HUNTSVILLE HEALTH CARE CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of neglect to HHSC for 1 of 5 residents reviewed for neglect. The facility did not report when CNA A did not have another staff member to provided care to Resident #1, left Resident #1 to obtain more supplies for care, and the resident rolled off of the bed. Resident #1 sustained a fracture of the left thigh bone near the knee.This failure could place residents at risk of harm due to delays in reporting neglect. Findings included:Record review of a face sheet dated 10/29/25 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage)/hemiparesis (one-sided muscle weakness) due to cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting left side, pain, peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), and hypertension (condition in which the force of the blood against the artery walls is too high).Record review of the state optional MDS dated [DATE] indicated Resident #1 required extensive assistance of 2 persons for bed mobility. Record review of a Fall Risk Screener dated 09/05/25 indicated Resident #1 was low risk for falls with a score of 9 out of 31 (0-9-low risk; 10-31-high risk).Record review of the quarterly MDS dated [DATE] indicated Resident #1 was dependent for toileting hygiene and required substantial-maximum assistance for roll left-to-right. Record review of an incident report dated 10/22/25 indicated Resident #1 while receiving peri-care from CNA A at 03:20 a.m., resident was rolled onto her side to provide care after an incontinent episode. While the resident was on her side, she suddenly had a large bowel movement in the middle of care. CNA A turned to get some more supplies from the cart he had in the doorway. During that time, the resident attempted to reach for something on her bedside table and rolled off the bed. Nurse was notified and upon arrival, performed a head to toe assessment. No injuries nor bruising noted on assessment. Vitals are normal, respiration was even and unlabored. Resident was assisted back to bed with the help of 2 staff. Resident #1 indicated she hurt all over and PRN pain medication was given as previously ordered by the physician. Record review of Progress Notes indicated a nurse note entry dated 10/22/25 at 03:44 a.m. resident slipped and fell as aid was performing peri care. No injuries nor bruising noted on assessment. Vitals are normal, resp is even and unlabored. Resident is assisted back to bed, pain medication given. Resident is stable condition.Record review of a Post Fall Review dated 10/23/25 at 08:00 a.m. indicated Resident #1 was awake, alert, and oriented to person, place, and time. Her vital signs and neuro checks were normal for the resident with no abnormal findings. Record review of neuro check monitoring documentation from 10/22/25 at 04:00 a.m. through 10/23/25 at 11:00 a.m. indicated no abnormal findings. Record review of Progress Notes with a nurse note entry dated 10/23/25 at 11:18 a.m. indicated Note Text : This nurse presented to patient's room during rounds, patient observed to be lethargic and responsive to painful stimuli only. Vitals were checks - BP: 145/84 HR:125 O2:88MD [name] contacted, verbal orders for ER send out for evaluation and treatment received along with 2L O2 via nasal canula.[Name] EMS contacted 1110[Name] EMS arrival 1120RP - [Name] notified 1118Report called in to ER nurse 1121Patient left facility via stretcher at 1128. During an interview on 10/29/25 at 10:25 a.m. the DON said Resident #1 did not have a fall. He said she was part way out of the bed. He said she was assisted back into bed with no complaints of pain or discomfort. He said the next day she started showing altered mental status, so they sent her to the hospital, and she had a UTI. He said nothing was said about her having a fracture until several days after she was admitted to the hospital. He said the x-ray report he received did not indicate the age of the fracture but did indicate she was osteopenic. He said he was trying to get a determinate of age of the fracture to know if it happened at the facility or at the hospital since he was told she possibly had a fall at the hospital.Record review of a hospital Imaging Report dated 10/23/25 provided by the DON via email on 10/29/25 at 12:37 p.m. indicated Resident #1 had a 2 view x-ray of the left femur at 06:34 p.m. with clinical history of fall injury. Findings were the femur was osteopenic (condition where the bone lacks enough minerals to be strong) and there was a fracture of the femoral (thigh bone) shift near the knee.During a phone interview on 10/29/25 at 01:33 p.m. CNA A said he was making his last 2 hour round on his residents. He said he knew Resident#1 required 2 staff for care. He said when he went to clean Resident #1 he was not able to find any other staff to assist because they were in other rooms. He said he went to clean her up and she had a large bowel movement which he needed more supplies to clean her. He said he lowered the bed but she would raise it up. He said his supply cart was at the room door so he went to get another trash bag and get more supplies. He said Resident #1 screamed and he saw her on the floor so he got the nurse. Resident #1 was not observed or interviewed as she was transferred to another facility from the hospital.During an interview on 10/30/25 at 05:08 p.m. the Administrator said any violation of neglect of a resident should be reported to HHSC. He said he was originally told Resident #1 did not have a fall because only her legs were hanging off the bed when CNA A provided care. He said he had been told several different stories about Resident #1 since then regarding what happened during her care. He said the resident's RP said she had two fractured legs a few days later. The Administrator said he did not know if they happened at the facility or at the hospital.Record review of an undated Abuse, Neglect, and Exploitation policy indicated: .VII. Reporting/ResponseA. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for care plans.The facility failed to ensure that Resident #1's, #2's and #3's care plans were initiated and included appropriate interventions for ADL Care.This failure could place residents who required assistance with care at risk of serious harm and injury. Findings included:1. Record review of a face sheet dated 10/29/25 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage)/hemiparesis (one-sided muscle weakness) due to cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting left side, pain, peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), and hypertension (condition in which the force of the blood against the artery walls is too high). Record review of the care plan initiated on 05/21/25 for Resident #1 did not address her ADL assistance requirements. Record review of the state optional MDS dated [DATE] indicated Resident #1 required extensive assistance of 2 persons for bed mobility. Record review of the quarterly MDS dated [DATE] indicated Resident #1 was dependent for toileting hygiene and required substantial-maximum assistance for roll left-to-right. Record review of an incident report dated 10/22/25 indicated Resident #1 while receiving peri-care from CNA A at 03:20 a.m., resident was rolled onto her side to provide care after an incontinent episode. While the resident was on her side, she suddenly had a large bowel movement in the middle of care. CNA A turned to get some more supplies from the cart he had in the doorway. During that time, the resident attempted to reach for something on her bedside table and rolled off the bed. Nurse was notified and upon arrival, performed a head to toe assessment. No injuries nor bruising noted on assessment. Vitals are normal, respiration was even and unlabored. Resident was assisted back to bed with the help of 2 staff. Resident #1 indicated she hurt all over and PRN pain medication was given as previously ordered by the physician. Record review of Progress Notes indicated a nurse note entry dated 10/22/25 at 03:44 a.m. resident slipped and fell as aid was performing peri care. No injuries nor bruising noted on assessment. Vitals are normal, resp is even and unlabored. Resident is assisted back to bed, pain medication given. Resident is stable condition.Record review of a Post Fall Review dated 10/23/25 at 08:00 a.m. indicated Resident #1 was awake, alert, and oriented to person, place, and time. Her vital signs and neuro checks were normal for the resident with no abnormal findings. Record review of neuro check monitoring documentation from 10/22/25 at 04:00 a.m. through 10/23/25 at 11:00 a.m. indicated no abnormal findings. Record review of Progress Notes with a nurse note entry dated 10/23/25 at 11:18 a.m. indicated Note Text : This nurse presented to patient's room during rounds, patient observed to be lethargic and responsive to painful stimuli only. Vitals were checks - BP: 145/84 HR:125 O2:88MD [name] contacted, verbal orders for ER send out for evaluation and treatment received along with 2L O2 via nasal canula.[Name] EMS contacted 1110[Name] EMS arrival 1120RP - [Name] notified 1118Report called in to ER nurse 1121Patient left facility via stretcher at 1128. During an interview on 10/29/25 at 10:25 a.m. the DON said Resident #1 did not have a fall. He said she was part way out of the bed. He said she was assisted back into bed with no complaints of pain or discomfort. He said the next day she started showing altered mental status, so they sent her to the hospital, and she had a UTI. He said nothing was said about her having a fracture until several days after she was admitted to the hospital. He said the x-ray report he received did not indicate the age of the fracture but did indicate she was osteopenic. He said he was trying to get a determinate of age of the fracture to know if it happened at the facility or at the hospital since he was told she possibly had a fall at the hospital.Record review of a hospital Imaging Report dated 10/23/25 provided by the DON via email on 10/29/25 at 12:37 p.m. indicated Resident #1 had a 2 view x-ray of the left femur at 06:34 p.m. with clinical history of fall injury. Findings were the femur was osteopenic (condition where the bone lacks enough minerals to be strong) and there was a fracture of the femoral (thigh bone) shift near the knee.During a phone interview on 10/29/25 at 01:33 p.m. CNA A said he was making his last 2 hour round on his residents. He said he knew Resident#1 required 2 staff for care. He said when he went to clean Resident #1 he was not able to find any other staff to assist because they were in other rooms. He said he went to clean her up and she had a large bowel movement which he needed more supplies to clean her. He said he lowered the bed but she would raise it up. He said his supply cart was at the room door so he went to get another trash bag and get more supplies. He said Resident #1 screamed and he saw her on the floor so he got the nurse. Resident #1 was not observed or interviewed as she was transferred to another facility from the hospital. 2. Record review of a face sheet dated 10/29/25 indicated Resident #2 was a admitted on [DATE] with a diagnoses of wedge compression fracture (the front part of a spinal bone collapses slightly, making the bone look like a wedge) of the of T9-T10 thoracic vertebrae (the twelve spine bones located in the middle section of the spine), dementia (loss of cognitive functioning), and anxiety (persistent and excessive worry that interferes with daily activities). Record review of the admission MDS dated [DATE] indicated Resident #2 was dependent on staff for personal hygiene and bathing and required maximum assistance with toileting and dressing. Record review of the care plan initiated 10/18/25 did not address Resident #2's ADL assistance requirements. During an observation and interview on 10/29/25 at 11:55 a.m. Resident #2 was up in her wheelchair in the dining room for lunch. She said she was doing fine and everyone was nice. She said staff assisted her when needed. 3. Record review of a face sheet dated 10/29/25 indicated Resident #3 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning), falls, and muscle weakness. Record review of the admission MDS dated [DATE] indicated Resident #3 required substantial to maximum assistance with lower body dressing and bathing, moderate assistance with upper body dressing and footwear, and touch assistance with toileting and eating. Record review of the care plan initiated on 09/30/25 did not address Resident #3's ADL assistance requirements. During an observation and interview on 10/29/25 at 11:58 a.m. Resident #3 was sitting in her wheelchair in the dining room. She said she was doing okay and had no unmet needs. She said staff would help her when needed. During an interview on 10/30/25 at 05:56 p.m. the DON said he was responsible for care plans and they were a collaboration of several people who met and developed the care plan according to the residents' needs and reviewed them at least quarterly or when there was a change in the resident or their needs. A policy for comprehensive care plans was requested but a Baseline Care Plan policy was provided by the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 3 of 4 residents reviewed for quality of care, (Resident #5, #39, and #41) in that:<BR/>The facility failed to remove worn and damaged mechanical lift slings from service.<BR/>The facility failed to obtain physician orders for mechanical lift transfers.<BR/>This deficient practice could result in a loss of quality of life due to injuries.<BR/>Findings included:<BR/>Record review of a facility's face sheet dated 5/21/24 for Resident #5 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia, depression, and type 2 diabetes.<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated that she was rarely/never understood and that Resident #5 was severely cognitively impaired. Assessment also indicated that she was totally dependent with transfers. <BR/>Record review of a comprehensive care plan dated 8/21/23 indicated that she was totally dependent on a mechanical lift with the assistance of 2 persons for transfers.<BR/>Record review of a physician order report dated 5/21/24 for Resident #5 indicated that she did not have a physician order for mechanical lift transfers. <BR/>Record review of a facility face sheet dated 5/21/24 for Resident #39 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: dementia, muscle weakness, and type 2 diabetes.<BR/>Record review of a Comprehensive MDS assessment dated [DATE] for Resident #39 indicated that he had a BIMS score of 5, which indicated that he had severely impaired cognition. Assessment also indicated that he was totally dependent with transfers.<BR/>Record review of a comprehensive care plan dated 7/21/23 for Resident #39 indicated that he was dependent on a mechanical lift with the assistance of 2 staff members for transfers.<BR/>Record review of a physician order report dated 5/21/24 for Resident #39 indicated that he did not have a physician order for mechanical lift transfer.<BR/>Record review of a facility face sheet dated 5/21/24 for Resident #41 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left side weakness/paralysis following a stroke), type 2 diabetes, and anxiety disorder.<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #41 indicated that she had a BIMS score of 15, which indicated that she was cognitively intact. Assessment also indicated that she was totally dependent with transfers.<BR/>Record review of a comprehensive care plan dated 8/21/23 for Resident #41 indicated that she required a mechanical lift with assistance of 2 staff members for transfers.<BR/>Record review of a physician order report dated 5/21/24 for Resident #41 indicated that she did not have a physician order for mechanical lift transfer. <BR/>During an observation on 5/20/23 at 11:45 am Residents #39 was observed in the dining area. Resident #39's mechanical lift sling straps were observed to be faded in color. Resident #39's sling was blue mesh and label indicated that it was a Medline brand sling. <BR/>During an observation and interview on 5/20/24 at 12:33 pm, Resident #41 was observed in her room with mechanical lift sling underneath her in her wheelchair. The lift sling was observed to have straps that were faded in color. Label indicated that it was a Medline brand sling. Resident #41 said that she had not had any falls from the lift.<BR/>During an observation on 5/21/24 at 10:00 am, Residents #39 and Resident #5 were observed in a common area. Resident #39 was up in his wheelchair and had a mechanical lift sling underneath him. Resident #39's sling was mesh and purple in color with multiple loose green strings noted along outer seam of sling, torn area next to hook straps, hook straps were noted to be faded in color, label was unreadable. Resident #5 was observed sitting up in a Broda (brand of wheelchair to assist with positioning) chair. She also had a mechanical lift sling underneath her. The mesh sling was observed to be purple in color, the label was unreadable, straps were faded in color (almost a grayish white), and multiple loose strings were observed along the edging of sling.<BR/>During an interview on 5/21/24 at 10:06 am, Laundry Aide said she had been employed by the facility in laundry for 24 years. She said she would inspect mechanical sling pads for torn spots and loose strings before putting them out for use. She said if she observed any that she would take them out of service. She said she did not use bleach on the lift pad slings. She said worn sling pads could break during use causing residents to fall. <BR/>During an interview on 5/21/24 at 10:10 am, DON observed the mechanical lift pads underneath Resident #5 and #39 in the common area and said they should not have been used to transfer the residents. He said sling pads should be inspected by the staff before using them to transfer a resident and that worn sling pads could put residents at risk for falls. <BR/>During an interview on 5/22/24 at 12:15 pm, the Administrator said there could be a chance of the sling breaking if it was worn. She said they ordered new slings and the DON would be inspecting them routinely from then on. She said they educated the CNAs and they would be expecting the CNAs to inspect all slings prior to using them for a resident. <BR/>During an interview on 5/22/24 at 1:00 pm, CNA D said she had been employed about a year and a half. She said she looked for signs of wear on the lift pads such as loose strings and faded coloring on the straps. She said if she observed any signs of wear, she would not use the lift pad to transfer a resident. She said worn pads could break causing a resident to fall. <BR/>During an interview on 5/22/24 at 1:10 pm, CNA E said she had been employed for about a month. She said she would look for loose seams, faded colors, rips and tears on the lift pads before use. She said that lift pads that had faded coloring, loose seams, and rips or tears could break while using them, and a resident could fall.<BR/>Record review of the facility's policy titled Lifting Machine, Using a Mechanical dated 2001 and revised July 2017 read .8. Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition . and .Discard any worn, frayed or ripped slings .<BR/>Record review of manufacture guidelines Full Body Slings - Instructions for use accessed at www.medline.com on 5/21/24 read .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use . and .Do not remove sling labels. If sling labels are removed or no longer legible, sling must be immediately removed from use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, 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 #12) reviewed for infection control.<BR/>The facility failed to ensure CNA C sanitized or washed her hands after changing gloves when providing incontinent care to Resident #12 on 5/20/2024.<BR/>This failure could place residents at risk of exposure to communicable diseases and infections.<BR/>Findings include:<BR/>Record review of an admission Record dated 5/21/2024 for Resident #12 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of hemiplegia and hemiparesis following cerebral infarction (paralysis on one side following a stroke), gastrostomy status (tube placed into the stomach for feeding), end stage renal disease (kidneys are no longer able to function on their own) and autistic disorder (a developmental disorder that could cause the inability to communicate or interact). <BR/>Record review of a Significant Change MDS assessment dated [DATE] for Resident #12 indicated he was rarely/never understood. He was dependent with all ADLs. He was always incontinent of bowel and bladder. <BR/>Record review of a care plan revised on 5/15/2024 for Resident #12 indicated he had an ADL self-care performance deficit related to confusion, impaired mobility with interventions to provide personal hygiene/oral care and was totally dependent on one staff. He had bowel/bladder incontinence and interventions to check on rounds as required for incontinence. <BR/>During an observation on 5/20/2024 at 11:20 AM, RN B and CNA C were present in Resident #12's room to provide wound care. RN B and CNA C sanitized/washed their hands and donned a gown and gloves. Wound care supplies were on waxed paper on the over bed table, supplies were placed on the wax paper. CNA C rolled Resident #12 onto his left side and pulled his brief down. RN B removed the dressing from his sacrum and placed it in the trash along with her gloves. RN B sanitized her hands and walked away from the bed to the door and removed gloves that was on the wall and placed gloves on both hands. RN B cleaned the sacral area with normal saline and gauze and placed it in the trash. RN B removed her gloves and placed them in the trash and sanitized her hands. RN B walked away from the bed to the door to get more gloves and applied them to both hands and used a gauze and patted sacrum area dry. CNA C removed wipes from a plastic bag and started wiping stool from his rectum front to back. CNA C placed the wipes in a trash bag and removed her gloves and put on gloves without washing or sanitizing her hands. RN B removed her gloves and placed in the trash, sanitized her hands, and walked to the door to get more gloves and applied them to both hands. RN B placed an alginate dressing to the wound bed and removed her gloves and placed them in the trash. RN B sanitized her hands and walked to the door to get more gloves and applied them to both hands. RN B applied a foam dressing. CNA C removed more wipes from the plastic bag and wiped his periarea in the front and removed gloves and placed in the trash. CNA C applied gloves to both hands without washing or sanitizing her hands. CNA C rolled the resident onto his right side and removed the brief and placed a clean brief underneath his buttocks and secured it. RN B removed her gloves and placed them in the trash. The resident was positioned in bed, and CNA C removed her gloves and placed them in the trash. Both RN B and CNA C removed their ppe and washed their hands. <BR/>During an interview on 5/20/2024 at 4:25 PM, CNA C said she had been employed at the facility for a year and worked the hall where Resident #12 resided. She said during the incontinent care/wound care provided to him earlier she should have washed or sanitized her hands between gloves changes. She said she did not have sanitizer with her. She said she could not leave the resident to go and wash her hands because RN B kept leaving the bedside to get more gloves from the wall mount after she removed her gloves. She said she had a check off about 3 months ago on hand hygiene. She said residents could be at risk of infections if staff did not wash or sanitize their hands between glove changes.<BR/>During an interview on 5/22/2024 at 11:06 AM, the ADON said she had been employed at the facility for 6 months. She said staff should be washing or sanitizing their hands before care, during and between, when putting a new brief, and when changing gloves. She said she was responsible for conducting the skills check offs with staff. She said she conducted in-service training on hand hygiene every 3 months. She said if staff did not perform hand hygiene, there was a risk of infections to the residents and cross contamination. She said going forward they would in-service staff and continue education.<BR/>During an interview on 5/22/2024 at 11:21, the DON said he had been employed at the facility since April 2024. He said staff should be washing or sanitizing their hands before care, during care and between glove changes. He said they would continue to in-service staff on hand wash/hygiene. He said residents could be at risk for infections and staff transferring infections to other residents. <BR/>During an interview on 5/22/2024 at 11:34 AM, the Administrator said staff should be sanitizing or washing their hands between care, when taking off gloves, and changing contact areas. She said going forward, they would continue to train, educate, in-service, and observe staff on hand hygiene. She said there was a risk of infections to the residents if staff did not follow proper hand hygiene.<BR/>Record review of a competency evaluation dated 12/15/2023 for CNA C indicated that she was checked off on hand washing/hygiene by the ADON.<BR/>Record review of the facility's policy titled Handwashing/Hand Hygiene revised August 2019 indicated, .This facility considers hand hygiene the primary means to prevent the spread of infection. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: a. Before and after coming on duty; m. After removing gloves; 8. Hand hygiene is the final step after removing and disposing of personal protective equipment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 3 of 4 residents reviewed for quality of care, (Resident #5, #39, and #41) in that:<BR/>The facility failed to remove worn and damaged mechanical lift slings from service.<BR/>The facility failed to obtain physician orders for mechanical lift transfers.<BR/>This deficient practice could result in a loss of quality of life due to injuries.<BR/>Findings included:<BR/>Record review of a facility's face sheet dated 5/21/24 for Resident #5 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia, depression, and type 2 diabetes.<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated that she was rarely/never understood and that Resident #5 was severely cognitively impaired. Assessment also indicated that she was totally dependent with transfers. <BR/>Record review of a comprehensive care plan dated 8/21/23 indicated that she was totally dependent on a mechanical lift with the assistance of 2 persons for transfers.<BR/>Record review of a physician order report dated 5/21/24 for Resident #5 indicated that she did not have a physician order for mechanical lift transfers. <BR/>Record review of a facility face sheet dated 5/21/24 for Resident #39 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: dementia, muscle weakness, and type 2 diabetes.<BR/>Record review of a Comprehensive MDS assessment dated [DATE] for Resident #39 indicated that he had a BIMS score of 5, which indicated that he had severely impaired cognition. Assessment also indicated that he was totally dependent with transfers.<BR/>Record review of a comprehensive care plan dated 7/21/23 for Resident #39 indicated that he was dependent on a mechanical lift with the assistance of 2 staff members for transfers.<BR/>Record review of a physician order report dated 5/21/24 for Resident #39 indicated that he did not have a physician order for mechanical lift transfer.<BR/>Record review of a facility face sheet dated 5/21/24 for Resident #41 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left side weakness/paralysis following a stroke), type 2 diabetes, and anxiety disorder.<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #41 indicated that she had a BIMS score of 15, which indicated that she was cognitively intact. Assessment also indicated that she was totally dependent with transfers.<BR/>Record review of a comprehensive care plan dated 8/21/23 for Resident #41 indicated that she required a mechanical lift with assistance of 2 staff members for transfers.<BR/>Record review of a physician order report dated 5/21/24 for Resident #41 indicated that she did not have a physician order for mechanical lift transfer. <BR/>During an observation on 5/20/23 at 11:45 am Residents #39 was observed in the dining area. Resident #39's mechanical lift sling straps were observed to be faded in color. Resident #39's sling was blue mesh and label indicated that it was a Medline brand sling. <BR/>During an observation and interview on 5/20/24 at 12:33 pm, Resident #41 was observed in her room with mechanical lift sling underneath her in her wheelchair. The lift sling was observed to have straps that were faded in color. Label indicated that it was a Medline brand sling. Resident #41 said that she had not had any falls from the lift.<BR/>During an observation on 5/21/24 at 10:00 am, Residents #39 and Resident #5 were observed in a common area. Resident #39 was up in his wheelchair and had a mechanical lift sling underneath him. Resident #39's sling was mesh and purple in color with multiple loose green strings noted along outer seam of sling, torn area next to hook straps, hook straps were noted to be faded in color, label was unreadable. Resident #5 was observed sitting up in a Broda (brand of wheelchair to assist with positioning) chair. She also had a mechanical lift sling underneath her. The mesh sling was observed to be purple in color, the label was unreadable, straps were faded in color (almost a grayish white), and multiple loose strings were observed along the edging of sling.<BR/>During an interview on 5/21/24 at 10:06 am, Laundry Aide said she had been employed by the facility in laundry for 24 years. She said she would inspect mechanical sling pads for torn spots and loose strings before putting them out for use. She said if she observed any that she would take them out of service. She said she did not use bleach on the lift pad slings. She said worn sling pads could break during use causing residents to fall. <BR/>During an interview on 5/21/24 at 10:10 am, DON observed the mechanical lift pads underneath Resident #5 and #39 in the common area and said they should not have been used to transfer the residents. He said sling pads should be inspected by the staff before using them to transfer a resident and that worn sling pads could put residents at risk for falls. <BR/>During an interview on 5/22/24 at 12:15 pm, the Administrator said there could be a chance of the sling breaking if it was worn. She said they ordered new slings and the DON would be inspecting them routinely from then on. She said they educated the CNAs and they would be expecting the CNAs to inspect all slings prior to using them for a resident. <BR/>During an interview on 5/22/24 at 1:00 pm, CNA D said she had been employed about a year and a half. She said she looked for signs of wear on the lift pads such as loose strings and faded coloring on the straps. She said if she observed any signs of wear, she would not use the lift pad to transfer a resident. She said worn pads could break causing a resident to fall. <BR/>During an interview on 5/22/24 at 1:10 pm, CNA E said she had been employed for about a month. She said she would look for loose seams, faded colors, rips and tears on the lift pads before use. She said that lift pads that had faded coloring, loose seams, and rips or tears could break while using them, and a resident could fall.<BR/>Record review of the facility's policy titled Lifting Machine, Using a Mechanical dated 2001 and revised July 2017 read .8. Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition . and .Discard any worn, frayed or ripped slings .<BR/>Record review of manufacture guidelines Full Body Slings - Instructions for use accessed at www.medline.com on 5/21/24 read .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use . and .Do not remove sling labels. If sling labels are removed or no longer legible, sling must be immediately removed from use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, 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 #12) reviewed for infection control.<BR/>The facility failed to ensure CNA C sanitized or washed her hands after changing gloves when providing incontinent care to Resident #12 on 5/20/2024.<BR/>This failure could place residents at risk of exposure to communicable diseases and infections.<BR/>Findings include:<BR/>Record review of an admission Record dated 5/21/2024 for Resident #12 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of hemiplegia and hemiparesis following cerebral infarction (paralysis on one side following a stroke), gastrostomy status (tube placed into the stomach for feeding), end stage renal disease (kidneys are no longer able to function on their own) and autistic disorder (a developmental disorder that could cause the inability to communicate or interact). <BR/>Record review of a Significant Change MDS assessment dated [DATE] for Resident #12 indicated he was rarely/never understood. He was dependent with all ADLs. He was always incontinent of bowel and bladder. <BR/>Record review of a care plan revised on 5/15/2024 for Resident #12 indicated he had an ADL self-care performance deficit related to confusion, impaired mobility with interventions to provide personal hygiene/oral care and was totally dependent on one staff. He had bowel/bladder incontinence and interventions to check on rounds as required for incontinence. <BR/>During an observation on 5/20/2024 at 11:20 AM, RN B and CNA C were present in Resident #12's room to provide wound care. RN B and CNA C sanitized/washed their hands and donned a gown and gloves. Wound care supplies were on waxed paper on the over bed table, supplies were placed on the wax paper. CNA C rolled Resident #12 onto his left side and pulled his brief down. RN B removed the dressing from his sacrum and placed it in the trash along with her gloves. RN B sanitized her hands and walked away from the bed to the door and removed gloves that was on the wall and placed gloves on both hands. RN B cleaned the sacral area with normal saline and gauze and placed it in the trash. RN B removed her gloves and placed them in the trash and sanitized her hands. RN B walked away from the bed to the door to get more gloves and applied them to both hands and used a gauze and patted sacrum area dry. CNA C removed wipes from a plastic bag and started wiping stool from his rectum front to back. CNA C placed the wipes in a trash bag and removed her gloves and put on gloves without washing or sanitizing her hands. RN B removed her gloves and placed in the trash, sanitized her hands, and walked to the door to get more gloves and applied them to both hands. RN B placed an alginate dressing to the wound bed and removed her gloves and placed them in the trash. RN B sanitized her hands and walked to the door to get more gloves and applied them to both hands. RN B applied a foam dressing. CNA C removed more wipes from the plastic bag and wiped his periarea in the front and removed gloves and placed in the trash. CNA C applied gloves to both hands without washing or sanitizing her hands. CNA C rolled the resident onto his right side and removed the brief and placed a clean brief underneath his buttocks and secured it. RN B removed her gloves and placed them in the trash. The resident was positioned in bed, and CNA C removed her gloves and placed them in the trash. Both RN B and CNA C removed their ppe and washed their hands. <BR/>During an interview on 5/20/2024 at 4:25 PM, CNA C said she had been employed at the facility for a year and worked the hall where Resident #12 resided. She said during the incontinent care/wound care provided to him earlier she should have washed or sanitized her hands between gloves changes. She said she did not have sanitizer with her. She said she could not leave the resident to go and wash her hands because RN B kept leaving the bedside to get more gloves from the wall mount after she removed her gloves. She said she had a check off about 3 months ago on hand hygiene. She said residents could be at risk of infections if staff did not wash or sanitize their hands between glove changes.<BR/>During an interview on 5/22/2024 at 11:06 AM, the ADON said she had been employed at the facility for 6 months. She said staff should be washing or sanitizing their hands before care, during and between, when putting a new brief, and when changing gloves. She said she was responsible for conducting the skills check offs with staff. She said she conducted in-service training on hand hygiene every 3 months. She said if staff did not perform hand hygiene, there was a risk of infections to the residents and cross contamination. She said going forward they would in-service staff and continue education.<BR/>During an interview on 5/22/2024 at 11:21, the DON said he had been employed at the facility since April 2024. He said staff should be washing or sanitizing their hands before care, during care and between glove changes. He said they would continue to in-service staff on hand wash/hygiene. He said residents could be at risk for infections and staff transferring infections to other residents. <BR/>During an interview on 5/22/2024 at 11:34 AM, the Administrator said staff should be sanitizing or washing their hands between care, when taking off gloves, and changing contact areas. She said going forward, they would continue to train, educate, in-service, and observe staff on hand hygiene. She said there was a risk of infections to the residents if staff did not follow proper hand hygiene.<BR/>Record review of a competency evaluation dated 12/15/2023 for CNA C indicated that she was checked off on hand washing/hygiene by the ADON.<BR/>Record review of the facility's policy titled Handwashing/Hand Hygiene revised August 2019 indicated, .This facility considers hand hygiene the primary means to prevent the spread of infection. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: a. Before and after coming on duty; m. After removing gloves; 8. Hand hygiene is the final step after removing and disposing of personal protective equipment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 one of four hallways (Hallway 200) reviewed for physical environment.<BR/>The facility failed to maintain the walls, ceiling, and floor in the shared restroom for rooms [ROOM NUMBERS] located on the 200 hallway.<BR/> The facility failed to remove a broken dresser from room [ROOM NUMBER] located on the 200 hallway.<BR/>The potential outcome statement goes here<BR/>Findings included:<BR/>During an observation on 06/16/2025 at 9:53 AM, the shared restroom for room [ROOM NUMBER] and 210 had 6 holes one inch to one and a half inch in diameter in the sheetrock wall beside the toilet, the floor was dirty, discolored gray, brown with no visible wax or coating and worn. Black-brown dirt debris substance was around the bottom of the toilet that had clear caulk over it. Dirt-dust debris was on the wall underneath the sink. There was a 6-inch area on the ceiling where the ceiling texture was flaking off from prior water damage. <BR/>During an observation on 06/16/2025 at 10:15 AM, room [ROOM NUMBER] had a dresser with a broken top, a ten-inch area of particle board was exposed which would not allow proper cleaning and disinfection of the surface and the vinyl trim was hanging loose from the left side edge of the dresser. <BR/>During an interview on 6/17/2025 at 10:30 AM, LVN L said the dresser had been damaged due to staff raising and lowering the electric bed while providing care and catching the dresser edge. She said the dresser needed to be replaced due to it could not be properly cleaned. She said the dresser should be moved to another area in the room to prevent more damage. <BR/>During an interview on 06/17/2025 at 11:30 AM, CNA M said she had only worked at the facility for a few weeks. She said she thought the broken dresser was not appropriate but did not know if it was acceptable or not or who exactly to report the broken dresser to. She said the broken dresser could not be properly cleaned and did not look nice.<BR/>During an interview on 06/17/2025 at 2:30 PM, the Director of Maintenance said he had worked at the facility for a couples of months and had been busy making repairs needed. He said he was not aware of the needed repairs to the bathroom shared by rooms [ROOM NUMBERS] but he would put it on his list.<BR/>During an interview on 6/18/2025 at 10:30 AM the Administrator said she expected the bathrooms to be maintained and furniture to be in good condition in the resident rooms. She said she would have the shared bathroom for room [ROOM NUMBER] and 210 holes cleaned and repaired. The Administrator said she had ordered new dressers for the resident rooms and would replace the dresser in room [ROOM NUMBER] She said the risk to the residents was to live in an environment that was not sanitary and safe.<BR/>Record Review of an undated facility policy titled, Resident Rooms reflected .Resident bedrooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents .10. Resident rooms will be furnished with functional furniture and arranged according to resident needs and preferences .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 3 of 4 residents reviewed for quality of care, (Resident #5, #39, and #41) in that:<BR/>The facility failed to remove worn and damaged mechanical lift slings from service.<BR/>The facility failed to obtain physician orders for mechanical lift transfers.<BR/>This deficient practice could result in a loss of quality of life due to injuries.<BR/>Findings included:<BR/>Record review of a facility's face sheet dated 5/21/24 for Resident #5 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia, depression, and type 2 diabetes.<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated that she was rarely/never understood and that Resident #5 was severely cognitively impaired. Assessment also indicated that she was totally dependent with transfers. <BR/>Record review of a comprehensive care plan dated 8/21/23 indicated that she was totally dependent on a mechanical lift with the assistance of 2 persons for transfers.<BR/>Record review of a physician order report dated 5/21/24 for Resident #5 indicated that she did not have a physician order for mechanical lift transfers. <BR/>Record review of a facility face sheet dated 5/21/24 for Resident #39 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: dementia, muscle weakness, and type 2 diabetes.<BR/>Record review of a Comprehensive MDS assessment dated [DATE] for Resident #39 indicated that he had a BIMS score of 5, which indicated that he had severely impaired cognition. Assessment also indicated that he was totally dependent with transfers.<BR/>Record review of a comprehensive care plan dated 7/21/23 for Resident #39 indicated that he was dependent on a mechanical lift with the assistance of 2 staff members for transfers.<BR/>Record review of a physician order report dated 5/21/24 for Resident #39 indicated that he did not have a physician order for mechanical lift transfer.<BR/>Record review of a facility face sheet dated 5/21/24 for Resident #41 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (left side weakness/paralysis following a stroke), type 2 diabetes, and anxiety disorder.<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #41 indicated that she had a BIMS score of 15, which indicated that she was cognitively intact. Assessment also indicated that she was totally dependent with transfers.<BR/>Record review of a comprehensive care plan dated 8/21/23 for Resident #41 indicated that she required a mechanical lift with assistance of 2 staff members for transfers.<BR/>Record review of a physician order report dated 5/21/24 for Resident #41 indicated that she did not have a physician order for mechanical lift transfer. <BR/>During an observation on 5/20/23 at 11:45 am Residents #39 was observed in the dining area. Resident #39's mechanical lift sling straps were observed to be faded in color. Resident #39's sling was blue mesh and label indicated that it was a Medline brand sling. <BR/>During an observation and interview on 5/20/24 at 12:33 pm, Resident #41 was observed in her room with mechanical lift sling underneath her in her wheelchair. The lift sling was observed to have straps that were faded in color. Label indicated that it was a Medline brand sling. Resident #41 said that she had not had any falls from the lift.<BR/>During an observation on 5/21/24 at 10:00 am, Residents #39 and Resident #5 were observed in a common area. Resident #39 was up in his wheelchair and had a mechanical lift sling underneath him. Resident #39's sling was mesh and purple in color with multiple loose green strings noted along outer seam of sling, torn area next to hook straps, hook straps were noted to be faded in color, label was unreadable. Resident #5 was observed sitting up in a Broda (brand of wheelchair to assist with positioning) chair. She also had a mechanical lift sling underneath her. The mesh sling was observed to be purple in color, the label was unreadable, straps were faded in color (almost a grayish white), and multiple loose strings were observed along the edging of sling.<BR/>During an interview on 5/21/24 at 10:06 am, Laundry Aide said she had been employed by the facility in laundry for 24 years. She said she would inspect mechanical sling pads for torn spots and loose strings before putting them out for use. She said if she observed any that she would take them out of service. She said she did not use bleach on the lift pad slings. She said worn sling pads could break during use causing residents to fall. <BR/>During an interview on 5/21/24 at 10:10 am, DON observed the mechanical lift pads underneath Resident #5 and #39 in the common area and said they should not have been used to transfer the residents. He said sling pads should be inspected by the staff before using them to transfer a resident and that worn sling pads could put residents at risk for falls. <BR/>During an interview on 5/22/24 at 12:15 pm, the Administrator said there could be a chance of the sling breaking if it was worn. She said they ordered new slings and the DON would be inspecting them routinely from then on. She said they educated the CNAs and they would be expecting the CNAs to inspect all slings prior to using them for a resident. <BR/>During an interview on 5/22/24 at 1:00 pm, CNA D said she had been employed about a year and a half. She said she looked for signs of wear on the lift pads such as loose strings and faded coloring on the straps. She said if she observed any signs of wear, she would not use the lift pad to transfer a resident. She said worn pads could break causing a resident to fall. <BR/>During an interview on 5/22/24 at 1:10 pm, CNA E said she had been employed for about a month. She said she would look for loose seams, faded colors, rips and tears on the lift pads before use. She said that lift pads that had faded coloring, loose seams, and rips or tears could break while using them, and a resident could fall.<BR/>Record review of the facility's policy titled Lifting Machine, Using a Mechanical dated 2001 and revised July 2017 read .8. Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition . and .Discard any worn, frayed or ripped slings .<BR/>Record review of manufacture guidelines Full Body Slings - Instructions for use accessed at www.medline.com on 5/21/24 read .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use . and .Do not remove sling labels. If sling labels are removed or no longer legible, sling must be immediately removed from use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure that residents who were fed by enteral feeding, received appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #12) reviewed for quality of care. <BR/>The facility failed to ensure that Resident #12's feeding tube bags were labeled which included the initials of staff that hung the bag and the time it was hung to ensure residents maintain nutritional status within optimal parameters on [DATE].<BR/>This failure could place residents receiving enteral feedings at risk of not receiving feeding care in a timely manner and receiving old or expired feed. <BR/>Findings included: <BR/>Record review of an admission Record dated [DATE] for Resident #12 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of hemiplegia and hemiparesis following cerebral infarction (paralysis on one side of the body following a stroke), gastrostomy status (tube inserted into the stomach for feeding), end stage renal disease (kidneys are no longer able to function on their own) and autistic disorder (a developmental disorder that can cause the inability to communicate or interact). <BR/>Record review of a Significant Change MDS assessment dated [DATE] for Resident #12 indicated he was rarely/never understood. He was dependent with all ADLs. He was always incontinent of bowel and bladder. He had a feeding tube while a resident during the 7-day look back period. <BR/>Record review of a care plan revised on [DATE] for Resident #12 indicated he required tube feeding related to CVA with dysphagia. Interventions included to administer enteral feeding, medications, and water flushes as ordered. Interventions also indicated to change feeding set/syringe/tubing daily and as needed. <BR/>Record review of active physician orders dated [DATE] for Resident #12 indicated he was on a NPO diet, g tube (feeding tube) continuous feeding of Nepro 1.8 at 55 cc/hr x18 hours.<BR/>During an observation on [DATE] at 11:10 AM, Resident #12 was in bed awake but nonverbal. He had tube feeding of Nepro on a pump infusing at 55 ml/hr with 30 ml water flush every 1 hr. A 1000 ml feeding bag that had approximately 500 ml of formula with a label dated [DATE], no time noted on bag or initials of who hung it. A 1000 ml bag of water noted with approximately 800 ml did not have a label on it.<BR/>During a phone interview on [DATE] at 9:36 PM, LVN A said she had been employed at the facility for 1 1/2 year and only worked the night shift from 6 pm to 6 am. She said the nursing staff were responsible for hanging feeding bags and labeling them. She said she took care of Resident #12 on the night of [DATE] and morning of [DATE]. She said her shift ended at 6 am on [DATE]. She said on Monday morning [DATE] at 4 am, she hung a new bag of feeding for him along with water. She said she always just placed a label on one of the bags because the bags came together as a set of two. She said the label should include the resident's name, date, time, rate of feeding, type of feeding and the initials of the staff that hung the bag. She said she did not realize that she did not put a time on the bag and probably should have labeled both bags. She said she had a skills check off in the past on medication administration with g-tubes and it included labeling the feeding bags. She said residents could be at risk of receiving incorrect feedings, incorrect flow rates or getting a feeding that was old if it was not labeled properly. She said residents could be at risk of GI issues because they ould not want to give a resident curdled milk.<BR/>During an interview on [DATE] at 11:06 AM, the ADON said she had been employed at the facility for 6 months. She said feeding tubes should be labeled and that included the resident's name, type of feeding, water flush, rate of feeding, the time it was hung, date, and initials of staff. She said both the feeding and water bag should be labeled. She said there was a risk of potentially getting old feedings if there was not a time indicated and it should have been immediately changed and an assessment completed on the resident. She said nursing was responsible for labeling the feedings and water. She said going forward, she would in-service staff to make sure the labels were complete and give them more education.<BR/>During an interview on [DATE] at 11:21 AM, the DON said he had been employed at the facility since [DATE]. He said g-tube feeding labels should include the initials of staff, time, type of feeding, date, and rate of flow, and the water bag should have a label also. He said the bags should be changed every 24 hours and the label should have a time to indicate when it was hung. He said going forward, he would in-service staff to ensure the feedings were labeled properly.<BR/>During an interview on [DATE] at 11:34 AM, the Administrator said maintenance of feeding tubes were the responsibility of the nursing staff. She said there was a risk of a feedings being old if there was not a time on it to show when it was hung. She said going forward, they would be monitoring along with the DON to ensure they were labeled properly.<BR/>Record review of a RN/LPN Competency Checklist dated [DATE] for LVN A by the ADON indicated she was competent in set up and maintain oxygen and maintenance of g-tubes.<BR/>Record review of the facility's policy titled Care and Treatment of Feeding Tube dated [DATE] indicated, .It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 7 residents (Resident #4) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #4's nasal cannula tubing, on their wheelchair, was changed every 7 days, labeled and bagged to prevent contaimination when not in use.<BR/>The deficient practice could place residents at risk of developing respiratory infections and complications.<BR/>Findings include:<BR/>Record review of Resident #4's facility face sheet, dated 04/03/2023, indicated Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, cough and chronic respiratory failure.<BR/>Record review of quarterly MDS, dated [DATE], indicated Resident # 4 required oxygen therapy and was cognitively intact.<BR/>Record review of Resident #4's care plan, review date 12/19/22 indicated Resident # 4 had shortness of breath and required oxygen therapy.<BR/>Record review of Resident #4's physician's order summary, dated 04/03/2023, indicated oxygen 2-4 liters per nasal cannula with a start date of 01/22/2022. <BR/>During an observation and interview on 04/02/23 at 12:11 PM revealed Resident # 4 's, O2 tubing and nasal cannula was not bagged or dated and was connected to the O2 cylinder on the wheelchair. The cannula and tubing was coiled up on the wheelchair handle, not bagged and not dated. Resident # 4 said she got up in her wheelchair every day and used the oxygen on her wheelchair when she would leave her room. <BR/>During an observation on 04/03/23 11:32 AM revealed the O2 cannula and tubing on Resident #4's wheelchair was not in use. The tubing was not dated, not bagged and was wound up around the right-side handle of the wheelchair.<BR/>During an observation on 4/03/23 at 2:00 PM revealed Resident #4 had a portable oxygen cylinder attached to her wheelchair with oxygen in use at 3 liters per nasal cannula. The cannula and tubing were undated. <BR/>During an observation and interview on 04/03/23 at 2:45 PM revealed Resident #4 was sitting in her wheelchair and had oxygen in place at 3 liters per nasal cannula connected to the cylinder on the wheelchair. The nasal cannula tubing was undated. She said she used her oxygen when up in her wheelchair to attend the resident council meeting held at 2:00 PM today.<BR/>During an interview and observation on 04/03/23 at 3:00 PM, LVN A said oxygen tubing and supplies were changed on the night shift each week but each nurse was responsible for their residents on each shift. She stated she was not aware any oxygen tubing on Resident #4's wheelchair was not dated or bagged. LVN A looked at the wheelchair in the resident's room, and said it belonged to Resident #4. She acknowledged the oxygen cannula and tubing were not dated or bagged and the tubing was coiled around the right-side handle of the wheelchair. She said the risk of not dating, changing tubing weekly and contaminating the tubing by wrapping it around the handle of the wheelchair could be respiratory infections. <BR/>During an interview on 04/03/2023 at 3:15 PM, the DON stated the nurses on the night shift were responsible for changing out the oxygen tubing and nebulizer setups each Sunday night or as needed. She stated she and the ADON was responsible for hall checks and ensuring tasks were completed. She stated the risk could be infection and improper distribution of oxygen. She stated she had been in her position as the DON for two years. She said the staff would be in-serviced on the facility policy and expected that all respiratory supplies were changed out weekly, dated and bagged when not in use. <BR/>During an interview on 04/03/2023 at 4:00 PM, the Administrator stated the DON and ADON were responsible for oversight in the nursing department. She stated she would assist with overseeing the DON and ADON were retraining nursing staff on policy and procedures and her expectation was that the policy and nursing standards of care were followed. <BR/>Record review of the facility policy and procedure titled Respiratory Therapy- Prevention of Infection, dated November 2022 revealed, Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .7. Change the oxygen cannula and tubing every 7days or as needed .8. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation.<BR/>1. <BR/>The facility failed to ensure the DA effectively wore a hair net to cover all his hair on 5/20/2024 and the Dietary Manager effectively wore a hair net to cover all her hair on 5/20/2024 and 5/21/2024.<BR/>2. <BR/>The facility failed to ensure foods stored in the refrigerators, freezers and dry pantry were labeled, dated, and not kept past their expiration dates.<BR/>3. <BR/>The facility failed to ensure containers of oil and sugar were sealed properly.<BR/>4. <BR/>The facility failed to ensure frozen green bean and frozen egg and cheese omelets were sealed and stored properly in freezer.<BR/>5. <BR/>The facility failed to ensure celery and bell peppers were stored properly and not kept beyond use by date.<BR/>6. <BR/>The facility failed to ensure foods in the freezer were not stored under a dripping pipe. <BR/>7. <BR/>The facility failed to ensure proper sanitation of the food processor between pureeing each food item. <BR/>8. <BR/>The facility failed to ensure proper hand washing between tasks.<BR/>These failures could place residents at risk of foodborne illness and food contamination.<BR/>Findings included:<BR/>During an observation on 5/20/2024 at 10:10 a.m. the DA and DM were observed in the kitchen wearing a hair net that did not completely cover their hair. They had hair that was sticking out on the sides of their heads by their ears and at the back of their head. <BR/>During an observation and interview on 5/20/2024 at 10:12 AM, sugar was observed stored under a table with the lid half off and cooking oil was observed with no lid. The DM said someone had just used them for breakfast and left them off. <BR/>During an observation 5/20/2024 at 10:20 AM the freezer had a pipe in the back wrapped with tape and water was observed dripping and refreezing. An open uncovered box of green beans was observed unsealed with no label or date and a box of frozen egg and cheese omelets was observed sitting under a dripping pipe frozen over with a thick layer of solid ice.<BR/>During an observation on 5/21/2024 at 10:50 AM kitchen staff (Cook, DA, and Dietitian) exited and reentered the kitchen several times during observation on 5/21/24 between 10:50 am and 11:45 am without washing or sanitizing their hands. <BR/>During an observation and interview on 5/20/2024 at 10:35 AM, the refrigerator had 1 box of open uncovered celery with brown spots observed on most of the stalk and wilted with use by date of 4/18/2024, 1 box of open uncovered bell peppers with brown, black, and white spots with use by date of 4/18/2024, 3 loaves of bread with use by date of 4/8/2024. A cart observed sitting in the cooler had unlabeled and undated items on it, including: one pitcher of milk with no date or label, two pitchers of juice with no date or label, 6 glasses of juice with no date or label, 3 glasses of milk with no date or label. DM said items on cart were from breakfast and they would be discarding them immediately and that all undated or unlabeled items would be removed from the cooler and items would be dated and labeled in the future.<BR/>During an observation and interview on 5/20/2024 at 10:40 AM, the dry storage area revealed 1 open bag of raisin bran cereal opened and sealed in zipper top bag with use by date of 4/30/2024, one package of rice crispies in sealed zippered plastic bag with use by date of 4/02/2024. DM said she did not know why they have raisin bran because they do not serve or have raisin bran on their menu.<BR/>During an observation and interview on 5/20/2024 at 10:42, the dry storage area was observed with the sugar's lid half off and the vegetable oil was observed with no lid. The lid was observed laying away from the oil bottle on top of the storage shelf. The DM said that someone must have used it preparing breakfast and did not reseal it.<BR/>During an observation and interview on 5/21/2024 at 10:50 AM, [NAME] was observed pureeing foods and failed to sanitize the food processor between each puree. She rinsed food processor with water and proceeded to puree next item. [NAME] was observed using ungloved hands when handling utensils to stir or dip out food for puree. <BR/>During an interview on 5/21/2024 at 1:30 pm, Maintenance Director said the pipe was not dripping. He stated the water was condensation due to the kitchen staff getting deliveries, propping the door to the freezer open when unloading the delivery truck, and storing the food in the freezer prior to closing the door. <BR/>During an interview on 5/21/24 at 3:00 pm, Dietician said not washing hands between tasks and not properly washing the food processor between foods could put residents at risk of cross contamination. He also said that improper food storage and outdated foods could put residents at risk of food borne illnesses. He said if dietary staff did not wear hair nets appropriately, foods could be contaminated with hair. He said he would ensure staff were educated and follow policy going forward.<BR/>During an interview on 5/21/22 at 3:30 PM, DM said the ice came from condensation and they had that problem in the past. She also said she had removed the green beans and egg omelets from the freezer.<BR/>During an interview on 5/22/24 at 12:30 pm, [NAME] said she should have put the food processor through the dishwasher after every puree and changed her gloves more often. She also said she should have washed her hands when exiting and re-entering the kitchen and between tasks. She said not washing hands between tasks and not properly washing the food processor between foods could cause residents to become sick.<BR/>During an interview on 5/22/24 at 12:35 pm, DM said she should have removed all undated and unlabeled foods. She said going forward, she would date and label all items and she would check dates and discard any items that were past the use by date. She said out of date items and improper storage could make residents ill. She said not covering all hair with hair nets could cause hair to get in the food and contaminate it. She said not properly washing your hands or not properly wearing gloves could transfer germs and bacteria. <BR/>Record review of the facility's policy titled Employee Sanitation dated October 1, 2018, read:<BR/> .Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces .;<BR/> .Employees must wash their hands and exposed portions of their arms at designated hand washing facilities at the following times: .During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks .after engaging in other activities that contaminate the hands .;<BR/> .gloves are not a substitute for thorough and frequent hand washing. When using gloves, always wash hands before touching or putting on new gloves .<BR/> .Change gloves: i. between each food preparation task .iv. When leaving food preparation area for any reason .<BR/>Record review of the facility's policy titled Food Receiving and Storage dated 2001 with revision date of November 2022 read:<BR/> .Food may not be stored .g. under leaking water lines, including leaking automatic fire sprinkler heads, or under lines on which water has condensed .; <BR/> .Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded .<BR/>Record review of the facility's policy titled General Kitchen Sanitation dated October 1, 2018, read .Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware, and food-contact surfaces of equipment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, 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 #12) reviewed for infection control.<BR/>The facility failed to ensure CNA C sanitized or washed her hands after changing gloves when providing incontinent care to Resident #12 on 5/20/2024.<BR/>This failure could place residents at risk of exposure to communicable diseases and infections.<BR/>Findings include:<BR/>Record review of an admission Record dated 5/21/2024 for Resident #12 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of hemiplegia and hemiparesis following cerebral infarction (paralysis on one side following a stroke), gastrostomy status (tube placed into the stomach for feeding), end stage renal disease (kidneys are no longer able to function on their own) and autistic disorder (a developmental disorder that could cause the inability to communicate or interact). <BR/>Record review of a Significant Change MDS assessment dated [DATE] for Resident #12 indicated he was rarely/never understood. He was dependent with all ADLs. He was always incontinent of bowel and bladder. <BR/>Record review of a care plan revised on 5/15/2024 for Resident #12 indicated he had an ADL self-care performance deficit related to confusion, impaired mobility with interventions to provide personal hygiene/oral care and was totally dependent on one staff. He had bowel/bladder incontinence and interventions to check on rounds as required for incontinence. <BR/>During an observation on 5/20/2024 at 11:20 AM, RN B and CNA C were present in Resident #12's room to provide wound care. RN B and CNA C sanitized/washed their hands and donned a gown and gloves. Wound care supplies were on waxed paper on the over bed table, supplies were placed on the wax paper. CNA C rolled Resident #12 onto his left side and pulled his brief down. RN B removed the dressing from his sacrum and placed it in the trash along with her gloves. RN B sanitized her hands and walked away from the bed to the door and removed gloves that was on the wall and placed gloves on both hands. RN B cleaned the sacral area with normal saline and gauze and placed it in the trash. RN B removed her gloves and placed them in the trash and sanitized her hands. RN B walked away from the bed to the door to get more gloves and applied them to both hands and used a gauze and patted sacrum area dry. CNA C removed wipes from a plastic bag and started wiping stool from his rectum front to back. CNA C placed the wipes in a trash bag and removed her gloves and put on gloves without washing or sanitizing her hands. RN B removed her gloves and placed in the trash, sanitized her hands, and walked to the door to get more gloves and applied them to both hands. RN B placed an alginate dressing to the wound bed and removed her gloves and placed them in the trash. RN B sanitized her hands and walked to the door to get more gloves and applied them to both hands. RN B applied a foam dressing. CNA C removed more wipes from the plastic bag and wiped his periarea in the front and removed gloves and placed in the trash. CNA C applied gloves to both hands without washing or sanitizing her hands. CNA C rolled the resident onto his right side and removed the brief and placed a clean brief underneath his buttocks and secured it. RN B removed her gloves and placed them in the trash. The resident was positioned in bed, and CNA C removed her gloves and placed them in the trash. Both RN B and CNA C removed their ppe and washed their hands. <BR/>During an interview on 5/20/2024 at 4:25 PM, CNA C said she had been employed at the facility for a year and worked the hall where Resident #12 resided. She said during the incontinent care/wound care provided to him earlier she should have washed or sanitized her hands between gloves changes. She said she did not have sanitizer with her. She said she could not leave the resident to go and wash her hands because RN B kept leaving the bedside to get more gloves from the wall mount after she removed her gloves. She said she had a check off about 3 months ago on hand hygiene. She said residents could be at risk of infections if staff did not wash or sanitize their hands between glove changes.<BR/>During an interview on 5/22/2024 at 11:06 AM, the ADON said she had been employed at the facility for 6 months. She said staff should be washing or sanitizing their hands before care, during and between, when putting a new brief, and when changing gloves. She said she was responsible for conducting the skills check offs with staff. She said she conducted in-service training on hand hygiene every 3 months. She said if staff did not perform hand hygiene, there was a risk of infections to the residents and cross contamination. She said going forward they would in-service staff and continue education.<BR/>During an interview on 5/22/2024 at 11:21, the DON said he had been employed at the facility since April 2024. He said staff should be washing or sanitizing their hands before care, during care and between glove changes. He said they would continue to in-service staff on hand wash/hygiene. He said residents could be at risk for infections and staff transferring infections to other residents. <BR/>During an interview on 5/22/2024 at 11:34 AM, the Administrator said staff should be sanitizing or washing their hands between care, when taking off gloves, and changing contact areas. She said going forward, they would continue to train, educate, in-service, and observe staff on hand hygiene. She said there was a risk of infections to the residents if staff did not follow proper hand hygiene.<BR/>Record review of a competency evaluation dated 12/15/2023 for CNA C indicated that she was checked off on hand washing/hygiene by the ADON.<BR/>Record review of the facility's policy titled Handwashing/Hand Hygiene revised August 2019 indicated, .This facility considers hand hygiene the primary means to prevent the spread of infection. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: a. Before and after coming on duty; m. After removing gloves; 8. Hand hygiene is the final step after removing and disposing of personal protective equipment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that all written grievance decisions included date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 1 of 8 residents (Resident # 10) reviewed for grievances. <BR/>The facility failed to provide rationale or response to the residents on their concerns or requests.<BR/>This failure could place residents who file grievances at risk of frustration, a decreased confidence in administration and a decrease in resident rights.<BR/>Findings include:<BR/>Record review of a face sheet dated 4/4/23 for Resident #10 revealed that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Schizophrenia (mental disorder in which people interpret reality abnormally), osteoarthritis (joint pain), and peripheral vascular disease (poor circulation). <BR/>Record review of a quarterly MDS dated [DATE] for Resident #10 revealed that she had a BIMS score of 15, indicating that she was cognitively intact with no impaired thinking. <BR/>During an interview on 4/02/2023 at 2:00 P.M. Resident #10 voiced concerns that administration did not listen to or follow up on her grievances. <BR/>During an interview on 4/03/2023 at 3:45 p.m. the SW said she was the grievance officer and had been in this position since January of 2023. She said she would always file a grievance form anytime a resident or family member came to her with a concern. She said it was their policy to have grievances resolved and followed up on within 5 days of it being filed. She said the resident or family member filing grievances would be notified of the resolution within those 5 days. <BR/>During an interview on 4/03/2023 at 3:50 p.m. the ADON said she would always file a grievance when a resident or family member came to her with any issues. She said if there were any concern with abuse or neglect issues, she would immediately report to Administrator due to being a short window to get those issues reported to the State Agency. <BR/>During an interview on 4/3/23 at 4:00 p.m. the DON and ADM both stated they always filed formal grievances when a resident or family member came to them with a grievance. Both said they always followed up with residents when investigations were completed and resolved. The ADM said she was not responsible for grievances, that it was the SW who was responsible for grievances and follow up. The DON said there could be a risk of psychosocial issues to residents who felt like they were not listened to and it could discourage them from coming forward with concerns. <BR/>During an interview with Resident #10 on 04/04/23 at 10:40 AM she said she had filed multiple grievances regarding the food and nurse aide's being rude to her and she had not been given a written copy or been followed up with verbally on any of her grievances. <BR/>During an interview on 4/4/23 at 10:58 a.m., the SW said she did not provide a written copy of the investigation and resolution for grievances unless the resident or family member requested one. She said she normally did not ask them if they wanted a copy, but she would just check no in that spot of the form if they did not specifically ask for one. She was unsure as to why there were blanks in the grievance form for 2/1/23 for Resident #10. She said that she must have overlooked them. She said she would ask going forward if the resident would like a copy provided to them. The SW clarified verbally that the blank in their facility policy should read 5 working days (please see below). She said she could not think of any harm that could come to the residents by not following up on grievances. <BR/>Record review of grievance log for January 1, 2023 through March 31, 2023 revealed the following: <BR/>Grievance dated 2/1/23 for Resident #10, with .date written opportunity presented to grievance official . left blank; .date of response . left blank; and .written decision of grievance requested . checked no.<BR/>Record review of facility policy titled Grievances/Complaints, Recording and Investigating dated 2001, revised April 2017 revealed: <BR/> .The Administrator has assigned the responsibility of investigating grievances and complaints to the Grievance Officer <BR/> .a written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 7 residents (Resident #4) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #4's nasal cannula tubing, on their wheelchair, was changed every 7 days, labeled and bagged to prevent contaimination when not in use.<BR/>The deficient practice could place residents at risk of developing respiratory infections and complications.<BR/>Findings include:<BR/>Record review of Resident #4's facility face sheet, dated 04/03/2023, indicated Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, cough and chronic respiratory failure.<BR/>Record review of quarterly MDS, dated [DATE], indicated Resident # 4 required oxygen therapy and was cognitively intact.<BR/>Record review of Resident #4's care plan, review date 12/19/22 indicated Resident # 4 had shortness of breath and required oxygen therapy.<BR/>Record review of Resident #4's physician's order summary, dated 04/03/2023, indicated oxygen 2-4 liters per nasal cannula with a start date of 01/22/2022. <BR/>During an observation and interview on 04/02/23 at 12:11 PM revealed Resident # 4 's, O2 tubing and nasal cannula was not bagged or dated and was connected to the O2 cylinder on the wheelchair. The cannula and tubing was coiled up on the wheelchair handle, not bagged and not dated. Resident # 4 said she got up in her wheelchair every day and used the oxygen on her wheelchair when she would leave her room. <BR/>During an observation on 04/03/23 11:32 AM revealed the O2 cannula and tubing on Resident #4's wheelchair was not in use. The tubing was not dated, not bagged and was wound up around the right-side handle of the wheelchair.<BR/>During an observation on 4/03/23 at 2:00 PM revealed Resident #4 had a portable oxygen cylinder attached to her wheelchair with oxygen in use at 3 liters per nasal cannula. The cannula and tubing were undated. <BR/>During an observation and interview on 04/03/23 at 2:45 PM revealed Resident #4 was sitting in her wheelchair and had oxygen in place at 3 liters per nasal cannula connected to the cylinder on the wheelchair. The nasal cannula tubing was undated. She said she used her oxygen when up in her wheelchair to attend the resident council meeting held at 2:00 PM today.<BR/>During an interview and observation on 04/03/23 at 3:00 PM, LVN A said oxygen tubing and supplies were changed on the night shift each week but each nurse was responsible for their residents on each shift. She stated she was not aware any oxygen tubing on Resident #4's wheelchair was not dated or bagged. LVN A looked at the wheelchair in the resident's room, and said it belonged to Resident #4. She acknowledged the oxygen cannula and tubing were not dated or bagged and the tubing was coiled around the right-side handle of the wheelchair. She said the risk of not dating, changing tubing weekly and contaminating the tubing by wrapping it around the handle of the wheelchair could be respiratory infections. <BR/>During an interview on 04/03/2023 at 3:15 PM, the DON stated the nurses on the night shift were responsible for changing out the oxygen tubing and nebulizer setups each Sunday night or as needed. She stated she and the ADON was responsible for hall checks and ensuring tasks were completed. She stated the risk could be infection and improper distribution of oxygen. She stated she had been in her position as the DON for two years. She said the staff would be in-serviced on the facility policy and expected that all respiratory supplies were changed out weekly, dated and bagged when not in use. <BR/>During an interview on 04/03/2023 at 4:00 PM, the Administrator stated the DON and ADON were responsible for oversight in the nursing department. She stated she would assist with overseeing the DON and ADON were retraining nursing staff on policy and procedures and her expectation was that the policy and nursing standards of care were followed. <BR/>Record review of the facility policy and procedure titled Respiratory Therapy- Prevention of Infection, dated November 2022 revealed, Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .7. Change the oxygen cannula and tubing every 7days or as needed .8. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use.

Based on observation, interview, and record review the facility failed to maintain and ensure safe and sanitary storage of resident's food items for 1 of 5 resident's personal refrigerators reviewed for food safety (Resident #9).<BR/>The refrigerator for Resident #9 had:<BR/>One small cup of strawberry applesauce with a best by date of March 9, 2023<BR/>One small cup of applesauce with a best by date of March 10, 2023 <BR/>These failures could place residents at risk for food borne illnesses.<BR/>The findings included:<BR/>During an observation and interview on 4/02/2023 at 10:47 AM, revealed the personal refrigerator of Resident #9 had one small cup of strawberry applesauce with a best by date of March 9, 2023, and one small cup of applesauce with a best by date of March 10, 2023. Resident #9 said she was not able to get anything out of her personal refrigerator and had to rely on staff to get items for her.<BR/>During an observation on 4/03/2023 at 9:50 AM, revealed Resident #9's personal refrigerator still had both cups of applesauce present with best by dates of March 9, 2023, and March 10, 2023.<BR/>During an observation on 4/04/2023 at 9:10 AM, revealed Resident #9's personal refrigerator still had both cups of applesauce present with best by dates of March 9, 2023, and March 10, 2023.<BR/>During an observation and interview on 4/04/2023 at 9:18 AM, the HSK Supervisor said he had been employed at the facility since November 2021 and was responsible for checking the personal refrigerators daily and had housekeeping staff check them on the weekends. He said he checked for cleanliness and temperatures, so the food did not spoil or freeze. He stated he also checked for expired foods. He said he checked the personal refrigerator of Resident #9 a couple of hours ago. He said the cups of applesauce were good until September of this year. This surveyor had him to look at the cups of applesauce again and he said he was reading it by the day, month, then year. He said they both expired March 2023 and placed them in the trash. He said if a resident ate foods that were past their best by dates, they could get sick.<BR/>During an interview on 4/04/2023 at 9:35 AM, the Administrator said the department heads conducted Angel rounds and every resident was assigned a person who they could voice concerns to and checked their rooms daily for any issues. She said she was not aware that Resident #9 had foods in her personal refrigerator that were past the best by date. She said the HSK supervisor was responsible for checking the personal refrigerators in the facility. She said going forward they would train the HSK Supervisor to read the dates on food items to ensure they were not past the best by or expiration date. She said they would have more than one person assigned to check the personal refrigerators daily and would add them to the department heads during their Angel rounds. She said if a resident ate foods that were past the best by date or expired it could make them sick. <BR/>Record review of a facility policy titled Foods Brought by Family/Visitors with a revised date of October 2017 indicated, .Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. 8. The nursing staff will discard perishable foods on or before the use by date .

Based on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 2 smoking areas (outside of dining room). <BR/>The facility failed to keep trash out of a red can designated for cigarette butts and ashes.<BR/>This failure could place residents at risk for injury, burns, and an unsafe smoking environment.<BR/>Findings include: <BR/>During an observation on 4/02/2023 at 3:24 PM outside of the dining room area, revealed a red metal can was present filled to the top with cigarette butts, ashes and had trash present that consisted of multiple empty cigarette boxes, a plastic cup a soda bottle.<BR/>During an interview on 4/03/2023 at 9:03 AM, the Maintenance Supervisor said on yesterday 4/2/2023 he emptied the red can and saw it had a lot of empty cigarette packs. He said he checked the cans daily. He said there was risk of a fire with putting trash in the red cans instead of cigarette butts and ashes. He said going forward he would place a sign on the cans to not place trash inside and would in-service staff starting today about not placing trash in the metal cans. <BR/>During an interview on 4/04/2023 at 9:55 AM, the Administrator said she was aware of the trash that was present in the red can outside of the dining room because the Maintenance Supervisor told her on 4/2/2023 that it just had cigarette boxes inside. She said they in-serviced staff on 4/2/2023 and a sign was placed on the cans to not put trash in them. She said staff was always present with the residents when they were smoking. She said going forward the Maintenance Supervisor would make sure the cans were checked daily and she would provide oversight to ensure it was done. She said the only items that should be in the cans were cigarette butts and ashes. She said there was potentially a risk for something to be flammable in the can if trash was placed there.<BR/>Record review of a facility policy titled Fire Safety and Prevention with a revised date of May 2011 indicated, .All personnel must learn methods of fire prevention and must report condition(s) that could result in a potential fire hazard. 1. Fire prevention is the responsibility of all personnel, residents, visitors, and the general public .

Based on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 1 of 15 staff (the DON) reviewed for develop and implement abuse policies.<BR/>The facility failed to ensure HR implemented the facility's abuse/neglect policy and procedure when she failed to complete a Criminal History check for the DON upon hire.<BR/>This failure could place residents at risk for abuse, neglect and/or exploitation. <BR/>Findings included: <BR/>Record review of the personnel file for the DON indicated he was hired at the facility on 4/8/2024 and his criminal history check was not done until 5/21/2024.<BR/>During an interview on 5/22/2024 at 10:55 AM, HR said she started at the facility October 2023 but did was not assigned HR duties until January 2024. She said she was responsible for new hires and conducting background checks. She said the criminal history checks were to be completed before the new hire came into the facility for orientation and then yearly thereafter. She said she did not know what happened and why the DON's criminal history was not checked. She said it was checked on yesterday 5/21/2024 when they realized he did not have one. She said she received training from the previous Administrator on completing the criminal history and background checks. She said going forward she would make sure everyone had their backgrounds check and would check before and after they were hired. <BR/>During an interview on 5/22/2024 at 11:34 AM, the Administrator said background checks and criminal history checks were the responsibility of HR. She said she was not sure why the DON did not have a criminal history check when he was hired at the facility. She said the criminal history check should be checked within 2 days of an offer letter and prior to starting employment. She said there could be a risk of hiring someone that has a criminal background. She said residents could be at risk for exploitation or abuse. She said going forward, the HR had a check list to use, and she was in-serviced on yesterday 5/21/2024 on background checks.<BR/>Record review of an in-service dated 5/21/2024 on background checks was conducted by the Administrator to HR. <BR/>Record review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation of Property Prevention, Protection and Response Policy and Procedures revised 12/17/2018 indicated, .1. Screening Issues: B. Criminal background checks as required .<BR/>Record review of the facility's policy titled Background Screening Investigation revised March 2019 indicated, .Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents. 2. Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relays the call directly to a staff member or a centralized staff work area from toilet and bathing facilities for 1 of 8 residents reviewed for call lights. (Resident #8).<BR/>The facility failed to ensure Resident #8's emergency call light in the bathroom would reach the floor. The call light cord for Resident #8 was three feet above the floor level.<BR/>This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.<BR/>Findings include:<BR/>Record review of a face sheet dated 6/18/2025 indicated that Resident #8 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia (confusion due to aging with inability to remember), muscle weakness, difficulty ambulating, and muscle wasting.<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #8 indicated that she had a BIMS score of 3, indicating that she had severe cognitive impairment. The MDS indicated that the resident required supervision or touch assist of one person for toilet use.<BR/>Record review of a comprehensive care plan with a revision date 6/06/2025, revealed Resident #8 was at risk for injuries related to falls and had a fall on 5/20/2025 with no injuries. <BR/>During an observation on 06/17/25 at 10:57 a.m., the emergency call light in Resident #8's bathroom was approximately 3 feet above the floor and not accessible if lying on the floor. Resident #8 was ambulating independently in her room. Resident #8 said she used her restroom with minimum assistance and would call for help if needed.<BR/>During an interview on 06/18/25 at 10:46 am LVN L said that the string being too short could cause the resident not to be able to reach it and not to be able to call for help if they had a fall in the bathroom.<BR/>During an interview on 6/18/25 at 9:00 am, the Director of Maintenance said the call lights in bathrooms needed to be accessible because if a resident were to fall, they needed to be able to reach the string to call for help. He said he had only worked at the facility for a few months and would make a facility sweep to correct all strings to the required length.<BR/>During an interview on 6/18/25 at 11:00 am, the Administrator said that call lights needed to be accessible always in case the resident needed assistance or if there were an emergency. She said the call lights in the bathroom needed to be accessible for a resident lying on the floor. The Administrator said if a resident were to fall, they needed to be able to reach the string to call for help. She said going forward, she would expect her staff to follow proper policy and procedure.<BR/>Record review of an undated facility policy titled Call Lights indicated .7. The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor .