have medications in the nurse's treatment/medication cart and could result in lost medications, drug diversion, harm due to accidental ingestion of unprescribed medications.<BR/>Findings included:<BR/>Observation on 07/01/24 at 10:30am revealed an unlocked medication/treatment cart located by the nurse's station. The medication/treatment cart was against the nurse's station and one staff member (LVN B) was located at the nurse's station. There were two residents by the nurse's station near the treatment cart. This surveyor opened the top drawer recognizing the treatment cart being unlocked. Multiple medications in bulk bottles were easily assessable and removable. This surveyor was able to open all drawers and go through various medications and treatment supplies. <BR/>In an interview on 07/01/24 at 10:31am, LVN B stated he did not know the treatment cart was unlocked. LVN B stated the treatment cart belonged to the LVN F and was unlocked because a resident was bleeding down the hall and LVN B came to grab supplies and left to tend to resident. LVN B stated all treatment/medication carts should be locked at all times so residents or visitors could not have access to supplies and medications. <BR/>In an interview on 07/01/24 at 10:37am LVN F stated she was alerted there was a resident who was possibly bleeding. LVN F stated the resident just had a surgical procedure and had a history of picking at the surgical staples. LVN F stated all staff went to the resident's room to assist and she grabbed supplies needed and forgot to lock the treatment cart. LVN F stated the cart should be locked at all times for resident safety and so residents could not get into the treatment cart and gain access to supplies and medications. LVN F stated the last in-service on locked treatment/medication carts was approximately sometime last month but could not remember. <BR/>In an interview on 07/01/24 at 10:53am the DON stated all treatment/medication carts should be locked at all times for the safety of residents and other unauthorized people. The DON stated anytime a staff member leaves the treatment/medication carts unattended, the treatment/medication cart should be locked even if there was a resident emergency. The DON stated the last in-service on locking treatment/medication carts was about a month ago. <BR/>Record review of General Dose Preparation and Medication Administration Policy dated 1/1/22 stated:<BR/>7. Facility should ensure that medication carts are always locked when out of sight or unattended.