Whispering Pines Lodge

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

9/12/25 at 12:51 p.m., the ADM said either LVN M or the DON reported the incident with Resident #15 to her. She said LVN M said she was stern with Resident #15. She said Resident #15 reported, LVN M used her hands when they were talking. She said if a staff member spoke to the resident in a disrespectful manner, then it was a dignity and resident rights issue. She said the resident could feel disrespected. She said everyone was responsible for ensuring the residents were treated with dignity and respect. Record

review of an undated facility's Resident Rights policy indicated, .the resident has a right to a dignified existence.a facility must treat each resident with respect and dignity.

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Whispering Pines Lodge

2131 Alpine Rd Longview, TX 75601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

training on abuse and neglect which included the following: examples such as failure to provide assistance with shower, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following physician orders, treating pain, administering medications, notify the physician of changes in condition, and providing adequate supervision to prevent falls or resident to resident altercations. It also included the abuse/neglect policy and procedure. *Record review of the in-service training report, dated 09/11/25, reflected the DON and Administrator signed and received in-service education on notifying physician of change in status which included the following: notifying the physician and responsible party of all changes in conditions such as abnormal vital signs, pain or injuries from accidents. It also included the Notifying the Physician of Change in Status policy. *Record review of the in-service training report dated 9/12/25, reflected the DON and Administrator signed and received in-service training on PCC Dashboard/ 24 Hour Report which included the following: the Charge nurses will monitor the PCC Dashboard/24hr report throughout their shift and at change of shift for any abnormal vital signs that need to be reported to

the physician. *During an interview on 09/12/25 at 3:08 PM, the Medical Director stated he was notified of

the immediate jeopardy situations at the facility. He said he was notified by the Regional Compliance Nurse

on 09/11/25 and it was discussed with plans being implemented. *During an interview on 09/12/25 at 4:05 PM, the DON stated she was provided 1:1 in-service education as follows: Abuse and neglect to include the types of abuse and examples of each. The DON stated that failure to provide care and services such as notifying the physician of change of condition, following physician orders,

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Whispering Pines Lodge

2131 Alpine Rd Longview, TX 75601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

condition where the heart muscle cannot pump blood effectively enough to meet the body's needs), type 2 diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and pressure ulcer of left heel, stage 3 (injuries extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone). Record review of Resident #2's quarterly MDS assessment dated [DATE REDACTED] indicated Resident #2 was understood and usually had the ability to understand others. Resident #2's had a BIMS score of 7 which indicated moderate cognitive impairment. Resident #2 required setup assistance for eating, supervision for oral hygiene, partial assistance for upper body dressing and personal hygiene, and dependent for toileting hygiene, shower/bathe self, and lower body dressing. Resident #2 was always incontinent for urine and occasionally incontinent for bowel. Resident #2 had one, stage 3 unhealed pressure ulcers/injuries. Resident #2 had pressure reducing device for bed and pressure ulcer/injury care. Record review of Resident #2's care plan, revised on 9/11/25, indicated Resident #2 had a pressure ulcer due to decreased mobility. Resident #2 had stage 3 pressure injury to left heel. Interventions included follow facility policies/protocols for the prevention/treatment of skin breakdown and administer medications as ordered. Record review of Resident #2's order summary report dated 9/11/25 indicated: Stage 3 pressure injury, cleanse left heel with normal saline, apply collagen powder, and cover with gauze island with border every day and as needed, one time

a day for wound healing. Start date 8/25/25. Record review of Resident #2's wound administration record dated 8/1/25-8/31/25 indicated: Cleanse left heel with normal saline, apply collagen powder, and cover with gauze island with border ev

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Whispering Pines Lodge

2131 Alpine Rd Longview, TX 75601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

eMAR report on Resident #15's oxycodone to see the actual times of administration. She said the DON was new to the facility and role as a DON. She said she asked the DON if Resident #15 had experienced any adverse effects from the medication error. She said the DON reported Resident #15 had not experienced adverse effects. She said the DON reported LVN E said she gave Resident #15's oxycodone too close together also. She said she instructed the DON to notify the MD of the incident and do a medication error report. She said if a drug diversion was suspected, then the facility suspended the MA or CN involved in the incident. She said the facility also drug tested the staff members if suspicious behavior was noted. She said it was important to prevent misappropriation because the resident needed their medications, and it affected their quality of life. She said the MAs and CNs were responsible for ensuring

the residents' medications were not misappropriated. She said the shift-to-shift count should ensure misappropriation did not occur. Record review of LVN E's Employee Disciplinary Report dated 8/15/25 indicated, .LVN E. date of Infraction: 8/15/25. written counseling. LVN E failed to adhere to the Corporate Code of Conduct by failing to meet their job duty/responsibility expectations. On 8/15/25, LVN E failed to administer medication correctly, resulting in a medication error. Record review of an undated facility's Abuse/Neglect policy indicated, . The resident has the right to be free from abuse, neglect, misappropriation of resident property. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff. misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Whispering Pines Lodge

2131 Alpine Rd Longview, TX 75601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

DON. The Administrator stated she was not responsible to follow -up on clinical side. The Administrator said neglect and misappropriation was considered abuse. The Administrator said she was the abuse coordinator for the facility. The Administrator said the lack of appropriate investigations of alleged allegations could result in a resident experiencing an increase in pain as well as a decreased quality of life.

Attempted telephone call to LVN E on 09/09/2025 at 01:15 PM left a voice message and requested a call back.

Attempted telephone call to LVN E on 09/09/2025 at 07:49 PM left a voice message and requested a call back.

Attempted telephone call to LVN E on 09/10/2025 at 02:30 PM left a voice message and requested a call back.

During an interview on 09/12/2025 at 10:57 AM, the DON stated she had not investigated the allegations of Resident # 9 not receiving pain medications. The DON stated that was the responsibility of the Administrator because she was the Abuse Coordinator. The DON stated when she had heard of the allegations it was days later and the resident was no longer complaining of pain. The DON said misappropriation was considered abuse. The DON said when allegations not investigated could leave the resident at risk of decreased quality of life if they had experience untreated pain.

Record review of the facility's undated “Abuse/Neglect Policy”, indicated, “The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart … Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist… All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated… The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC… The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s)…”

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Whispering Pines Lodge

2131 Alpine Rd Longview, TX 75601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident #12 happy. The Social Worker stated Resident #13 just liked to wander and ended up in Resident #12's room. During an interview on 09/11/25 at 11:15 AM, The DON stated she had been completing the staffing schedule the last few weeks. The DON stated she tried to schedule 2 nurses, 2 MAs, and 5 CNAs

on the day shift. The DON stated she tried to schedule 2 MAs, 2 nurses, and 4 - 5 CNAs. The DON stated MAs worked 8 hour shifts, but the nurses and CNAs worked 12 hour shifts. The DON stated the facility has been unable to schedule what she needs since April 2025, when she started. The DON stated any time someone calls off and she was unable to get it covered, she has to work the floor. The DON stated she has tried to ask sister facilities for help, but she does not always get the help she requested. The DON stated

she has received numerous complaints from residents, staff, and families about the care the residents receive and the inability to complete their assigned duties. The DON stated she has spoken with the Administrator, ADO, and Regional Compliance Nurse to let them know she needed help with staffing with no success. The DON stated the corporation has approved sign-on bonuses and extra shift bonuses for existing staff picking up extra shifts. The DON stated it was important to ensure the facility was sufficiently staffed so residents received good quality of care. The DON stated not receiving good quality of care could cause a decline the residents health and well-being. During an interview on 09/11/25 at 1:02 PM, The Administrator stated it was important to ensure the building was sufficiently staffed to ensure the residents were receiving the care they need. The Administrator stated if the residents were not receiving the care

they needed it could have been harmful to them. The Administrator stated she had not received any complaints about one staff member being scheduled to the secured unit. The Administrator stated she was having complaints about the night shift on the secured unit and started havi

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Whispering Pines Lodge

2131 Alpine Rd Longview, TX 75601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

prevent falls or resident to resident altercations. There were 36 staff signatures. 15. Record review of the in-service training report, dated 09/11/25, reflected in-service education was provided to all staff on notifying physician of change in status which included the following: notifying the physician and responsible party of all changes in conditions such as pain or injuries from accidents. It also included the Notifying the Physician of Change in Status policy. There were 36 staff signatures. 16. Record review of the in-service training report, dated 09/11/25, reflected in-service education was provided to direct care staff on the enteral nutrition policy and procedure, which included: adequate positioning with the head of the bed elevated to prevent the risk of aspiration, notification of the charge nurse if a resident was improperly positioned, and signs or symptoms of aspiration such as coughing, drooling, choking, fever, noisy breathing, shortness of breath or wheezing. There were 22 staff signatures. 17. During interviews between 09/12/25 and 09/13/25, staff from all departments and all shifts to include: the AD, Medical Records, MDS Coordinator QQ, MDS Coordinator RR, [NAME] HH, [NAME] KK, [NAME] MM, Dietary LL, Dietary NN, DM, Housekeeper OO, Housekeeping Supervisor PP, RN P, RN T, LVN A, LVN M, LVN Q, MA B, MA Z, MA UU, CNA C, CNA G, CNA V, CNA SS, CNA TT, Speech Therapist VV, Director of Rehabilitation WW, COTA XX, COTA ZZ, and PTA YY were provided in-service education and were able to verbalize the following: Abuse and Neglect to include the types of abuse and examples of each. The staff were able to give examples of neglect which included: failure to provide assistance with shower, changing clothes, meal trays, eating, positioning with enteral feeding, providing treatments, following physician orders, treating pain, administering medications, notify the physician of changes in condition, and providing adequate supervision to prevent falls or resident to resident altercations. The staff reported the Administrator was the abuse coordinator and any type of abuse should be reported immediately. Notification of changes in condition to include examples of resident change in condition such as new skin issues or increased or new pain. The staff were able to verbalize a change of condition should be reported to the charge nurse immediately. The charge nurses were able to verbalize the appropriate assessments and notifications of the physician and family during a change of condition. Enteral feeding policy to include adequate positioning. The facility staff reported residents would be checked for positioning at least every 2 hours by the CNAs, MAs, and nurses.

The staff were able to verbalize residents who received enteral nutrition should have the head of the bed elevated at least 30 degrees. Staff reported if they noticed any residents were positioned improperly the charge nurse would be notified. The staff were able to verbalize the signs or symptoms of aspiration, which included: coughing, drooling, or wheezing. The Administrator was informed the IJ was removed on 09/12/25 at 4:40 PM. The facility remained out of compliance at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Whispering Pines Lodge

2131 Alpine Rd Longview, TX 75601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

12:18 p.m., CNA R said when she was assigned the hall Resident #6 was on, she was a Hospitality Aide.

She said she could not provide ADL care on him. She said she never touched Resident #6 but noticed when other staff did, he would be in pain. She said Resident #6 would scream out in pain, push staff away, or say leave me alone. She said when he was in pain, she saw the CNAs tell the nurses. She said she never saw a nurse give Resident #6 pain medication before turning or changing him. She said Resident #6 would have benefited from prn pain medications if he got cares done before the next scheduled dose.

Record review of an undated facility's Abuse/Neglect policy indicated, . Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of an undated facility's Pain Management, Assessment Scale policy indicated, . Pain is a subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological. or psychological stimuli. Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility.

PRN-if the resident comp

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Whispering Pines Lodge

2131 Alpine Rd Longview, TX 75601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

was a [AGE] year-old female who initially admitted to the facility on [DATE REDACTED] with diagnoses of senile degeneration of brain (encompasses a range of neurological disorders characterized by a progressive decline in cognitive function, impacting memory, reasoning, and the ability to perform everyday activities).

Record review of the significant change MDS assessment, dated 08/06/25, reflected Resident #19 had unclear speech, was sometimes understood, and was sometimes able to understand others. Resident #19 had a BIMS score of 4, which indicated severe cognitive impairment. The MDS reflected Resident #19 had

a lower extremity impairment to both sides which interfered with daily function. Resident #19 was totally dependent on staff for ADLs, which included eating. The MDS reflected Resident #19 had a fall within the last month prior to admission. Resident #19 was checked for signs and symptoms of a swallowing disorder: holding food in mouth/cheeks or residual food in mouth after meals. Resident #19 required a mechanically altered diet while a resident of the facility. The MDS reflected Resident #19 was at risk for developing pressure ulcers/injuries. Resident #19 had a pressure reducing device for the bed. Record review of Resident #19's comprehensive care plan, last reviewed 09/09/25, reflected the following: Resident #19 had

an ADL self-care performance deficit and required staff assistance x 1 with eating and was resistive to eating at times. Resident #19 had a history of falls and the interventions included: fall mat beside bed, appropriate footwear, call light in reach, anticipate needs, and staff assistance x 2 with transfers. Resident #19 had a stage 2 pressure ulcer to her right buttocks. The interventions included: treatments as ordered and monitor for effectiveness and follow facility policies/protocols for the prevention/treatment of pressure injuries. Record review of Resident #19's order summary report, dated 09/12/25, reflected the following: Regular diet with pureed texture, and regular c

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Whispering Pines Lodge

2131 Alpine Rd Longview, TX 75601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

of each resident's door who was positive for COVID-19. The Administrator said signage should have been placed outside the front door of the building to alert the community of the outbreak status. The Administrator stated she was unaware isolation precautions signage was not on all the doors, or the nursing staff had no access to the PPE supplies. The Administrator said the ADON was responsible for ensuring nursing staff had access to the appropriate PPE supplies. The Administrator stated she expected nursing staff to communicate their needs with the DON and ADON. The Administrator stated it was important to ensure infection control protocols were followed to protect the residents, staff, and community from the spread of COVID-19. During an interview on 09/09/25 at 8 AM, the Administrator stated an N-95 mask was required for entrance onto the secured unit. The Administrator stated an N-95 mask should have been worn down D Hall as well. During an observation on 09/09/25 at 8:30 AM, signage was noted outside

the secured unit doors that stated, Warm Zone. The surveyor entered the secured unit and observed MA U was wearing two surgical masks, she was passing medications. LVN A was wearing a KN-95 mask. During

an observation on 09/09/25 at 8:37 AM, MA U left the secured unit. LVN A took over medication administration. Medical Records entered the secured unit with no mask on her face. Medical Records obtained a surgical mask and put it on her face below her chin. During an observation on 09/09/25 at 8:43 AM, Medical Records went into a resident's room with the surgical mask on her chin. During an observation

on 09/09/25 at 8:48 AM, there were no face shield or goggles on the isolation carts in the secured unit.

Resident #1 had signage for the required PPE but no signage to indicate type of isolation precautions required. During an observation and interview on 09/09/25 at 9:22 AM, Medical Records stated she was not aware an N-95 mask was required to enter the secured unit. Medical Records was wearing her surgical mask on her chin. When the surveyor asked her if that was the appropriate way to wear her mask, she stated Oh my god. Medical Records stated she was unable to breathe in the surgical mask and understood

it was a risk for her. Medical Records stated the good Lord would protect her from any harm. On 09/09/25 at 2:30 PM, attempted to contact CNA C by phone. Unable to leave a message. During an interview on 09/12/25 at 1:28 PM, MA B stated she should have worn the appropriate mask, which was an N-95 with gown, gloves, and a face shield or goggles, when going into a COVID-19 positive room. She stated she should have performed hand hygiene before putting on and taking off her PPE. She stated she did not use

a face shield or goggles or perform hand hygiene on 09/08/25 because she did not have access. MA B stated it was important to follow infection control protocols especially during an outbreak to prevent the spread of COVID-19.

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