MARBRIDGE VILLA

Keep residents' personal and medical records private and confidential.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 (D/E Hall) medication room reviewed for pharmacy services.<BR/>The facility failed to ensure expired medication and medical supplies were removed from D/E-halls medication storage room. <BR/>This failure could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose, inaccurate results, and/or contamination from expired supplies.<BR/>Findings included:<BR/>During an observation on 05/29/2025 at 07:58 AM, with the ADON revealed a bottle of omeprazole 20mg with an expiration date of 01/2025, a bottle of omeprazole 20mg with an expiration date of 03/2025, 10 BioSign Flu A+B tests with an expiration date of 07/31/2024, a sterile CleanWipe foam swab with an expiration date of 11/2023, a gray top vacutainer (blood collection device for labs) with an expiration date of 05/31/2024, and a gray top vacutainer with an expiration date of 08/31/2024. <BR/>In an interview on 05/29/2025 at 08:25 AM, the ADON stated the medication and supplies found were expired. She stated if an expired medication was given to a resident, the medication may not be as effective or may cause an unintended adverse reaction. She stated she was not sure who was responsible for checking the medication room for expired medications and supplies. <BR/>In an interview on 05/29/2025 at 11:58 AM, with MA K stated she had worked at the facility for 13 years. She stated medication aides was responsible for checking the medication room on Hall D/E for expired medications and supplies, but she did not know how often. She stated that nursing management should be following up once a month to ensure there are no expired medications or supplies. She stated that tests could be inaccurate if supplies were expired, and the resident might not receive the correct dosage of medication or not achieve the desired effect if the medication was expired.<BR/>In an interview on 05/29/2025 at 12:46 PM, MA G stated she had worked at the facility for 10 years. She stated the medication aide that is assigned to the hall is responsible for checking for expired medications and supplies in the respective medication rooms once a month. MA G stated she thought nursing management followed up behind the medication aids to ensure all expired medications and supplies were removed from inventory. She stated if expired medications or supplies were used on the residents then it could be dangerous by causing an adverse reaction to the medication or an infection could occur due to contamination, or even false results could occur. <BR/>In an interview on 05/29/2025 at 01:11 PM, the DON stated she had worked at the facility for 6 years. She stated the central supply person stocked the medication rooms weekly with over-the-counter medications and was responsible for ensuring the over-the-counter medications were not expired. She stated a medication technician consultant performed an audit every 3 months to ensure all expired medications were removed from inventory. The DON stated the nurse managers were responsible for performing a quick survey of the medication rooms weekly. She stated if expired medications or supplies were used for residents then they might have an adverse effect. <BR/>In an interview on 05/29/2025 at 01:41 PM, the ADM stated he had worked at the facility for almost 10 years. He stated he was ultimately responsible for everything that occurs in the building, but the DON was responsible for ensuring all expired supplies and medications were removed from inventory in the medication rooms, but he was unsure how often it was reviewed. He stated if expired medications and supplies were used for residents then it could cause an adverse reaction to the medication or false readings in supplies. <BR/>Record review of facility policy titled Medication Labeling and Storage, dated 2001 and revised last 02/2023, reflected Policy Statement<BR/>The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys.<BR/>Policy Interpretation and Implementation<BR/>Medication Storage<BR/> .<BR/>3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items .

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation.<BR/>1. The DSM failed to ensure all items in the kitchen were labeled, dated, and discarded prior to their expiration date.<BR/>2. The DSM failed to ensure all personnel food items were stored separate from resident food items.<BR/>3. The DM failed to properly sanitize the thermometer probe when taking the temperature of food items.<BR/>Findings included:<BR/>Observations of the reach-in refrigerator on 3/06/2023 from 9:13 a.m. - 9:24 a.m. revealed the following:<BR/>At 9:13 a.m., the reach-in refrigerator contained 12 bags of yellow unidentifiable substance unlabeled and undated. <BR/>At 9:15 a.m., the reach-in refrigerator contained five foam containers of unidentifiable substance unlabeled and undated.<BR/>At 9:16 a.m., the reach-in refrigerator contained three small foam containers of unidentifiable substance unlabeled and undated.<BR/>At 9:17 a.m., the reach-in refrigerator contained a foam container, undated and labeled with the DSM's name. <BR/>At 9:23 a.m., the reach-in refrigerator contained a bag of shredded carrots with a best-if-used-by date of 1/30/2023. The carrots appeared browned and had a foul odor. <BR/>At 9:24 a.m., the reach-in refrigerator contained three sandwiches labeled PBH dated 2/26/2023. <BR/>During an interview on 3/06/2023 at 9:30 a.m., the DM stated all items in the refrigerator should be labeled and dated. The DM stated the yellow substance was egg and usually they put it in a container with a label. The DM stated the items in the foam containers were parfait and whipped topping. The DM stated all items in the refrigerator needed to be labeled and dated. The DM stated all leftovers were discarded after seven days, the sandwiches were eight days old, and she would discard them. The DM stated the facility followed best-if-used-by dates and stated she would not serve the shredded carrots. The DM stated the foam container labeled with the DSM's name was the DSM's meal from the day prior. The DM stated the kitchen had a separate cooler for employee food items. <BR/>An observation on 3/07/2023 at 10:46 a.m. revealed six bulk bins labeled sugar, rice, thickener powder, powdered milk, flour, and jasmine rice. These bins were labeled but not dated. <BR/>Observations on 3/07/2023 from 11:10 a.m. - 11:20 a.m. revealed the DM took the temperatures of seven food items on the steam table and used a white rag to wipe the thermometer probe between each food item. <BR/>During an interview on 3/07/2023 at 11:20 a.m., the DM stated no she had not sanitized the thermometer probe in between temping the food items because she had dipped the towel in sanitizer solution prior to temping the food items. The DM stated the kitchen did not have disposable sanitizer wipes. <BR/>During an interview on 3/07/2023 at 3:17 p.m., the RDN stated the kitchen's policy on labeling and dating refrigerated items included the use of FIFO and stated staff labeled everything when it came in. The RDN stated it was not necessary to date bulk bin items as long as the container did not appear old and crusted. The RDN stated she would question it if it looked that way but stated the kitchen's stuff always looked fresh. The RDN then stated all food items needed a label and a date. The RDN stated she instructed kitchen staff to get rid of old produce if it looked wilted or was spotting and stated yes she would have expected staff to discard a bag of shredded carrots with a foul odor and a best-if-used-by date of over one month ago. The RDN stated the DM and the DSM inventoried the kitchen once or twice a week to identify and discard old food items. The RDN stated leftover food items such as sandwiches needed to be discarded after seven days. The RDN stated staff should use alcohol sanitizer wipes to sanitize the thermometer probe between temping different food items. The RDN stated that was how she trained staff to take food temperatures. The RDN stated the kitchen had sanitizer wipes and she expected them to use them. The RDN stated personal food items could be kept in the personal fridge or in the DSM's office. The RDN stated no that personal food items should not be kept in the reach-in refrigerator. The RDN stated all kitchen staff had been trained on food storage and sanitation through obtaining their Texas food handlers license upon hire. The RDN stated herself as well as the DM and DSM completed in-service trainings with staff on food storage and sanitation. The RDN stated she monitored the kitchen by completing monthly sanitation audits. The RDN stated she was in the kitchen a couple times a month and she would do a walk-through and make observations of tray line and the dining room. The RDN stated the kitchen was monitored daily by either the DM or DSM. The RDN stated they monitored the kitchen by going through to make sure items were labeled, dated, and covered. The RDN stated if policies on food storage and sanitation were not followed, there could be potential for foodborne illness. <BR/>During an interview on 3/08/2023 at 4:01 p.m., the ADM stated the kitchen's policy on food storage included covering, labeling and dating food items. The ADM stated leftovers should be tossed. The ADM stated old produce with a best-if-used-by date of over a month ago should have been thrown away already. The ADM stated there was a personal refrigerator where employee's personal food items should be stored. The ADM stated yes that all items removed from their original package should have a label and a date. The ADM stated he did not know what the facility's policy was on sanitizing thermometer probes when temping food but stated it should be sanitized appropriately in between. The ADM stated all kitchen staff were trained on food storage and sanitation through obtaining their certification and through in-service trainings. The ADM stated the DSM, the RDN and himself monitored the kitchen by making frequent rounds. The ADM stated the RDN monitored the kitchen via visits at least once a month, by completing a report, and through communication with the ADM about how things were going in the kitchen. The ADM stated he was in the kitchen twice a week to make sure there was not anything out of hand. The ADM stated if food storage policies were not followed, someone could get sick and if sanitation policies were not followed, infections could spread. <BR/>A record review of the facility's policy titled Taking Accurate Temperatures using Metal Stem Thermometers dated 2021 reflected the following: <BR/>Thermometers should be sanitized according to manufacturer's instructions. Bimetallic thermometers may be sanitized using a dish machine or three sink method. In between uses at one meal, an alcohol swab may be used to sanitize. (use a new swab for each sanitizing.)<BR/>A record review of the facility's policy titled Food Storage dated 2021 reflected the following: <BR/>Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contamination or cross contamination.<BR/>Procedure: <BR/>8. Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated.<BR/>12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2017 Federal Food Code.<BR/>13. Refrigerated food storage: <BR/>f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.<BR/>h. Refrigerated foods should be stored upon delivery and careful rotation procedures should be followed.<BR/>A record review of the facility's undated policy titled Policy for Personnel Food Items reflected that employee's personal food items were to be stored in a mini fridge located in the hallway near the kitchen or in the DSM's office. <BR/>A record review of the RDN's monthly sanitation audit titled Food Safety and Sanitation Checklist dated 2/28/2023 reflected no that the facility did not identify food not stored in its original container by its proper name and out of date leftovers x 4-5. <BR/>A record review of the FDA's 2017 Food Code reflected the following: <BR/>Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils.<BR/>The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.<BR/>Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils.<BR/>Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. Food-contact surfaces and equipment used for time/temperature control for safety foods should be cleaned as needed throughout the day but must be cleaned no less than every 4 hours to prevent the growth of microorganisms on those surfaces.<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.<BR/>(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of 24 residents (Residents #55, 57, and 76) and one of four medication carts reviewed for infection control.<BR/>1. Resident #55 scratched herself in the perineal area multiple times resulting in soiled hands and fingers, and she touched people and things in the common area without intervention from staff.<BR/>2. LVN A stored and locked her used scrub-top in the drawer of a medication cart that contains medications and treatment supplies. <BR/>3. LVN C assisted both Residents #57 and 76 with eating, using the same hand, and did not perform hand hygiene between them.<BR/>These failures placed residents at risk of transmission of infectious diseases. <BR/>Findings included:<BR/>Review of the undated face sheet for Resident #55 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of pruritus (itchiness), chronic gingivitis, irritable bowel syndrome, slow transit constipation, diarrhea, impacted cerumen, hypothyroidism, Alzheimer's disease with early onset, intellectual disabilities, gastroesophageal reflux disease, down syndrome, Reynaud's syndrome without gangrene (a condition in which body overreacts to certain situations causing cold and numbness in the hands and feet.), anorexia, major depressive disorder, impulse disorder, and insomnia.<BR/>Review of the quarterly MDS for Resident #55 dated 02/07/23 reflected a BIMS score of 99, indicating a severe cognitive impairment. It reflected Resident #55 required the extensive assistance of one staff member with personal hygiene. <BR/>Review of the care plan for Resident #55 dated 08/03/22 reflected the following: Bowel and bladder incontinence r/t cognitive deficits. Resident will not have any direct complications from incontinence such as skin problems. Assist w/ incontinent care as indicated. Encourage self-care wiping and give resident praise for doing so.<BR/>Observation and interview on 03/07/23 between 12:29 PM and 02:15 PM revealed Resident #55 walking all around the common area on the DE side of the facility, frequently reaching her hands into the front and back of her pants and underwear and scratching. In between scratching inside her pants, she touched multiple surfaces including the back of several chairs, a medication cart, the overbed table CNAs used while entering their charting notes, staff members' hands and shoulders, and a toy car belonging to another resident. kissing staff on the hand. LVN D assisted Resident #55 with reapplying an arm sling, and Resident #55 put her hands on the sling, on LVN D's hands, and on LVN D's shoulder. Immediately after this, LVN D went into the nurse's station and began working on the computer. She did not perform hand hygiene. At 01:34 PM, Resident #55 again reached into the back side of her pants, scratched, withdrew, looked at, and smelled her hand, and said Ew! Her hand was covered in a brown substance, and she showed it to the surveyor, who asked loudly if she wanted to show any of the staff present. LVN D, LVN E, and MA F were each within four feet when this occurred, but none of them acknowledged the situation. MA F walked past Resident #55, and Resident #55 reached out to her and touched her arm as she walked by. Resident #55 continued to touch other things around the area, including her own face and the inside of her nose. MA F went to a sink behind the nurse's station and washed her hands. Shortly after, LVN E washed her hands in the same sink. At 01:38 PM, LVN D came out from behind the nurse's station and donned gloves. LVN D stated she was about to clean her medication cart. When asked why she had not performed hand hygiene since assisting Resident #55 with her arm sling, LVN D stated she thought she had and pulled a small bottle of hand alcohol-based hand run out of her pocket. When asked if she noticed that Resident #55 had been reaching her hands in her pants and touching things, LVN D stated, Yes, she does that. We try to redirect her. LVN D stated she should perform hand hygiene after assisting any resident with care, including the reapplication of a sling, and she should have assisted Resident #55 with hand hygiene often after she scratched inside her pants. When asked if she had received any specific training on how to address Resident #55's behavior, LVN D stated she was sure that the behavior was in Resident #55's care plan.<BR/>During an interview on 03/07/23 at 02:19 PM, the ADON stated she had witnessed Resident #55 scratching herself under her underwear, and this was a fairly common behavior for her due to her resistance to care and activities of daily living. The ADON stated the staff should be taking her to the bathroom to sanitize her hands if they witness the behavior. When asked how the staff knew to respond to the behavior that way, she stated they had infection control in-services. The ADON stated there had been no in-servicing specific to Resident #55, but because of the nature of the material that came out on her hands when she digs and scratches under her pants, her hands needed to be sanitized every time she did it. The ADON stated she thought there was a behavioral care plan for Resident #55, but the only thing she saw was the care plan item about being resistant to care with ADLs. The ADON stated the staff should have known what to do, though, because it was common sense for infection control. <BR/>During an interview on 03/08/23 at 03:13 PM, the DON stated hand hygiene for someone who has touched or dug under their underwear was common sense. She stated treating the behavior for Resident #55 presents with a unique challenge, because people with downs syndrome who develop dementia are extremely difficult to redirect. The DON stated she knew the staff washed Resident #55's hands when they provided assistance with toileting. The DON stated she did not think they had a specific intervention for Resident #55 but that any time someone is soiled the staff needed to clean them. The DON stated Resident #55 walking around touching things in the common area was hazardous due to being an infection control issue, and the area in which she had been doing that should have had a deep clean. <BR/>During an interview on 03/08/23 at 04:02 PM, the ADM stated they had to monitor sanitation all over the building and needed to monitor someone like Resident #55 very closely to make sure they did not have an infection control issue. He stated the hard part about residents with Downs syndrome who have dementia is they will be up and out and all over the place and trying to keep up with her will sometimes succeed and not others. The ADM stated if they saw her touching something she should not have touched with soiled hands, they should be intervening immediately. The Adm stated the problem often was that staff got nervous while surveyors were watching and failed to do what they normally would. <BR/>Review of facility policy dated August 2019 and titled Cleaning and Disinfection oc Environmental Surfaces reflected the following: Housekeeping surfaces (e.g. floors, table tops) will be cleaned on a regular basis, when spills occur, and when the surfaces are visibly soiled. Environmental services will be disinfected or clean on a regular basis (e.g. daily), three times per week, and when surfaces are visibly soiled. Spills of blood and other potentially infectious materials will promptly be cleaned and decontaminated.<BR/>2.<BR/>During an observation on 03/06/2023 at 10.30 AM revealed the storage of a green colored slightly faded scrub- top in the bottom drawer of a medication cart in the medication room situated at Hall A of the facility. There were wound care supplies, compound benzoin tincture swab sticks, oxygen tubing, sanitary pads, liquid medications in bottles and gastrotomy care supplies were in that drawer. LVN A was assisting the investigator by opening the drawers of the cart one by one for medication storage inspection. The scrub was found above the medications and treatment supplies in the bottom drawer, in plain without any package or wrap. LVN A removed the scrub immediately from the drawer and stated she regrets for storing it in the med cart. <BR/>During an interview on 03/06/23 at 10.45 AM LVN A stated the scrub owned by her and should not have stored in the med cart after the use. When asked about the adverse result of storing used scrub with medications, LVN A stated the scrub could contaminate the medications and treatment supplies stored in the med cart and helps to spread diseases. <BR/>During an interview on 03/07/23 at 3:00 PM ADON stated the med cart was exclusively for storing medications and treatment items and should not be used for storing any other materials like food or clothes. She stated this was necessary to minimize spreading diseases through cross contamination. <BR/>During an interview on 03/08/23 at 2:00 PM DON stated no materials other than medications and treatment items should be there in the med cart. She stated used clothes stored in a med cart could contaminate the medications in the cart and this compromises infection control efforts. <BR/>Review on 03/08/23 of the facility policy Storage of Medications dated November 2020 reflected:<BR/>The facility stores all drugs and biologicals in a safe, secure, and orderly manner . <BR/> . 3.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . <BR/>3.<BR/>A record review of Resident #57's Resident Dashboard dated 03/08/23 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of mild intellectual abilities, hypertension (high blood pressure), hyperlipidemia (high cholesterol), legal blindness, gastro-esophageal reflux disease (acid reflux), dysphagia (difficulty swallowing), schizoaffective disorder (mental condition causing delusions), major depressive disorder (depression), bipolar disorder (extreme mood swings), and repeated falls. <BR/>A record review of Resident #57's MDS assessment dated [DATE] reflected she was unable to complete a BIMS assessment. A review of Section G (Functional Status) reflected Resident #57 required supervision and a one-person physical assist with eating. <BR/>A record review of Resident #57's care plan last revised on 01/29/23 reflected she had ADL self-care deficit related to physical limitations and eyesight, and required meal set up, verbalized placement of food on table and verbal cueing as needed.<BR/>A record review of Resident #76's Resident Dashboard dated 03/08/23 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of muscle weakness, unspecified convulsions, severe intellectual disabilities, irritable bowel syndrome, and epilepsy (nervous system disorder).<BR/>A record review of Resident #76's MDS assessment dated [DATE] reflected she was unable to complete a BIMS assessment. A review of Section G (Functional Status) reflected Resident #76 was totally dependent on staff and required a one-person physical assist with eating. <BR/>A record review of Resident #76's care plan last revised on 01/28/23 reflected she had ADL self-care deficit related to altered cognitive status, cerebral palsy, and autistic disorder. Resident #76's care plan reflected she needed to be spoon fed all meals. <BR/>An observation on 03/06/23 at 11:58 AM revealed LVN C was sitting between Resident #76 and Resident #57 in the dining room. LVN C was observed feeding Resident #76. Resident #57 was observed to be having trouble feeding herself, LVN C began feeding her with the same hand she used to feed Resident #76. LVN C went back and forth three times between feeding Resident #76 and Resident #57 without using hand hygiene in between. <BR/>During an interview on 03/06/23 at 12:04 PM, LVN C stated she did not use hand hygiene in between feeding Resident #76 and Resident #57 because she did not believe it was cross-contamination since she did not touch the resident themselves. LVN C stated Resident #57 usually ate on her own but that day she needed help. LVN C then stated she should have used hand hygiene in between. <BR/>During an interview on 03/07/23 at 02:31 PM the ADON stated she expected staff to sanitize their hands in between feeding different residents. The ADON stated all staff were trained on proper hand hygiene upon hire. When asked what potential negative resident impact there could be if staff did not practice proper hand hygiene when feeding residents, the ADON stated, they are exchanging different bacteria when changing from one resident to another. <BR/>During an interview on 03/08/23 at 3:20 PM, the DON stated the facility's policy on hand hygiene during meal assistance included that staff were to perform hand hygiene between each resident. The DON stated yes that hands should be sanitized between feeding one resident and another. The DON stated staff were trained during orientation on proper hand hygiene during meal service. The DON stated herself, the ADON, and other management personnel monitored for compliance of proper hand hygiene by completing audits with staff. The DON stated if the facility's policy on hand hygiene during meal service were not followed, it would be an infection control issue.<BR/>During an interview on 03/08/23 at 04:01 PM, the ADM stated staff should perform hand hygiene between feeding multiple residents. The ADM stated all staff were trained on this upon hire. The ADM stated typically the nurse managers monitored staff to ensure they used proper hand hygiene. When asked what potential negative resident impact there could be if the facility's policy on hand hygiene in the dining room were not followed, the ADM stated, it is not best practice, it is not the right thing to do, and there was not an infection that came out of it.<BR/>A record review of the facility's orientation checklist titled Employee Onboarding Checklist reflected LVN C was trained on the facility's policy on hand hygiene in the dining room on 02/08/23. LVN C signed a statement reflecting she understood the policy for hand hygiene in the dining room. <BR/>A record review of the facility's undated policy titled Hand Hygiene in the Dining Room reflected the following:<BR/>It is the policy of (facility name) to make every effort to prevent the spread of infection in the facility. In complying with this policy, we will make every effort to ensure that hand hygiene is practiced by all staff while in the dining room serving trays or assisting residents with eating.<BR/>Policy Interpretation and Implementation: <BR/>6. If you are assisting a resident to eat, hand hygiene must be done prior to the beginning of the actual feeding or assistance.<BR/>7. You may feed two residents at the same time as long as you maintain a clean hand that is dedicated to touching only the silverware, plate or glassware of each resident. If you touch either resident with your dedicated hand, you must perform hand hygiene before you resume feeding or assisting the resident.<BR/>8. If you move from a resident at one table to a resident at another table to begin feeding or assisting, you must perform hand hygiene before assisting the new resident.<BR/>9. Hand hygiene is to be considered high priority when working in the dining room. If in doubt of the need as to perform hand hygiene, remember it cannot be done too frequently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with resident rights, that include measurable objectives and time frames to meet resident's mental and psychosocial needs for 1 of 4 residents (Resident #39) reviewed for care plans. <BR/>The facility failed to update Resident #39's care plan to reflect current needs for heel protectors to be worn at all times. <BR/>This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being.<BR/>Findings included: <BR/>Review of Resident #39's Face Sheet dated 04/10/2024 revealed a 56 Record review of Resident #80's face-sheet dated 04/09/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: other skin changes (changes in your skin can be clues that there's an internal issue with your health), severe intellectual disabilities (a condition in which your brain doesn't develop properly or function normally), and peripheral vascular disease (the reduce circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel). <BR/>Record review of Resident # 39's Quarterly MDS Assessment, dated 02/26/2024, reflected Resident #39 was never/ rarely understood and was not capable of completing the BIMS questions. His cognitive patterns were assessed by the staff. Resident #39 had poor short- and long-term memory recall. His decision-making abilities was severely impaired. Resident #39 was dependent on staff for all his ADL's. Resident #39 was also assessed to be at risk for developing pressure ulcers/ injuries. Resident #39's MDS also reflected he required a pressure reducing device for chair and for his bed. <BR/>Record review of Resident #39's Comprehensive Care Plan, dated 03/14/2024, reflected Resident #39 had alteration in skin integrity related to incontinence, physical limitations, and cognitive impairment. Interventions: monitor skin during showers for any areas of redness or excoriation and report to nurse. Off load (using a pillow or wedge under the calf to leave the foot suspended above the mattress) bilateral heels at all times. Resident #39 had ADL self-care deficit related to severe cognitive deficits. Resident #39 was also assessed to require total assistance with dressing, personal hygiene, toileting, and shower. He required 2-person Hoyer lift for transfers. <BR/>Record review of Resident #39's Physician Order for the month of 04/2024 reflected a physician order dated 04/10/2024 wear heel protectors at all times; offload right heel when in bed. <BR/>In an interview and record review on 04/10/2024, LVN C stated Resident #39 had an official physician order in the electronic medical record on 04/10/2024. She viewed Resident #39's physician order and care plan during the interview. She stated on the care plan, it reflected Resident #39 was to offload his heels when in bed. LVN C also stated the care plan date was 03/14/2024 and it was the most current care plan. She stated the care plan was completed prior to the new physician order dated 04/10/2024 for Resident # 39's heel protectors to be used at all times. She stated Resident #39's care plan had an intervention of offloading heels. However, this was different than wearing heel protectors. LVN C stated the interventions for the staff to follow required to be very specific. LVN C stated anytime there was a change in a resident care or any new order for any device the residents' care plan was expected to be updated. She reviewed Resident #39's care plan during the interview and stated the care plan was not updated to reflect the new physician order for the resident to have heel protectors on his feet. She stated care plan said to offload his heels but the care plan was written prior to him developing the red area on his right heel and offloading was not the same as wearing heel protector. She stated someone would probably update the care plan to reflect he needed heel protectors. She stated someone in the nurse administration department would review Resident #39's care plan and add the heel protectors to the care plan. LVN C also stated it was the MDS Nurse, the DON or the ADON revised the care plan. <BR/>In an interview and /record review on 04/11/2024 at 9:30 AM, CNA F stated there was a form in Resident #39's room explaining the care he required. She stated the CNAs referred to the form for any changes in Resident #39's care. CNA F stated LVN E gave her report that morning about Resident #39 and to place heel protectors on him at all times. She stated if she saw offloading heels at all times documented, she would not know exactly what it meant. She stated she would need further guidance from the nurse to ensure she knew what to do if she saw the residents' heels needed to be offloaded. CNA F stated if she saw heel protectors on any of Resident #39's forms, she would know exactly what to do and she would place heel protectors on his feet. <BR/>In an interview and record review on 04/11/2024 at 8:40 AM, the Director of Nurses stated as she was reviewing the Resident #39's care plan during the interview the interventions was not revised to reflect he was to wear heel protectors at all times. She stated the last care plan was revised on 3/14/2024 and the new physician order for heel protectors was dated 04/10/2024. She stated, in the perfect world the care plan would be revised. She also stated the care plan was the record the staff referred to when developing person center care for each resident. She stated offloading heels was on the care plan and that was when staff would use pillows under residents' feet. She stated again in a perfect world the care plan would be revised. <BR/>In an interview on 04/11/2024 at 3:25 PM, the Administrator stated the care plan for Resident #39 did not reflect specific heel protectors on the care plan. He stated the care plan had offloading and he believed offloading and heel protectors was the same thing but he was not a nurse. He also stated he was not going to discuss the potential negative outcome of a resident not wearing heel protectors because he was not a nurse. <BR/>Record review of the facility's policy on Goals and Objectives, Care Plans dated 2009 reflected objectives were entered on the resident's care plan so that all disciplines have access to such information and were able to report whether or not the desired outcome were being achieved. Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of eight residents (Resident # 40 and Resident # 63) reviewed for quality of life.<BR/>The facility failed to ensure Resident #40 and Resident #63's nails were cleaned.<BR/>This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.<BR/>Findings included:<BR/>1. Record review of Resident # 40 Face Sheet dated 04/11/2024 reflected Resident #40 was admitted on [DATE] with diagnosis of muscle weakness (lack of strength in muscles), mild intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently), and age-related osteoporosis without current pathological fracture (reduce bone mass). <BR/>Record review of Resident #40's Quarterly MDS Assessment, dated 02/26/2024, reflected resident was rarely/never understood. The staff completed Resident #40's cognitive status. Resident #40 was assessed to have poor short- and long-term memory recall. She was also assessed to have poor decision-making ability. Resident #40 was dependent on staff for all ADLS including personal hygiene. Resident #40 did not reject care. <BR/>Record review of Resident #40's Comprehensive Care Plan dated 01/18/2024 reflected Resident #40 had an ADL self-care deficit related to general weaknesses, and cognitive deficits. Intervention: Explain to Resident #40 all care being given to her. <BR/>Observation and Interview on 04/09/2024 at 1:19 PM Resident #40 had a blackish/brownish hard substance underneath the nails on her fore finger and middle finger on her left hand and underneath the nails on her middle finger and ring finger on her right hand. Resident #40 was not interview able. <BR/>Record review of Resident # 63's Face Sheet dated 04/11/2024 reflected Resident #63 was admitted to the facility on [DATE] with diagnosis of: down syndrome (a condition in which a person has an extra chromosome or an extra piece of a chromosome), dementia in other diseases classified elsewhere, unspecified severity (lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement), and delusional disorders ( unshakeable belief in something that is not true).<BR/>Record review of Resident #63's Quarterly MDS dated [DATE] reflected Resident #63 rarely/ never understood others. Her cognitive assessment was completed by staff. She was assessed to have poor short- and long-term memory recall and her decision-making ability was severely impaired. Resident required assistance with all ADLs. <BR/>Record review of Resident #63's Comprehensive Care Plan dated 03/07/2024 reflected Resident #63 had ADL self-care deficit related to cognitive deficits. Care plan reflected Resident #63's ADL needs will be met. <BR/>Observation and Interview on 04/09/2024 at 1:11 PM Resident #63's middle and forefinger nails on her right had had blackish/brownish hard substance underneath the nails. Resident #63 was not interview able.<BR/>In an interview on 04/11/2024 at 9:15 AM, LVN E stated the nurses and CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. LVN E stated it was the CNA's responsibility to clean and trim all other residents' nails. She stated the CNAs reported to nurses of any diabetic resident's nails to be cleaned. She stated the nurses' made rounds and checked residents, with diabetic nails. She also stated the Cans usually did nail care when residents received a shower or as needed. She stated if anyone observed a brownish and/or blackish substance underneath residents nails the nursing staff were expected to clean the resident's nails or ask the appropriate nurse to complete the nail care. She stated the blackish/ brownish substance possibility may had feces or any type of bacteria underneath the resident's nails. LVN E stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. She also stated a resident may become dehydrated and may require to be transfer to hospital for further medical assessment. She stated she had been in- serviced on nail care and infection control. She stated she was not aware of Resident #40 or Resident #63 refusing nail care.<BR/>In an interview on 04/11/2024 at 9:30 AM, CNA F stated CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually trimmed and cleaned nails during showers. She stated the nails could be cleaned or trimmed by nurses or CNAs as needed. CNA F stated the nursing staff was expected to clean and trim residents' nails immediately if there was a blackish substance underneath the residents' nails and/ or if their nails needed to be trimmed. CNA F stated the blackish substance may be fecal matter underneath the residents' nails. She stated if a resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues or any type of intestinal issues. She stated there was a possibility a Resident may need to be assessed at the emergency room if they became severely ill. She stated she gave care to Resident #40 and Resident #63, and with her experience they did not refuse nail care. <BR/>In an interview on 04/11/2024 at 10:40 AM, the Director of Nurses stated it was the nurse's responsibility to trim/clean residents with a diagnosis of diabetes. She stated CNAs were expected to give nail care to other residents during showers or as needed. She stated if a resident had blackish substance underneath the nails and the resident ingested the substance there was a possibility the resident may become ill such as: vomiting or diarrhea. Director of Nurses stated if staff saw a blackish substance underneath a resident's nails, he expected the nails to be cleaned immediately. She stated only nurses were assigned to trim or clean residents nails with a diagnosis of diabetes. <BR/>In an interview on 04/11/2024 at 3:25 AM, the Administrator stated nail care was overseen by nurses and the CNAs assisted with nail care directed by the nurse. He stated the nurses were expected to keep the residents' nails trimmed, cleaned, and filed. He stated he was not a nurse and could not speculate what may happen to a resident if the resident ingested some type of bacteria. <BR/>Record review of the facility's policy on Fingernails/Toenails, dated February 2018, reflected nail care included daily cleaning and regular trimming. Clean the nail bed and keep the nails trimmed, and to prevent infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Residents #5) reviewed for pressure ulcers. <BR/>1. The facility failed to ensure the provider treatment plan for Resident #5 was implemented. <BR/>2. The facility did not provide wound care as ordered by the provider for Resident #5. <BR/>These failures placed residents at risk of pain, worsening of wounds and wound infection. <BR/>Findings included:<BR/>Record review of Resident #5's Face Sheet dated 03/07/23 reflected Resident #5 was a [AGE] year-old male, and he was admitted to the facility on [DATE]. Resident #5 had diagnoses of Dysphagia (difficult to swallow), Parkinsonism, Chronic pain, Deficiency of B and D vitamins, Allergic rhinitis due to pollen, Epilepsy, Constipation, Intellectual disabilities, Muscle Weakness, Need for assistance with personal care, Psychosis, Pain in left Foot, Pain in left knee and Pressure-induced deep tissue damage of left heel.<BR/>Record review of Resident #5's MDS assessment dated [DATE] reflected Resident #5 had slurred or mumbled words and limited ability to make concrete requests. Resident #5 also had a BIMS score of 11, indicated Resident #5 had moderate cognitive impairment. He required to have full staff performance every time during entire 7-day period. Resident #5 was incontinent for both bowel and bladder. The MDS assessment indicated Resident #5 had one or more unhealed pressure ulcers/injuries and treatment included pressure reducing device for chair and bed and pressure ulcer/injury care. <BR/>Record review of Resident #5's Care Plan dated 02/03/23 reflected no statement of any pressure ulcer. <BR/>Record review of Resident #5's weekly skin assessment dated [DATE] reflected Resident #5 had left heel wound measuring 3cm L x 2cm W x 0cm D with clear drainage. Resident informed he had a burning sensation from that. Resident#5's left toe had a blackish colored spot above the toenail measuring 1cm L x 1cm W x 0 cm D.<BR/>Record review on 03/7/23 of the evaluation of the wounds of Resident #5 on 2/22/22 at 1:53pm by APRN, stated:<BR/>Wound #1, Date of onset: 2/22/23, Location: left heel (2 areas), Description: Medial Area:1.5cm x 1.4cm and 0.8cm x0.7 cm. Etiology: DTI, Treatment plan: change treatment to: Apply skin prep and cover with sock. Continue booties. <BR/>Wound #2, Location: left great toe. Description: Proximal Area:0.8cm x0.6 cm. Etiology: DTI. Treatment plan: change treatment to: Apply skin prep and cover with sock. Apply booties.<BR/>Record review of clinical physician's order on 03/07/23 dated 02/22/23 at 1:07pm by APRN, stated: Left heel wound: Apply skin prep and cover with sock.<BR/>Record review of clinical physician's order on 03/07/23 dated 03/07/23 at 1:12pm by APRN, stated Left great toe DTI: Apply skin prep and cover with sock. <BR/>The treatment order on 02/22/23 at 1:07pm for Resident#5's wound on his left heel was as per the treatment plan dated 02/22/23, however, the treatment order on 03/07/23 at 1:12pm for Resident #5's left great toe was ordered 13 days after the completion of wound evaluation and treatment plan dated 02/22/23. <BR/>Record review of February,2023 TAR on 03/07/23 at 01:18pm stated: <BR/> Left heel wound: Apply skin prep and cover with sock every evening shift for Left heel wound, -Start Date-02/24/2023, 1400. <BR/>Record review of March,2023 TAR on 03/7/23 at 1.28 pm stated:<BR/>1.Left heel wound: Apply skin prep and cover with sock every evening shift for Left heel wound, -Start Date-02/24/2023, 1400 <BR/>2.Left great toe DTI: Apply skin prep and cover with sock. Every evening shifts. -Start Date-03/07/2023 1400. <BR/>Record review on 03/07/2023 at 11.30am of the TAR reflected that as on 03/07/2023, 11.30am there were no evidence of any treatment provided as per the order to Resident#5's wounds starting from 02/24/2023, as per the order. <BR/>Observation of Resident #5's wound dressing on 03/07/23 at 11:30 AM revealed Resident #5's left heel wound had redness without any secretion and the left toe wound was visible as a red spot without any secretion.<BR/>An interview with LVN B on 03/07/23 at 11:30 am, LVN B stated she was not aware of the pressure ulcer treatment for Resident #5. LVN B said she was aware of the order for Witch Hazel Liquid (medicinal ointment) that was applied on 3/7/23 to Resident#5's face, neck, behind ears topically. This was provided every day as per the order. When asked about the adherence to TAR orders, LVN B stated it was mandatory that the treatments had to be provided by nurses as per the directions in the treatment order in the TAR.<BR/>During an interview on 03/07/23 at 2.00pm the ADON stated that LVN B reported to her about the issue of the omission of wound treatment. ADON stated both orders for treatment were placed only on 03/07/23 by the APRN. She added that the facility had a new APRN who started few weeks ago and getting used to the system. When the investigator asked about the treatment order by APRN on 02/22/23 for the wound treatment for the left heel that was transcribed into the TAR clearly stating to commence from 02/24/23, ADON said most likely there was a software glitch in the EMR and transcribed the commencement date wrongly. When asked about the compliance by the nurses to the treatment order, ADON stated the nurses should strictly follow the treatment order in the TAR. <BR/>During the interview on 03/08/23 at 2:30 pm the DON stated the nurses and MAs must follow the MAR and TAR while providing treatments and administering medications. DON stated the APRN did not place the orders for the treatments and that was the reason for not providing the treatment. When the investigator showed the treatment order for left heel wound on TAR scheduled to start from 02/24/23, DON stated that the commencement date on the TAR was wrong and most likely there was some issue with the EMR software. When asked about the risk of such software issues, she stated there was high risk of not getting very important medications and treatments to the residents on time if the EMR was malfunctioning. DON stated this was the first time happening like this. <BR/>During the interview on 03/08/23 at 2pm the APRN stated she was new to the facility and settling in with the system at the facility. When asked about the treatment orders for the pressure ulcers of Resident#5, she stated on 02/22/23 after her wound evaluation she made a treatment plan, and not a treatment order. When the investigator asked when there was a treatment order for the wound on the heel, based on the treatment plan on 02/22/23, why there was not an order for the wound on the toe on 02/22/23 itself but only 13 days after on 03/07/23, though both of them had treatment plan on 02/22/23, APRN said she was not familiar with the EMR and might not have entered properly. <BR/>During the interview on 03/08/23 at 3.30pm, the ADM stated the clinical aspects were taken care by DON and he was in charge of the administration. When the investigator asked about the accuracy and reliability of the EMR system, he stated it was a very reliable software and never heard of any complaints. He said, in case if any issues there, that could be immediately resolved with the support of the readily available EMR software technicians. He added, the facility never had any concerns about the reliability and accuracy of the system. The ADM stated there was no specific policy and procedure for medication administration and the nurses supposed to follow the standard clinical rules for medication administration and treatment.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation.<BR/>1. The DSM failed to ensure all items in the kitchen were labeled, dated, and discarded prior to their expiration date.<BR/>2. The DSM failed to ensure all personnel food items were stored separate from resident food items.<BR/>3. The DM failed to properly sanitize the thermometer probe when taking the temperature of food items.<BR/>Findings included:<BR/>Observations of the reach-in refrigerator on 3/06/2023 from 9:13 a.m. - 9:24 a.m. revealed the following:<BR/>At 9:13 a.m., the reach-in refrigerator contained 12 bags of yellow unidentifiable substance unlabeled and undated. <BR/>At 9:15 a.m., the reach-in refrigerator contained five foam containers of unidentifiable substance unlabeled and undated.<BR/>At 9:16 a.m., the reach-in refrigerator contained three small foam containers of unidentifiable substance unlabeled and undated.<BR/>At 9:17 a.m., the reach-in refrigerator contained a foam container, undated and labeled with the DSM's name. <BR/>At 9:23 a.m., the reach-in refrigerator contained a bag of shredded carrots with a best-if-used-by date of 1/30/2023. The carrots appeared browned and had a foul odor. <BR/>At 9:24 a.m., the reach-in refrigerator contained three sandwiches labeled PBH dated 2/26/2023. <BR/>During an interview on 3/06/2023 at 9:30 a.m., the DM stated all items in the refrigerator should be labeled and dated. The DM stated the yellow substance was egg and usually they put it in a container with a label. The DM stated the items in the foam containers were parfait and whipped topping. The DM stated all items in the refrigerator needed to be labeled and dated. The DM stated all leftovers were discarded after seven days, the sandwiches were eight days old, and she would discard them. The DM stated the facility followed best-if-used-by dates and stated she would not serve the shredded carrots. The DM stated the foam container labeled with the DSM's name was the DSM's meal from the day prior. The DM stated the kitchen had a separate cooler for employee food items. <BR/>An observation on 3/07/2023 at 10:46 a.m. revealed six bulk bins labeled sugar, rice, thickener powder, powdered milk, flour, and jasmine rice. These bins were labeled but not dated. <BR/>Observations on 3/07/2023 from 11:10 a.m. - 11:20 a.m. revealed the DM took the temperatures of seven food items on the steam table and used a white rag to wipe the thermometer probe between each food item. <BR/>During an interview on 3/07/2023 at 11:20 a.m., the DM stated no she had not sanitized the thermometer probe in between temping the food items because she had dipped the towel in sanitizer solution prior to temping the food items. The DM stated the kitchen did not have disposable sanitizer wipes. <BR/>During an interview on 3/07/2023 at 3:17 p.m., the RDN stated the kitchen's policy on labeling and dating refrigerated items included the use of FIFO and stated staff labeled everything when it came in. The RDN stated it was not necessary to date bulk bin items as long as the container did not appear old and crusted. The RDN stated she would question it if it looked that way but stated the kitchen's stuff always looked fresh. The RDN then stated all food items needed a label and a date. The RDN stated she instructed kitchen staff to get rid of old produce if it looked wilted or was spotting and stated yes she would have expected staff to discard a bag of shredded carrots with a foul odor and a best-if-used-by date of over one month ago. The RDN stated the DM and the DSM inventoried the kitchen once or twice a week to identify and discard old food items. The RDN stated leftover food items such as sandwiches needed to be discarded after seven days. The RDN stated staff should use alcohol sanitizer wipes to sanitize the thermometer probe between temping different food items. The RDN stated that was how she trained staff to take food temperatures. The RDN stated the kitchen had sanitizer wipes and she expected them to use them. The RDN stated personal food items could be kept in the personal fridge or in the DSM's office. The RDN stated no that personal food items should not be kept in the reach-in refrigerator. The RDN stated all kitchen staff had been trained on food storage and sanitation through obtaining their Texas food handlers license upon hire. The RDN stated herself as well as the DM and DSM completed in-service trainings with staff on food storage and sanitation. The RDN stated she monitored the kitchen by completing monthly sanitation audits. The RDN stated she was in the kitchen a couple times a month and she would do a walk-through and make observations of tray line and the dining room. The RDN stated the kitchen was monitored daily by either the DM or DSM. The RDN stated they monitored the kitchen by going through to make sure items were labeled, dated, and covered. The RDN stated if policies on food storage and sanitation were not followed, there could be potential for foodborne illness. <BR/>During an interview on 3/08/2023 at 4:01 p.m., the ADM stated the kitchen's policy on food storage included covering, labeling and dating food items. The ADM stated leftovers should be tossed. The ADM stated old produce with a best-if-used-by date of over a month ago should have been thrown away already. The ADM stated there was a personal refrigerator where employee's personal food items should be stored. The ADM stated yes that all items removed from their original package should have a label and a date. The ADM stated he did not know what the facility's policy was on sanitizing thermometer probes when temping food but stated it should be sanitized appropriately in between. The ADM stated all kitchen staff were trained on food storage and sanitation through obtaining their certification and through in-service trainings. The ADM stated the DSM, the RDN and himself monitored the kitchen by making frequent rounds. The ADM stated the RDN monitored the kitchen via visits at least once a month, by completing a report, and through communication with the ADM about how things were going in the kitchen. The ADM stated he was in the kitchen twice a week to make sure there was not anything out of hand. The ADM stated if food storage policies were not followed, someone could get sick and if sanitation policies were not followed, infections could spread. <BR/>A record review of the facility's policy titled Taking Accurate Temperatures using Metal Stem Thermometers dated 2021 reflected the following: <BR/>Thermometers should be sanitized according to manufacturer's instructions. Bimetallic thermometers may be sanitized using a dish machine or three sink method. In between uses at one meal, an alcohol swab may be used to sanitize. (use a new swab for each sanitizing.)<BR/>A record review of the facility's policy titled Food Storage dated 2021 reflected the following: <BR/>Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contamination or cross contamination.<BR/>Procedure: <BR/>8. Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated.<BR/>12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2017 Federal Food Code.<BR/>13. Refrigerated food storage: <BR/>f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.<BR/>h. Refrigerated foods should be stored upon delivery and careful rotation procedures should be followed.<BR/>A record review of the facility's undated policy titled Policy for Personnel Food Items reflected that employee's personal food items were to be stored in a mini fridge located in the hallway near the kitchen or in the DSM's office. <BR/>A record review of the RDN's monthly sanitation audit titled Food Safety and Sanitation Checklist dated 2/28/2023 reflected no that the facility did not identify food not stored in its original container by its proper name and out of date leftovers x 4-5. <BR/>A record review of the FDA's 2017 Food Code reflected the following: <BR/>Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils.<BR/>The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.<BR/>Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils.<BR/>Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. Food-contact surfaces and equipment used for time/temperature control for safety foods should be cleaned as needed throughout the day but must be cleaned no less than every 4 hours to prevent the growth of microorganisms on those surfaces.<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.<BR/>(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of 24 residents (Residents #55, 57, and 76) and one of four medication carts reviewed for infection control.<BR/>1. Resident #55 scratched herself in the perineal area multiple times resulting in soiled hands and fingers, and she touched people and things in the common area without intervention from staff.<BR/>2. LVN A stored and locked her used scrub-top in the drawer of a medication cart that contains medications and treatment supplies. <BR/>3. LVN C assisted both Residents #57 and 76 with eating, using the same hand, and did not perform hand hygiene between them.<BR/>These failures placed residents at risk of transmission of infectious diseases. <BR/>Findings included:<BR/>Review of the undated face sheet for Resident #55 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of pruritus (itchiness), chronic gingivitis, irritable bowel syndrome, slow transit constipation, diarrhea, impacted cerumen, hypothyroidism, Alzheimer's disease with early onset, intellectual disabilities, gastroesophageal reflux disease, down syndrome, Reynaud's syndrome without gangrene (a condition in which body overreacts to certain situations causing cold and numbness in the hands and feet.), anorexia, major depressive disorder, impulse disorder, and insomnia.<BR/>Review of the quarterly MDS for Resident #55 dated 02/07/23 reflected a BIMS score of 99, indicating a severe cognitive impairment. It reflected Resident #55 required the extensive assistance of one staff member with personal hygiene. <BR/>Review of the care plan for Resident #55 dated 08/03/22 reflected the following: Bowel and bladder incontinence r/t cognitive deficits. Resident will not have any direct complications from incontinence such as skin problems. Assist w/ incontinent care as indicated. Encourage self-care wiping and give resident praise for doing so.<BR/>Observation and interview on 03/07/23 between 12:29 PM and 02:15 PM revealed Resident #55 walking all around the common area on the DE side of the facility, frequently reaching her hands into the front and back of her pants and underwear and scratching. In between scratching inside her pants, she touched multiple surfaces including the back of several chairs, a medication cart, the overbed table CNAs used while entering their charting notes, staff members' hands and shoulders, and a toy car belonging to another resident. kissing staff on the hand. LVN D assisted Resident #55 with reapplying an arm sling, and Resident #55 put her hands on the sling, on LVN D's hands, and on LVN D's shoulder. Immediately after this, LVN D went into the nurse's station and began working on the computer. She did not perform hand hygiene. At 01:34 PM, Resident #55 again reached into the back side of her pants, scratched, withdrew, looked at, and smelled her hand, and said Ew! Her hand was covered in a brown substance, and she showed it to the surveyor, who asked loudly if she wanted to show any of the staff present. LVN D, LVN E, and MA F were each within four feet when this occurred, but none of them acknowledged the situation. MA F walked past Resident #55, and Resident #55 reached out to her and touched her arm as she walked by. Resident #55 continued to touch other things around the area, including her own face and the inside of her nose. MA F went to a sink behind the nurse's station and washed her hands. Shortly after, LVN E washed her hands in the same sink. At 01:38 PM, LVN D came out from behind the nurse's station and donned gloves. LVN D stated she was about to clean her medication cart. When asked why she had not performed hand hygiene since assisting Resident #55 with her arm sling, LVN D stated she thought she had and pulled a small bottle of hand alcohol-based hand run out of her pocket. When asked if she noticed that Resident #55 had been reaching her hands in her pants and touching things, LVN D stated, Yes, she does that. We try to redirect her. LVN D stated she should perform hand hygiene after assisting any resident with care, including the reapplication of a sling, and she should have assisted Resident #55 with hand hygiene often after she scratched inside her pants. When asked if she had received any specific training on how to address Resident #55's behavior, LVN D stated she was sure that the behavior was in Resident #55's care plan.<BR/>During an interview on 03/07/23 at 02:19 PM, the ADON stated she had witnessed Resident #55 scratching herself under her underwear, and this was a fairly common behavior for her due to her resistance to care and activities of daily living. The ADON stated the staff should be taking her to the bathroom to sanitize her hands if they witness the behavior. When asked how the staff knew to respond to the behavior that way, she stated they had infection control in-services. The ADON stated there had been no in-servicing specific to Resident #55, but because of the nature of the material that came out on her hands when she digs and scratches under her pants, her hands needed to be sanitized every time she did it. The ADON stated she thought there was a behavioral care plan for Resident #55, but the only thing she saw was the care plan item about being resistant to care with ADLs. The ADON stated the staff should have known what to do, though, because it was common sense for infection control. <BR/>During an interview on 03/08/23 at 03:13 PM, the DON stated hand hygiene for someone who has touched or dug under their underwear was common sense. She stated treating the behavior for Resident #55 presents with a unique challenge, because people with downs syndrome who develop dementia are extremely difficult to redirect. The DON stated she knew the staff washed Resident #55's hands when they provided assistance with toileting. The DON stated she did not think they had a specific intervention for Resident #55 but that any time someone is soiled the staff needed to clean them. The DON stated Resident #55 walking around touching things in the common area was hazardous due to being an infection control issue, and the area in which she had been doing that should have had a deep clean. <BR/>During an interview on 03/08/23 at 04:02 PM, the ADM stated they had to monitor sanitation all over the building and needed to monitor someone like Resident #55 very closely to make sure they did not have an infection control issue. He stated the hard part about residents with Downs syndrome who have dementia is they will be up and out and all over the place and trying to keep up with her will sometimes succeed and not others. The ADM stated if they saw her touching something she should not have touched with soiled hands, they should be intervening immediately. The Adm stated the problem often was that staff got nervous while surveyors were watching and failed to do what they normally would. <BR/>Review of facility policy dated August 2019 and titled Cleaning and Disinfection oc Environmental Surfaces reflected the following: Housekeeping surfaces (e.g. floors, table tops) will be cleaned on a regular basis, when spills occur, and when the surfaces are visibly soiled. Environmental services will be disinfected or clean on a regular basis (e.g. daily), three times per week, and when surfaces are visibly soiled. Spills of blood and other potentially infectious materials will promptly be cleaned and decontaminated.<BR/>2.<BR/>During an observation on 03/06/2023 at 10.30 AM revealed the storage of a green colored slightly faded scrub- top in the bottom drawer of a medication cart in the medication room situated at Hall A of the facility. There were wound care supplies, compound benzoin tincture swab sticks, oxygen tubing, sanitary pads, liquid medications in bottles and gastrotomy care supplies were in that drawer. LVN A was assisting the investigator by opening the drawers of the cart one by one for medication storage inspection. The scrub was found above the medications and treatment supplies in the bottom drawer, in plain without any package or wrap. LVN A removed the scrub immediately from the drawer and stated she regrets for storing it in the med cart. <BR/>During an interview on 03/06/23 at 10.45 AM LVN A stated the scrub owned by her and should not have stored in the med cart after the use. When asked about the adverse result of storing used scrub with medications, LVN A stated the scrub could contaminate the medications and treatment supplies stored in the med cart and helps to spread diseases. <BR/>During an interview on 03/07/23 at 3:00 PM ADON stated the med cart was exclusively for storing medications and treatment items and should not be used for storing any other materials like food or clothes. She stated this was necessary to minimize spreading diseases through cross contamination. <BR/>During an interview on 03/08/23 at 2:00 PM DON stated no materials other than medications and treatment items should be there in the med cart. She stated used clothes stored in a med cart could contaminate the medications in the cart and this compromises infection control efforts. <BR/>Review on 03/08/23 of the facility policy Storage of Medications dated November 2020 reflected:<BR/>The facility stores all drugs and biologicals in a safe, secure, and orderly manner . <BR/> . 3.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . <BR/>3.<BR/>A record review of Resident #57's Resident Dashboard dated 03/08/23 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of mild intellectual abilities, hypertension (high blood pressure), hyperlipidemia (high cholesterol), legal blindness, gastro-esophageal reflux disease (acid reflux), dysphagia (difficulty swallowing), schizoaffective disorder (mental condition causing delusions), major depressive disorder (depression), bipolar disorder (extreme mood swings), and repeated falls. <BR/>A record review of Resident #57's MDS assessment dated [DATE] reflected she was unable to complete a BIMS assessment. A review of Section G (Functional Status) reflected Resident #57 required supervision and a one-person physical assist with eating. <BR/>A record review of Resident #57's care plan last revised on 01/29/23 reflected she had ADL self-care deficit related to physical limitations and eyesight, and required meal set up, verbalized placement of food on table and verbal cueing as needed.<BR/>A record review of Resident #76's Resident Dashboard dated 03/08/23 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of muscle weakness, unspecified convulsions, severe intellectual disabilities, irritable bowel syndrome, and epilepsy (nervous system disorder).<BR/>A record review of Resident #76's MDS assessment dated [DATE] reflected she was unable to complete a BIMS assessment. A review of Section G (Functional Status) reflected Resident #76 was totally dependent on staff and required a one-person physical assist with eating. <BR/>A record review of Resident #76's care plan last revised on 01/28/23 reflected she had ADL self-care deficit related to altered cognitive status, cerebral palsy, and autistic disorder. Resident #76's care plan reflected she needed to be spoon fed all meals. <BR/>An observation on 03/06/23 at 11:58 AM revealed LVN C was sitting between Resident #76 and Resident #57 in the dining room. LVN C was observed feeding Resident #76. Resident #57 was observed to be having trouble feeding herself, LVN C began feeding her with the same hand she used to feed Resident #76. LVN C went back and forth three times between feeding Resident #76 and Resident #57 without using hand hygiene in between. <BR/>During an interview on 03/06/23 at 12:04 PM, LVN C stated she did not use hand hygiene in between feeding Resident #76 and Resident #57 because she did not believe it was cross-contamination since she did not touch the resident themselves. LVN C stated Resident #57 usually ate on her own but that day she needed help. LVN C then stated she should have used hand hygiene in between. <BR/>During an interview on 03/07/23 at 02:31 PM the ADON stated she expected staff to sanitize their hands in between feeding different residents. The ADON stated all staff were trained on proper hand hygiene upon hire. When asked what potential negative resident impact there could be if staff did not practice proper hand hygiene when feeding residents, the ADON stated, they are exchanging different bacteria when changing from one resident to another. <BR/>During an interview on 03/08/23 at 3:20 PM, the DON stated the facility's policy on hand hygiene during meal assistance included that staff were to perform hand hygiene between each resident. The DON stated yes that hands should be sanitized between feeding one resident and another. The DON stated staff were trained during orientation on proper hand hygiene during meal service. The DON stated herself, the ADON, and other management personnel monitored for compliance of proper hand hygiene by completing audits with staff. The DON stated if the facility's policy on hand hygiene during meal service were not followed, it would be an infection control issue.<BR/>During an interview on 03/08/23 at 04:01 PM, the ADM stated staff should perform hand hygiene between feeding multiple residents. The ADM stated all staff were trained on this upon hire. The ADM stated typically the nurse managers monitored staff to ensure they used proper hand hygiene. When asked what potential negative resident impact there could be if the facility's policy on hand hygiene in the dining room were not followed, the ADM stated, it is not best practice, it is not the right thing to do, and there was not an infection that came out of it.<BR/>A record review of the facility's orientation checklist titled Employee Onboarding Checklist reflected LVN C was trained on the facility's policy on hand hygiene in the dining room on 02/08/23. LVN C signed a statement reflecting she understood the policy for hand hygiene in the dining room. <BR/>A record review of the facility's undated policy titled Hand Hygiene in the Dining Room reflected the following:<BR/>It is the policy of (facility name) to make every effort to prevent the spread of infection in the facility. In complying with this policy, we will make every effort to ensure that hand hygiene is practiced by all staff while in the dining room serving trays or assisting residents with eating.<BR/>Policy Interpretation and Implementation: <BR/>6. If you are assisting a resident to eat, hand hygiene must be done prior to the beginning of the actual feeding or assistance.<BR/>7. You may feed two residents at the same time as long as you maintain a clean hand that is dedicated to touching only the silverware, plate or glassware of each resident. If you touch either resident with your dedicated hand, you must perform hand hygiene before you resume feeding or assisting the resident.<BR/>8. If you move from a resident at one table to a resident at another table to begin feeding or assisting, you must perform hand hygiene before assisting the new resident.<BR/>9. Hand hygiene is to be considered high priority when working in the dining room. If in doubt of the need as to perform hand hygiene, remember it cannot be done too frequently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of eight residents (Resident #55) reviewed for care plans.<BR/>Resident #55 scratched herself in the perineal area multiple times resulting in soiled hands and fingers, and she touched people and things in the common area without intervention from staff, and this was not included in a behavioral care plan. <BR/>This failure placed residents at risk of not attaining their higest practicable well-being. <BR/>Findings included:<BR/>Review of the undated face sheet for Resident #55 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of pruritus (itchiness), chronic gingivitis, irritable bowel syndrome, slow transit constipation, diarrhea, impacted cerumen, hypothyroidism, Alzheimer's disease with early onset, intellectual disabilities, gastroesophageal reflux disease, down syndrome, Reynaud's syndrome without gangrene (a condition in which body overreacts to certain situations causing cold and numbness in the hands and feet.), anorexia, major depressive disorder, impulse disorder, and insomnia.<BR/>Review of the quarterly MDS for Resident #55 dated 02/07/23 reflected a BIMS score of 99, indicating a severe cognitive impairment. It reflected Resident #55 required the extensive assistance of one staff member with personal hygiene. <BR/>Review of the care plan for Resident #55 dated 08/03/22 reflected the following: Bowel and bladder incontinence r/t cognitive deficits. Resident will not have any direct complications from incontinence such as skin problems. Assist w/ incontinent care as indicated. Encourage self-care wiping and give resident praise for doing so.<BR/>Observation and interview on 03/07/23 between 12:29 PM and 02:15 PM revealed Resident #55 walking all around the common area on the DE side of the facility, frequently reaching her hands into the front and back of her pants and underwear and scratching. In between scratching inside her pants, she touched multiple surfaces including the back of several chairs, a medication cart, the overbed table CNAs used while entering their charting notes, staff members' hands and shoulders, and a toy car belonging to another resident. kissing staff on the hand. LVN D assisted Resident #55 with reapplying an arm sling, and Resident #55 put her hands on the sling, on LVN D's hands, and on LVN D's shoulder. Immediately after this, LVN D went into the nurse's station and began working on the computer. She did not perform hand hygiene. At 01:34 PM, Resident #55 again reached into the back side of her pants, scratched, withdrew, looked at, and smelled her hand, and said Ew! Her hand was covered in a brown substance, and she showed it to the surveyor, who asked loudly if she wanted to show any of the staff present. LVN D, LVN E, and MA F were each within four feet when this occurred, but none of them acknowledged the situation. MA F walked past Resident #55, and Resident #55 reached out to her and touched her arm as she walked by. Resident #55 continued to touch other things around the area, including her own face and the inside of her nose. MA F went to a sink behind the nurse's station and washed her hands. Shortly after, LVN E washed her hands in the same sink. At 01:38 PM, LVN D came out from behind the nurse's station and donned gloves. LVN D stated she was about to clean her medication cart. When asked why she had not performed hand hygiene since assisting Resident #55 with her arm sling, LVN D stated she thought she had and pulled a small bottle of hand alcohol-based hand run out of her pocket. When asked if she noticed that Resident #55 had been reaching her hands in her pants and touching things, LVN D stated, Yes, she does that. We try to redirect her. LVN D stated she should perform hand hygiene after assisting any resident with care, including the reapplication of a sling, and she should have assisted Resident #55 with hand hygiene often after she scratched inside her pants. When asked if she had received any specific training on how to address Resident #55's behavior, LVN D stated she was sure that the behavior was in Resident #55's care plan.<BR/>During an interview on 03/07/23 at 02:19 PM, the ADON stated she had witnessed Resident #55 scratching herself under her underwear, and this was a fairly common behavior for her due to her resistance to care and activities of daily living. The ADON stated the staff should be taking her to the bathroom to sanitize her hands if they witness the behavior. When asked how the staff knew to respond to the behavior that way, she stated they had infection control in-services. The ADON stated there had been no in-servicing specific to Resident #55, but because of the nature of the material that came out on her hands when she digs and scratches under her pants, her hands needed to be sanitized every time she did it. The ADON stated she thought there was a behavioral care plan for Resident #55, but the only thing she saw was the care plan item about being resistant to care with ADLs. The ADON stated the staff should have known what to do, though, because it was common sense for infection control. <BR/>During an interview on 03/08/23 at 03:13 PM, the DON stated hand hygiene for someone who has touched or dug under their underwear was common sense. She stated treating the behavior for Resident #55 presents with a unique challenge, because people with downs syndrome who develop dementia are extremely difficult to redirect. The DON stated she knew the staff washed Resident #55's hands when they provided assistance with toileting. The DON stated she did not think they had a specific intervention for Resident #55 but that any time someone is soiled the staff needed to clean them. The DON stated Resident #55 walking around touching things in the common area was hazardous due to being an infection control issue, and the area in which she had been doing that should have had a deep clean. <BR/>During an interview on 03/08/23 at 04:02 PM, the ADM stated they had to monitor sanitation all over the building and needed to monitor someone like Resident #55 very closely to make sure they did not have an infection control issue. He stated the hard part about residents with Downs syndrome who have dementia is they will be up and out and all over the place and trying to keep up with her will sometimes succeed and not others. The ADM stated if they saw her touching something she should not have touched with soiled hands, they should be intervening immediately. The Adm stated the problem often was that staff got nervous while surveyors were watching and failed to do what they normally would.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Residents #5) reviewed for pressure ulcers. <BR/>1. The facility failed to ensure the provider treatment plan for Resident #5 was implemented. <BR/>2. The facility did not provide wound care as ordered by the provider for Resident #5. <BR/>These failures placed residents at risk of pain, worsening of wounds and wound infection. <BR/>Findings included:<BR/>Record review of Resident #5's Face Sheet dated 03/07/23 reflected Resident #5 was a [AGE] year-old male, and he was admitted to the facility on [DATE]. Resident #5 had diagnoses of Dysphagia (difficult to swallow), Parkinsonism, Chronic pain, Deficiency of B and D vitamins, Allergic rhinitis due to pollen, Epilepsy, Constipation, Intellectual disabilities, Muscle Weakness, Need for assistance with personal care, Psychosis, Pain in left Foot, Pain in left knee and Pressure-induced deep tissue damage of left heel.<BR/>Record review of Resident #5's MDS assessment dated [DATE] reflected Resident #5 had slurred or mumbled words and limited ability to make concrete requests. Resident #5 also had a BIMS score of 11, indicated Resident #5 had moderate cognitive impairment. He required to have full staff performance every time during entire 7-day period. Resident #5 was incontinent for both bowel and bladder. The MDS assessment indicated Resident #5 had one or more unhealed pressure ulcers/injuries and treatment included pressure reducing device for chair and bed and pressure ulcer/injury care. <BR/>Record review of Resident #5's Care Plan dated 02/03/23 reflected no statement of any pressure ulcer. <BR/>Record review of Resident #5's weekly skin assessment dated [DATE] reflected Resident #5 had left heel wound measuring 3cm L x 2cm W x 0cm D with clear drainage. Resident informed he had a burning sensation from that. Resident#5's left toe had a blackish colored spot above the toenail measuring 1cm L x 1cm W x 0 cm D.<BR/>Record review on 03/7/23 of the evaluation of the wounds of Resident #5 on 2/22/22 at 1:53pm by APRN, stated:<BR/>Wound #1, Date of onset: 2/22/23, Location: left heel (2 areas), Description: Medial Area:1.5cm x 1.4cm and 0.8cm x0.7 cm. Etiology: DTI, Treatment plan: change treatment to: Apply skin prep and cover with sock. Continue booties. <BR/>Wound #2, Location: left great toe. Description: Proximal Area:0.8cm x0.6 cm. Etiology: DTI. Treatment plan: change treatment to: Apply skin prep and cover with sock. Apply booties.<BR/>Record review of clinical physician's order on 03/07/23 dated 02/22/23 at 1:07pm by APRN, stated: Left heel wound: Apply skin prep and cover with sock.<BR/>Record review of clinical physician's order on 03/07/23 dated 03/07/23 at 1:12pm by APRN, stated Left great toe DTI: Apply skin prep and cover with sock. <BR/>The treatment order on 02/22/23 at 1:07pm for Resident#5's wound on his left heel was as per the treatment plan dated 02/22/23, however, the treatment order on 03/07/23 at 1:12pm for Resident #5's left great toe was ordered 13 days after the completion of wound evaluation and treatment plan dated 02/22/23. <BR/>Record review of February,2023 TAR on 03/07/23 at 01:18pm stated: <BR/> Left heel wound: Apply skin prep and cover with sock every evening shift for Left heel wound, -Start Date-02/24/2023, 1400. <BR/>Record review of March,2023 TAR on 03/7/23 at 1.28 pm stated:<BR/>1.Left heel wound: Apply skin prep and cover with sock every evening shift for Left heel wound, -Start Date-02/24/2023, 1400 <BR/>2.Left great toe DTI: Apply skin prep and cover with sock. Every evening shifts. -Start Date-03/07/2023 1400. <BR/>Record review on 03/07/2023 at 11.30am of the TAR reflected that as on 03/07/2023, 11.30am there were no evidence of any treatment provided as per the order to Resident#5's wounds starting from 02/24/2023, as per the order. <BR/>Observation of Resident #5's wound dressing on 03/07/23 at 11:30 AM revealed Resident #5's left heel wound had redness without any secretion and the left toe wound was visible as a red spot without any secretion.<BR/>An interview with LVN B on 03/07/23 at 11:30 am, LVN B stated she was not aware of the pressure ulcer treatment for Resident #5. LVN B said she was aware of the order for Witch Hazel Liquid (medicinal ointment) that was applied on 3/7/23 to Resident#5's face, neck, behind ears topically. This was provided every day as per the order. When asked about the adherence to TAR orders, LVN B stated it was mandatory that the treatments had to be provided by nurses as per the directions in the treatment order in the TAR.<BR/>During an interview on 03/07/23 at 2.00pm the ADON stated that LVN B reported to her about the issue of the omission of wound treatment. ADON stated both orders for treatment were placed only on 03/07/23 by the APRN. She added that the facility had a new APRN who started few weeks ago and getting used to the system. When the investigator asked about the treatment order by APRN on 02/22/23 for the wound treatment for the left heel that was transcribed into the TAR clearly stating to commence from 02/24/23, ADON said most likely there was a software glitch in the EMR and transcribed the commencement date wrongly. When asked about the compliance by the nurses to the treatment order, ADON stated the nurses should strictly follow the treatment order in the TAR. <BR/>During the interview on 03/08/23 at 2:30 pm the DON stated the nurses and MAs must follow the MAR and TAR while providing treatments and administering medications. DON stated the APRN did not place the orders for the treatments and that was the reason for not providing the treatment. When the investigator showed the treatment order for left heel wound on TAR scheduled to start from 02/24/23, DON stated that the commencement date on the TAR was wrong and most likely there was some issue with the EMR software. When asked about the risk of such software issues, she stated there was high risk of not getting very important medications and treatments to the residents on time if the EMR was malfunctioning. DON stated this was the first time happening like this. <BR/>During the interview on 03/08/23 at 2pm the APRN stated she was new to the facility and settling in with the system at the facility. When asked about the treatment orders for the pressure ulcers of Resident#5, she stated on 02/22/23 after her wound evaluation she made a treatment plan, and not a treatment order. When the investigator asked when there was a treatment order for the wound on the heel, based on the treatment plan on 02/22/23, why there was not an order for the wound on the toe on 02/22/23 itself but only 13 days after on 03/07/23, though both of them had treatment plan on 02/22/23, APRN said she was not familiar with the EMR and might not have entered properly. <BR/>During the interview on 03/08/23 at 3.30pm, the ADM stated the clinical aspects were taken care by DON and he was in charge of the administration. When the investigator asked about the accuracy and reliability of the EMR system, he stated it was a very reliable software and never heard of any complaints. He said, in case if any issues there, that could be immediately resolved with the support of the readily available EMR software technicians. He added, the facility never had any concerns about the reliability and accuracy of the system. The ADM stated there was no specific policy and procedure for medication administration and the nurses supposed to follow the standard clinical rules for medication administration and treatment.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation.<BR/>1. The DSM failed to ensure all items in the kitchen were labeled, dated, and discarded prior to their expiration date.<BR/>2. The DSM failed to ensure all personnel food items were stored separate from resident food items.<BR/>3. The DM failed to properly sanitize the thermometer probe when taking the temperature of food items.<BR/>Findings included:<BR/>Observations of the reach-in refrigerator on 3/06/2023 from 9:13 a.m. - 9:24 a.m. revealed the following:<BR/>At 9:13 a.m., the reach-in refrigerator contained 12 bags of yellow unidentifiable substance unlabeled and undated. <BR/>At 9:15 a.m., the reach-in refrigerator contained five foam containers of unidentifiable substance unlabeled and undated.<BR/>At 9:16 a.m., the reach-in refrigerator contained three small foam containers of unidentifiable substance unlabeled and undated.<BR/>At 9:17 a.m., the reach-in refrigerator contained a foam container, undated and labeled with the DSM's name. <BR/>At 9:23 a.m., the reach-in refrigerator contained a bag of shredded carrots with a best-if-used-by date of 1/30/2023. The carrots appeared browned and had a foul odor. <BR/>At 9:24 a.m., the reach-in refrigerator contained three sandwiches labeled PBH dated 2/26/2023. <BR/>During an interview on 3/06/2023 at 9:30 a.m., the DM stated all items in the refrigerator should be labeled and dated. The DM stated the yellow substance was egg and usually they put it in a container with a label. The DM stated the items in the foam containers were parfait and whipped topping. The DM stated all items in the refrigerator needed to be labeled and dated. The DM stated all leftovers were discarded after seven days, the sandwiches were eight days old, and she would discard them. The DM stated the facility followed best-if-used-by dates and stated she would not serve the shredded carrots. The DM stated the foam container labeled with the DSM's name was the DSM's meal from the day prior. The DM stated the kitchen had a separate cooler for employee food items. <BR/>An observation on 3/07/2023 at 10:46 a.m. revealed six bulk bins labeled sugar, rice, thickener powder, powdered milk, flour, and jasmine rice. These bins were labeled but not dated. <BR/>Observations on 3/07/2023 from 11:10 a.m. - 11:20 a.m. revealed the DM took the temperatures of seven food items on the steam table and used a white rag to wipe the thermometer probe between each food item. <BR/>During an interview on 3/07/2023 at 11:20 a.m., the DM stated no she had not sanitized the thermometer probe in between temping the food items because she had dipped the towel in sanitizer solution prior to temping the food items. The DM stated the kitchen did not have disposable sanitizer wipes. <BR/>During an interview on 3/07/2023 at 3:17 p.m., the RDN stated the kitchen's policy on labeling and dating refrigerated items included the use of FIFO and stated staff labeled everything when it came in. The RDN stated it was not necessary to date bulk bin items as long as the container did not appear old and crusted. The RDN stated she would question it if it looked that way but stated the kitchen's stuff always looked fresh. The RDN then stated all food items needed a label and a date. The RDN stated she instructed kitchen staff to get rid of old produce if it looked wilted or was spotting and stated yes she would have expected staff to discard a bag of shredded carrots with a foul odor and a best-if-used-by date of over one month ago. The RDN stated the DM and the DSM inventoried the kitchen once or twice a week to identify and discard old food items. The RDN stated leftover food items such as sandwiches needed to be discarded after seven days. The RDN stated staff should use alcohol sanitizer wipes to sanitize the thermometer probe between temping different food items. The RDN stated that was how she trained staff to take food temperatures. The RDN stated the kitchen had sanitizer wipes and she expected them to use them. The RDN stated personal food items could be kept in the personal fridge or in the DSM's office. The RDN stated no that personal food items should not be kept in the reach-in refrigerator. The RDN stated all kitchen staff had been trained on food storage and sanitation through obtaining their Texas food handlers license upon hire. The RDN stated herself as well as the DM and DSM completed in-service trainings with staff on food storage and sanitation. The RDN stated she monitored the kitchen by completing monthly sanitation audits. The RDN stated she was in the kitchen a couple times a month and she would do a walk-through and make observations of tray line and the dining room. The RDN stated the kitchen was monitored daily by either the DM or DSM. The RDN stated they monitored the kitchen by going through to make sure items were labeled, dated, and covered. The RDN stated if policies on food storage and sanitation were not followed, there could be potential for foodborne illness. <BR/>During an interview on 3/08/2023 at 4:01 p.m., the ADM stated the kitchen's policy on food storage included covering, labeling and dating food items. The ADM stated leftovers should be tossed. The ADM stated old produce with a best-if-used-by date of over a month ago should have been thrown away already. The ADM stated there was a personal refrigerator where employee's personal food items should be stored. The ADM stated yes that all items removed from their original package should have a label and a date. The ADM stated he did not know what the facility's policy was on sanitizing thermometer probes when temping food but stated it should be sanitized appropriately in between. The ADM stated all kitchen staff were trained on food storage and sanitation through obtaining their certification and through in-service trainings. The ADM stated the DSM, the RDN and himself monitored the kitchen by making frequent rounds. The ADM stated the RDN monitored the kitchen via visits at least once a month, by completing a report, and through communication with the ADM about how things were going in the kitchen. The ADM stated he was in the kitchen twice a week to make sure there was not anything out of hand. The ADM stated if food storage policies were not followed, someone could get sick and if sanitation policies were not followed, infections could spread. <BR/>A record review of the facility's policy titled Taking Accurate Temperatures using Metal Stem Thermometers dated 2021 reflected the following: <BR/>Thermometers should be sanitized according to manufacturer's instructions. Bimetallic thermometers may be sanitized using a dish machine or three sink method. In between uses at one meal, an alcohol swab may be used to sanitize. (use a new swab for each sanitizing.)<BR/>A record review of the facility's policy titled Food Storage dated 2021 reflected the following: <BR/>Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contamination or cross contamination.<BR/>Procedure: <BR/>8. Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated.<BR/>12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded as per the 2017 Federal Food Code.<BR/>13. Refrigerated food storage: <BR/>f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.<BR/>h. Refrigerated foods should be stored upon delivery and careful rotation procedures should be followed.<BR/>A record review of the facility's undated policy titled Policy for Personnel Food Items reflected that employee's personal food items were to be stored in a mini fridge located in the hallway near the kitchen or in the DSM's office. <BR/>A record review of the RDN's monthly sanitation audit titled Food Safety and Sanitation Checklist dated 2/28/2023 reflected no that the facility did not identify food not stored in its original container by its proper name and out of date leftovers x 4-5. <BR/>A record review of the FDA's 2017 Food Code reflected the following: <BR/>Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils.<BR/>The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.<BR/>Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils.<BR/>Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. Food-contact surfaces and equipment used for time/temperature control for safety foods should be cleaned as needed throughout the day but must be cleaned no less than every 4 hours to prevent the growth of microorganisms on those surfaces.<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.<BR/>(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under &sect; 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of 24 residents (Residents #55, 57, and 76) and one of four medication carts reviewed for infection control.<BR/>1. Resident #55 scratched herself in the perineal area multiple times resulting in soiled hands and fingers, and she touched people and things in the common area without intervention from staff.<BR/>2. LVN A stored and locked her used scrub-top in the drawer of a medication cart that contains medications and treatment supplies. <BR/>3. LVN C assisted both Residents #57 and 76 with eating, using the same hand, and did not perform hand hygiene between them.<BR/>These failures placed residents at risk of transmission of infectious diseases. <BR/>Findings included:<BR/>Review of the undated face sheet for Resident #55 reflected a [AGE] year-old female admitted to the facility on [DATE] and having diagnoses of pruritus (itchiness), chronic gingivitis, irritable bowel syndrome, slow transit constipation, diarrhea, impacted cerumen, hypothyroidism, Alzheimer's disease with early onset, intellectual disabilities, gastroesophageal reflux disease, down syndrome, Reynaud's syndrome without gangrene (a condition in which body overreacts to certain situations causing cold and numbness in the hands and feet.), anorexia, major depressive disorder, impulse disorder, and insomnia.<BR/>Review of the quarterly MDS for Resident #55 dated 02/07/23 reflected a BIMS score of 99, indicating a severe cognitive impairment. It reflected Resident #55 required the extensive assistance of one staff member with personal hygiene. <BR/>Review of the care plan for Resident #55 dated 08/03/22 reflected the following: Bowel and bladder incontinence r/t cognitive deficits. Resident will not have any direct complications from incontinence such as skin problems. Assist w/ incontinent care as indicated. Encourage self-care wiping and give resident praise for doing so.<BR/>Observation and interview on 03/07/23 between 12:29 PM and 02:15 PM revealed Resident #55 walking all around the common area on the DE side of the facility, frequently reaching her hands into the front and back of her pants and underwear and scratching. In between scratching inside her pants, she touched multiple surfaces including the back of several chairs, a medication cart, the overbed table CNAs used while entering their charting notes, staff members' hands and shoulders, and a toy car belonging to another resident. kissing staff on the hand. LVN D assisted Resident #55 with reapplying an arm sling, and Resident #55 put her hands on the sling, on LVN D's hands, and on LVN D's shoulder. Immediately after this, LVN D went into the nurse's station and began working on the computer. She did not perform hand hygiene. At 01:34 PM, Resident #55 again reached into the back side of her pants, scratched, withdrew, looked at, and smelled her hand, and said Ew! Her hand was covered in a brown substance, and she showed it to the surveyor, who asked loudly if she wanted to show any of the staff present. LVN D, LVN E, and MA F were each within four feet when this occurred, but none of them acknowledged the situation. MA F walked past Resident #55, and Resident #55 reached out to her and touched her arm as she walked by. Resident #55 continued to touch other things around the area, including her own face and the inside of her nose. MA F went to a sink behind the nurse's station and washed her hands. Shortly after, LVN E washed her hands in the same sink. At 01:38 PM, LVN D came out from behind the nurse's station and donned gloves. LVN D stated she was about to clean her medication cart. When asked why she had not performed hand hygiene since assisting Resident #55 with her arm sling, LVN D stated she thought she had and pulled a small bottle of hand alcohol-based hand run out of her pocket. When asked if she noticed that Resident #55 had been reaching her hands in her pants and touching things, LVN D stated, Yes, she does that. We try to redirect her. LVN D stated she should perform hand hygiene after assisting any resident with care, including the reapplication of a sling, and she should have assisted Resident #55 with hand hygiene often after she scratched inside her pants. When asked if she had received any specific training on how to address Resident #55's behavior, LVN D stated she was sure that the behavior was in Resident #55's care plan.<BR/>During an interview on 03/07/23 at 02:19 PM, the ADON stated she had witnessed Resident #55 scratching herself under her underwear, and this was a fairly common behavior for her due to her resistance to care and activities of daily living. The ADON stated the staff should be taking her to the bathroom to sanitize her hands if they witness the behavior. When asked how the staff knew to respond to the behavior that way, she stated they had infection control in-services. The ADON stated there had been no in-servicing specific to Resident #55, but because of the nature of the material that came out on her hands when she digs and scratches under her pants, her hands needed to be sanitized every time she did it. The ADON stated she thought there was a behavioral care plan for Resident #55, but the only thing she saw was the care plan item about being resistant to care with ADLs. The ADON stated the staff should have known what to do, though, because it was common sense for infection control. <BR/>During an interview on 03/08/23 at 03:13 PM, the DON stated hand hygiene for someone who has touched or dug under their underwear was common sense. She stated treating the behavior for Resident #55 presents with a unique challenge, because people with downs syndrome who develop dementia are extremely difficult to redirect. The DON stated she knew the staff washed Resident #55's hands when they provided assistance with toileting. The DON stated she did not think they had a specific intervention for Resident #55 but that any time someone is soiled the staff needed to clean them. The DON stated Resident #55 walking around touching things in the common area was hazardous due to being an infection control issue, and the area in which she had been doing that should have had a deep clean. <BR/>During an interview on 03/08/23 at 04:02 PM, the ADM stated they had to monitor sanitation all over the building and needed to monitor someone like Resident #55 very closely to make sure they did not have an infection control issue. He stated the hard part about residents with Downs syndrome who have dementia is they will be up and out and all over the place and trying to keep up with her will sometimes succeed and not others. The ADM stated if they saw her touching something she should not have touched with soiled hands, they should be intervening immediately. The Adm stated the problem often was that staff got nervous while surveyors were watching and failed to do what they normally would. <BR/>Review of facility policy dated August 2019 and titled Cleaning and Disinfection oc Environmental Surfaces reflected the following: Housekeeping surfaces (e.g. floors, table tops) will be cleaned on a regular basis, when spills occur, and when the surfaces are visibly soiled. Environmental services will be disinfected or clean on a regular basis (e.g. daily), three times per week, and when surfaces are visibly soiled. Spills of blood and other potentially infectious materials will promptly be cleaned and decontaminated.<BR/>2.<BR/>During an observation on 03/06/2023 at 10.30 AM revealed the storage of a green colored slightly faded scrub- top in the bottom drawer of a medication cart in the medication room situated at Hall A of the facility. There were wound care supplies, compound benzoin tincture swab sticks, oxygen tubing, sanitary pads, liquid medications in bottles and gastrotomy care supplies were in that drawer. LVN A was assisting the investigator by opening the drawers of the cart one by one for medication storage inspection. The scrub was found above the medications and treatment supplies in the bottom drawer, in plain without any package or wrap. LVN A removed the scrub immediately from the drawer and stated she regrets for storing it in the med cart. <BR/>During an interview on 03/06/23 at 10.45 AM LVN A stated the scrub owned by her and should not have stored in the med cart after the use. When asked about the adverse result of storing used scrub with medications, LVN A stated the scrub could contaminate the medications and treatment supplies stored in the med cart and helps to spread diseases. <BR/>During an interview on 03/07/23 at 3:00 PM ADON stated the med cart was exclusively for storing medications and treatment items and should not be used for storing any other materials like food or clothes. She stated this was necessary to minimize spreading diseases through cross contamination. <BR/>During an interview on 03/08/23 at 2:00 PM DON stated no materials other than medications and treatment items should be there in the med cart. She stated used clothes stored in a med cart could contaminate the medications in the cart and this compromises infection control efforts. <BR/>Review on 03/08/23 of the facility policy Storage of Medications dated November 2020 reflected:<BR/>The facility stores all drugs and biologicals in a safe, secure, and orderly manner . <BR/> . 3.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . <BR/>3.<BR/>A record review of Resident #57's Resident Dashboard dated 03/08/23 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of mild intellectual abilities, hypertension (high blood pressure), hyperlipidemia (high cholesterol), legal blindness, gastro-esophageal reflux disease (acid reflux), dysphagia (difficulty swallowing), schizoaffective disorder (mental condition causing delusions), major depressive disorder (depression), bipolar disorder (extreme mood swings), and repeated falls. <BR/>A record review of Resident #57's MDS assessment dated [DATE] reflected she was unable to complete a BIMS assessment. A review of Section G (Functional Status) reflected Resident #57 required supervision and a one-person physical assist with eating. <BR/>A record review of Resident #57's care plan last revised on 01/29/23 reflected she had ADL self-care deficit related to physical limitations and eyesight, and required meal set up, verbalized placement of food on table and verbal cueing as needed.<BR/>A record review of Resident #76's Resident Dashboard dated 03/08/23 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of muscle weakness, unspecified convulsions, severe intellectual disabilities, irritable bowel syndrome, and epilepsy (nervous system disorder).<BR/>A record review of Resident #76's MDS assessment dated [DATE] reflected she was unable to complete a BIMS assessment. A review of Section G (Functional Status) reflected Resident #76 was totally dependent on staff and required a one-person physical assist with eating. <BR/>A record review of Resident #76's care plan last revised on 01/28/23 reflected she had ADL self-care deficit related to altered cognitive status, cerebral palsy, and autistic disorder. Resident #76's care plan reflected she needed to be spoon fed all meals. <BR/>An observation on 03/06/23 at 11:58 AM revealed LVN C was sitting between Resident #76 and Resident #57 in the dining room. LVN C was observed feeding Resident #76. Resident #57 was observed to be having trouble feeding herself, LVN C began feeding her with the same hand she used to feed Resident #76. LVN C went back and forth three times between feeding Resident #76 and Resident #57 without using hand hygiene in between. <BR/>During an interview on 03/06/23 at 12:04 PM, LVN C stated she did not use hand hygiene in between feeding Resident #76 and Resident #57 because she did not believe it was cross-contamination since she did not touch the resident themselves. LVN C stated Resident #57 usually ate on her own but that day she needed help. LVN C then stated she should have used hand hygiene in between. <BR/>During an interview on 03/07/23 at 02:31 PM the ADON stated she expected staff to sanitize their hands in between feeding different residents. The ADON stated all staff were trained on proper hand hygiene upon hire. When asked what potential negative resident impact there could be if staff did not practice proper hand hygiene when feeding residents, the ADON stated, they are exchanging different bacteria when changing from one resident to another. <BR/>During an interview on 03/08/23 at 3:20 PM, the DON stated the facility's policy on hand hygiene during meal assistance included that staff were to perform hand hygiene between each resident. The DON stated yes that hands should be sanitized between feeding one resident and another. The DON stated staff were trained during orientation on proper hand hygiene during meal service. The DON stated herself, the ADON, and other management personnel monitored for compliance of proper hand hygiene by completing audits with staff. The DON stated if the facility's policy on hand hygiene during meal service were not followed, it would be an infection control issue.<BR/>During an interview on 03/08/23 at 04:01 PM, the ADM stated staff should perform hand hygiene between feeding multiple residents. The ADM stated all staff were trained on this upon hire. The ADM stated typically the nurse managers monitored staff to ensure they used proper hand hygiene. When asked what potential negative resident impact there could be if the facility's policy on hand hygiene in the dining room were not followed, the ADM stated, it is not best practice, it is not the right thing to do, and there was not an infection that came out of it.<BR/>A record review of the facility's orientation checklist titled Employee Onboarding Checklist reflected LVN C was trained on the facility's policy on hand hygiene in the dining room on 02/08/23. LVN C signed a statement reflecting she understood the policy for hand hygiene in the dining room. <BR/>A record review of the facility's undated policy titled Hand Hygiene in the Dining Room reflected the following:<BR/>It is the policy of (facility name) to make every effort to prevent the spread of infection in the facility. In complying with this policy, we will make every effort to ensure that hand hygiene is practiced by all staff while in the dining room serving trays or assisting residents with eating.<BR/>Policy Interpretation and Implementation: <BR/>6. If you are assisting a resident to eat, hand hygiene must be done prior to the beginning of the actual feeding or assistance.<BR/>7. You may feed two residents at the same time as long as you maintain a clean hand that is dedicated to touching only the silverware, plate or glassware of each resident. If you touch either resident with your dedicated hand, you must perform hand hygiene before you resume feeding or assisting the resident.<BR/>8. If you move from a resident at one table to a resident at another table to begin feeding or assisting, you must perform hand hygiene before assisting the new resident.<BR/>9. Hand hygiene is to be considered high priority when working in the dining room. If in doubt of the need as to perform hand hygiene, remember it cannot be done too frequently.

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.