GRANBURY REHAB & NURSING

Based on interview and record review, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 9 of 9 confidential resident council members reviewed for resident/group response. The facility failed to provide a verbal or written response to the Resident Council addressing the grievances reported from their meetings on February 2025, March 2025, and August 2025 which included issues with nursing services, dietary services, and housekeeping services. These failures could place residents at risk of unresolved grievances, a decreased sense of self-worth, and a decline in quality of life.Findings Included:Record review of the Grievance logs for February 2025 reflected Resident Council made 2 grievances. The first grievance dated 2/28/2025 involving housekeeping services reflected the SW documented that residents were notified of resolution by one-to-one discussion. The second grievance dated 2/28/2025 involving nursing services reflected no documentation that residents were notified of resolution. Record review of the Grievance logs for March 2025 reflected the Resident Council made 3 grievances. The first grievance dated 3/27/2025 involving housekeeping services reflected the SW documented that residents were notified of resolution by one-to-one discussion. The second grievance dated 3/27/2025 involving dietary services reflected the SW documented that residents were notified of resolution by one-to-one discussion. The third grievance dated 3/27/2025 involving nursing services reflected the SW documented that residents were notified of resolution by one-to-one discussion. Record review of the Grievance logs for August 2025 reflected the Resident Council made 10 grievances dated 8/28/2025. There were 3 grievances involving nursing services and seven grievances involving dietary services. On all the grievances the SW documented that residents were notified of resolution by one-to-one discussion. Record review of the Grievance logs reflected an undated grievance by Resident Council involving residents not being assisted outside for smoke breaks by staff at designated time with no facility follow up documented and no documentation that residents were notified of resolution. In a confidential group interview at an undisclosed date at an undisclosed time, 9 of 9 residents stated that no one had gotten back with them about their grievances from August. They stated that rarely anyone had come into the meeting and verified those people were the administrator and the dietary manager. They stated the issues they had filed grievances on all the issues were still ongoing. During an interview on 9/17/2025 at 10:53 a.m., the AD stated she was present during the Resident Council meetings per the residents' request. She stated she would take notes and would fill out grievance forms for the council members. She stated she would hand the completed grievance forms to the SW. The AD stated she believed those forms were then distributed to the various departments. She stated that no staff would come to the Resident Council meetings to go over the resolutions unless the Resident Council members asked for those staff members to attend. She stated the ADMN and DM had come to the meeting before to discuss resolutions. She stated she felt bad that the residents felt they were not notified of grievance notifications. She confirmed that there had never been a nurse or SW invited to the meetings. She stated there had not been any follow up on the grievances that she was aware of. She stated her plan moving forward would be to get the grievance resolutions from the SW prior to the Resident Council meetings to discuss them with the council members. During an interview on 9/17/2025 at 11:17 a.m., the SW stated she was responsible for grievances. She stated she would receive grievance forms and then would hand them to the department head they pertained to. She stated the department heads would then fill out the form with what they had done and hand them back to her. She stated she would ask for the form if she did not get them back. She stated one-to-one meant that she would talk to the resident or family member who made the grievance about how it was resolved. She stated that if the resident council had made the grievance, she believed one-to-one meant that she may have spoken to the Resident Council president but had no documentation of that occurring. She stated that moving forward, the facility decided the AD would announce the resolutions at the next council meeting but that had not been done before. She stated she monitored grievances weekly. She stated the failure occurred due to there was too much for one person to do especially if the grievance was resolved by another department head. She stated the effect of not notifying the Resident Council members of resolution to their grievances could cause them to feel that their concerns were not acknowledged. During an interview on 9/17/2025 at 1:40 p.m., the ADMN stated he expected for grievances to be handled by the SW. He stated after grievances were made, the department heads would investigate the issue and then the person who made the grievance would be informed of the outcome of the investigation. He stated he believed that the Resident Council members had been informed of the outcome of the investigation, but they may have forgotten that discussion. He stated he knew that he, the DM, and the DON had notified the Resident Council members of some of the issue resolutions. He stated not informing residents of the outcome of a grievance could make them feel that they were not being heard. He did not feel that any negative outcome had occurred because he, the SW and the DON had an open-door policy and felt that all residents could come to them if there were any issues. During a confidential follow up interview on 9/18/2025 at 10:21 a.m., a resident revealed they attended all the Resident Council meetings. They stated only once had the ADMN addressed the Resident Council about their grievances. The stated only twice had the DM addressed the Resident Council about their grievances. They verified no SW or nurse had ever addressed the Resident Council's grievances. They stated that the dietary issues, laundry issues, nursing issues have not been resolved from what was reported by the resident council during their meetings. Record review of the facility's policy titled Grievance Policy revised on 11/19/2016 reflected The designated grievance officer is the Administrator. Resident concerns should be taken seriously and that the ability to voice a grievance is an important right and protection for residents. Social Service under the guidance of the Administrator is responsible for the following: *maintains a system to keep records (file, log, copy of grievance registration forms, etc.) of all complaints reported which contains the date of report, circumstances, specifics of investigation, action taken, and follow-up with the complainant *Conduct/designate routine interviews with residents and families related to specific areas of facility life and resident ca. Document negative findings on a grievance form. The Administrator (grievance officer) is responsible for the following *Maintains a Grievance Log for 3 years *Review grievances to validate investigation of the facts and circumstances of the grievance *Written findings of fact, conclusion and recommendations and validate with person issuing the grievance timely *Establish a mechanism for all associates to communicate resident or family grievances to the designated staff so that all grievances will be documented and timely response developed and implemented.*Coordinate orientation and in-service training to ensure that all facility associates are knowledgeable of the facility grievance procedures and their role in providing responsive customer service to residents and families in grievance resolution. *Validates designee follows up with resident/family regarding resolution or explanation.

**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 baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 2 (Resident #131) reviewed for baseline care plans.<BR/>The facility failed to develop a baseline careplan that included the needs of Resident #131's foley catheter.<BR/>This failure placed residents that admitted to the facility with a foley catheter of having their needs met.<BR/>Findings included:<BR/>Record review of Resident #131's Facesheet dated 06/14/23 revealed a [AGE] year-old male that admitted to the facility on [DATE]. He had a diagnosis list that included dysuria dated 06/12/23.<BR/>Record review of Resident #131's admission Evaluation dated 06/08/23 revealed that resident was incontinent of urine with no comment regarding Resident #131 had a foley catheter. <BR/>Record review of Resident #131's Bowel and Bladder Program Screener dated 06/08/23 revealed that resident never voided appropriately without incontinence and no comment regarding he had a foley catheter.<BR/>Record review of Resident 131's Physician's Orders dated 06/13/23 revealed:<BR/>Change the BSD bag along with the catheter if visibly soiled, to collect a urine specimen, or if the closed system has been compromised. as needed. Start date of 06/08/23. <BR/>Flush foley catheter with 60ml of sterile water or normal saline. as needed for non-patency. Start date of 06/08/23. <BR/>Provide catheter care every shift for Urinary catheter use. Start date 06/08/23. <BR/>Record fluid intake and output. Review each week for fluid imbalance. every shift. Start date of 06/08/23.<BR/>Urinary catheter FR CC bulb to gravity (BSD). Change the catheter if it becomes occluded, to obtain a urine specimen, or if the closed system has become compromised. every shift for urinary retention. Start date of 06/08/23. <BR/>Record review of Resident #131's Baseline Careplan initiated 06/09/23 revealed no problem regarding resident care needs for a foley catheter. <BR/>During an observation and interview on 06/12/23 at 11:31AM of Resident #131, he had a foley catheter draining to gravity that had a noted blood clot in tubing and pink blood-tinged urine in the drainage bag. Resident #131 was repetitive in his remarks and spoke in a word salad. He was unable to express when and why he came to the facility. <BR/>During an interview on 06/14/23 at 2:38PM with the DON, she said they had a baseline careplan assessment. She said, whatever is on the baseline assessment would be on their baseline careplan. She, or an RN if on weekends, would begin the comprehensive care plan within 24 hours. DON said the baseline careplan would have the ADL needs if any. DON said if a resident had a catheter, then that would be considered as they were incontinent. She said the baseline careplan assessment had a box to check that the resident was continent or incontinent. So, with that, a catheter would mean incontinent, and staff would know they needed to go check on that resident. She said the admission nurse would also put physician orders in to indicate that a resident had a catheter. The physician orders would include what type/size the catheter was, to empty it, monitoring of the catheter. DON said the nurse aides did not have direct access to resident physician orders so the only way they would know if a resident had a catheter would be by going into the resident room and checking on them. She said, the baseline care plan assessment did not have a direct question regarding if a resident had a catheter. DON said there was a section at the bottom of that assessment that the nurse could summarize what was answered in that assessment and nothing more. She said the admission assessment and the bowel and bladder assessment would also have been completed as well. DON review of all 3 assessments did not include an area to checkbox that a resident did or did not have a catheter. It only had a checkbox that they were continent or incontinent of bowel and bladder. She said the reason that Resident #131 did not have a baseline careplan area directly identifying his catheter was due to the system generated assessments not having an area of addressing a catheter directly. DON said that the comprehensive care plan would address the resident catheter with further details, however they had at least 7 days to complete the comprehensive care plan. She said the comprehensive care plan policy should address baseline care plans as well.<BR/>Record review of facility policy labeled Comprehensive Care Plans revised September of 2010 revealed no area specifically addressing baseline careplans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to include in the care plan services that will be provided to the resident for 3 (Resident #9, Resident #54, and Resident #72) of 22 residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #9's comprehensive care plan had resident specific care needs for pressure ulcer.2. The facility failed to ensure Resident #54's comprehensive care plan had interventions care needs and interventions for dialysis.3. The facility failed to ensure Resident #72's comprehensive care plan had appropriate interventions for current transfer and sleeping status.4. The facility failed to ensure Resident #72's comprehensive care plan had correct code status and interventions to match her orders and wishes. These failures could affect the residents by placing them at risk for not receiving care and services to meet their wishes and needs.The findings included: Resident #9Record review of Resident #9's electronic face sheet dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease, muscle wasting and atrophy (decrease in muscle mass causing weakness), and left knee effusion (fluid buildup in joint of left knee). Record review of Resident #9's admission MDS dated [DATE] reflected: BIMS score of 07 which indicated severe cognitive impairment. Further review of the MDS Section M - Skin Conditions reflected that resident had a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) that was present upon admission. Record review of Resident #9's care plan dated [DATE] and revised on [DATE] reflected Resident has a pressure ulcer and is at risk for infection, pain, and a decline in functional abilities.Interventions: Negative pressure wound therapy (a device with a suction pump, tubing, and a dressing that promotes wound healing by placing foam in wound bed which is sealed with a dressing so that there is negative pressure sucking out wound drainage to store in bin attached to the device) date initiated: [DATE]. Record review of Resident #9's electronic physician orders dated [DATE] reflected no order for negative pressure therapy. During an observation and interview on [DATE] at 8:58 a.m., Resident #9 was sitting in a wheelchair in his room beside his bed. There was foam device in his bed that he stated was for his foot. He stated staff changed the dressing on his left foot that was covered with sock during this observation. No evidence of negative pressure therapy (a device with a suction pump, tubing, and a dressing that promotes wound healing by placing foam in wound bed which is sealed with a dressing so that there is negative pressure sucking out wound drainage to store in bin attached to the device) observed. During an interview on [DATE] at 4:00 p.m., LVN F stated Resident #9 did not have a negative pressure therapy that she was aware of. LVN F stated if Resident #9 did not use negative pressure therapy, then it should not be in his care plan. She stated she did not update care plans but the nurse managers and MDS nurse were responsible for updating the care plans. Resident #54Record review of Resident #54's electronic face sheet dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: unspecified severe protein-calorie malnutrition (significant loss of body weight without trying), muscle wasting and atrophy (decrease in muscle mass causing weakness), dysphagia (difficulty swallowing), and overactive bladder. Record review of Resident #54's admission MDS dated [DATE] revealed: BIMS score of 12 which indicated moderate cognitive impairment. Further review of the MDS Section O - Special Treatments reflected Resident #54 was on hemodialysis (dialysis from blood being taken from the body and ran through a machine to clear out the toxins then put back into the body) on admission and while a resident. Record review of Resident #54's care plan dated [DATE] reflected she required Enhanced Barrier Precautions for implanted vascular access device for dialysis with intervention to wear gown and gloved during high-contact resident care activities. Further review of the care plan reflected no evidence to assess the resident's condition and monitor for complications before and after dialysis treatments received as a certified dialysis facility. There was no evidence of ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Record review of Resident #54's medical record reflected an admission letter dated [DATE] from dialysis center with dialysis schedule starting on [DATE]. During an observation and interview on [DATE] at 12:00 p.m., Resident #54 was sitting in wheelchair talking to a visitor. Resident #54 appeared to have a central line dressing that was dry and intact, with no drainage noted. The dressing was also labeled with staff initials, date, and time. This resident was alert and oriented providing information of dialysis transport twice a week. Resident #72Record review of Resident #72's electronic face sheet dated [DATE] reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: muscle wasting and atrophy (decrease in muscle mass causing weakness), lack of coordination, bilateral osteoarthritis of knee (degenerative condition in which the cartilage in your joint slowly breaks down which could lead to swelling, pain, and stiffness of both knees), and chronic instability of both right and left knee. Record review of Resident #72's admission MDS dated [DATE] reflected: BIMS score of 15 which indicated cognition was intact. Further review of the MDS Section GG - Functional Abilities reflected Resident #72 was dependent on staff (helper did all the effort) during transfer from bed to chair transfer and sit to stand was not attempted due to medical condition or safety concerns. Record review of Resident #72's care plan dated [DATE] reflected Focus: [Resident #72] prefers to sleep in a recliner and requests the bed be removed from her room. Date Initiated [DATE]. Further review of Resident #72's care plan reflected [Resident #72] has physician's orders that include a status of full code. Date Initiated: [DATE] with interventions that included Ensure Full Code order on chart and Begin CPR after absence of vital signs, call 911, notify physician and notify family/responsible party. Continued review reflected Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to: debility Date Initiated: [DATE] with interventions that included ADL Assistance required.Transfers: x1 Record review of Resident #72's electronic physician orders dated [DATE] reflected Resident #72 was a DNR on [DATE]. Record review of Resident #72's medical record reflected OOH-DNR form completed on [DATE]. During an observation and interview on [DATE] at 9:05 a.m., Resident #72 was lying in the bed in her room. She stated she used to sleep in a recliner at home but since she cannot stand, the facility staff use a machine to lift her and transfer her from the bed to wheelchair and then back into the bed. She stated the facility had asked her if she would like to have CPR and she stated she did. During an interview on [DATE] at 9:31 a.m., CNA E stated Resident #72 transferred with a mechanical lift and it took 2 staff to transfer her from the bed to the wheelchair then back to the bed. During an interview on [DATE] at 10:07 a.m., RN C stated Resident #72 was a DNR because she had physician's order to be a DNR. She stated she also could tell a resident's code status by looking in the medical record under code status. RN C confirmed that Resident #72 was transferred using a mechanical lift and 2 staff members. During an interview on [DATE] at 4:03 p.m., the MDS nurse stated as she looked through Resident #9's medical record that she did not see any orders or documentation that he was ever on negative pressure therapy. She stated Resident #72 did not sleep in a recliner and did not know if she ever did during her stay at the facility. She stated that care plan transfer should reflect 2 people if resident used a mechanical lift. She stated transfer x1 meant one person assistance was needed. The MDS nurse also confirmed that Resident #72 had order for DNR and stated that care plan should match the code status in the orders. She stated her expectation would be that care plans to match current needs of the residents. The MDS nurse stated it was her responsibility to initiate the care plans then the IDT were responsible for maintaining them. She stated the IDT included herself, DON, ADONs, therapy, DM, AD, and SW. She stated the DOR was responsible for maintaining the transfer status and the SW was responsible for maintaining the code status. She stated she did not know why the care plans were not updated that the resident's current needs. She stated the DOR was away from facility on vacation at this time and she had been away on medical leave until recently. During an interview on [DATE] at 2:54 p.m., the DON stated Resident #54's dialysis treatment and anything needed concerning dialysis should be on the care plan. She verified the only the Enhanced Barrier Precautions were in the comprehensive care plan for Resident #54. She stated the last care plan conference for Resident #54 was on [DATE]. She stated she did not attend that conference and did not know why care plan did not have information on monitoring of dialysis site. She stated she and the nurses that worked the hall monitored the care plans were completed. She stated she had faith that the RNs would complete and update the care plans as needed. She stated the effect could lead to someone not knowing that she had dialysis access site that could cause bleeding or infection. During an interview on [DATE] at 3:10 p.m., the SW stated the IDT addressed care needs for the resident during care plan meetings. She stated if someone is on dialysis, it should have been addressed on preadmission and physician's orders reviewed the day of admission. She stated the nurses should have known Resident #54 was being admitted to facility on dialysis. She verified that she did attend care plan meetings and that it was the nurse's responsibility for maintaining the care plan to include dialysis care needs. She stated the IDT reviewed care plans and did not know why dialysis needs were not addressed on the care plan. She stated the failure occurred during IDT review. During an interview on [DATE] at 4:24 p.m., ADON D stated Resident #9 had never been on negative pressure therapy that she could remember. She stated negative pressure therapy was an option when pressure ulcer was triggered by MDS, and she felt that someone didn't uncheck that option which led to negative pressure therapy showing up on care plan. She stated she was not sure why Resident #72's code status, bed preference, and transfer status were not correct to match Resident #72's status and wishes. She stated the MDS nurse had been out on medical leave and that may have led to the failure, but she was not sure. She stated when the MDS nurse was on leave, corporate performed the MDS nurses duties. She stated care plans should match the residents' current needs and wishes. She stated care plans were updated by the IDT during quarterly care plan meetings. She stated the effect of care plans not being updated could lead to care not being provided as needed to the residents. During a follow up interview on [DATE] at 4:31 p.m., the DON stated her expectation would be that the care plan reflects the residents' current needs. She stated the IDT were responsible for monitoring the care plans were correct. She stated the IDT included the SW, DOR, AD, DM, ADONs and herself. She stated Resident #72 may have come to the facility with a recliner and ability to stand. She felt the failure on Resident #72's sleeping preference and transfer status may have occurred due to changing rooms from the rehabilitation hall to long term care hall. She was not sure what may have led to Resident #72's code status and Resident #9's negative pressure therapy not being accurate in the care plans. She stated the effect could be inappropriate care to the residents. Record review of facility policy titled Comprehensive Care Plans revised on [DATE] reflected: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to make sure that its menus are followed and document any substitutions made to the menus on 4 of 4 halls reviewed for food and nutrition services. The facility failed to ensure residents who ate from the kitchen received all food items according to the menu or an approved alternative during lunch meal on 9/15/2025. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss.Findings included:Resident #54Record review of Resident #54's electronic face sheet dated 9/16/2025 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: unspecified severe protein-calorie malnutrition (significant loss of body weight without trying), and dysphagia (difficulty swallowing). Record review of Resident #54's admission MDS dated [DATE] revealed: BIMS score of 12 which indicated moderate cognitive impairment. Further review of the MDS Section K - Swallowing/Nutritional Status reflected Resident #54 was on a mechanically altered diet. Record review of Resident #54's care plan dated 9/15/2025 reflected she had a swallowing problem with intervention Diet to be followed as prescribed Date Initiated: 08/26/2025. Record review of facility document with lunch notes revealed there were 2 residents (Resident #10 & Resident #54) with puree diets 9/15/2025 for the lunch service. Record review of facility's grievance log in 2025 reflected: 2/3/2025 grievance about not getting what was asked for most of the time; 2/12/2025 grievance about resident not getting a tray for breakfast and only had some bacon left so bacon and cold cereal offered to resident; 2/17/2025 grievance about lunch supposed to be pot roast and a baked potato but received a grilled cheese; 3/30/2025 grievance about resident receiving chicken tenders for lunch instead of fried chicken; 4/10/2025 another grievance about resident receiving chicken tenders instead of fried chicken; 8/4/2025 grievance about receiving grilled cheese sandwiches for 2 days in a row because the kitchen ran out of food; 8/28/2025 grievance about not getting all items that belong on delivery tray (i.e. missing drinks, missing food, and missing utensils). During an observation on 9/15/2025 at 12:32 p.m., the dry erase board in the dining room titled Menu had Week 3 written to the left side of it and Monday 9/15/25 Lunch Kielbasa Sausage, Macaroni Salad, [NAME] Peas, Dinner Roll, and Chocolate Brownie. During an observation on 9/15/2025 at 12:30 p.m., the DON was standing at the door from the kitchen leading into the dining room and asked that the food be served without the macaroni salad since the residents were waiting on the food. She stated that she realized that there were regulations, but the residents needed to eat. During an observation on 9/15/2025 at 12:33 p.m., [NAME] B started plating food. She plated food for the hall that Resident #54 resided on. Resident #54 received all items except pureed roll. All other residents residing on that hall did not receive macaroni salad. During an observation on 9/15/2025 at 12:39 p.m., ADON D observed checking trays at the door between the kitchen and the dining room for the hall that Resident #54 resided on. During an observation on 9/15/2025 at 12:41 p.m., trays left the dining room and were served down A hall without macaroni salad for residents with diets other than puree. Dining room was served trays without macaroni salad. During an observation on 9/15/2025 at 1:02 p.m., several residents left the dining room without receiving macaroni salad or a substitute. During an observation on 9/15/2025 at 1:04 p.m., trays left the dining room and were served down B hall without macaroni salad for resident with diets other than puree. During an interview on 9/15/2025 at 1:14 p.m., CNA I stated there had not been any macaroni salad served on the trays due to the kitchen did not have it available. She stated she had not informed the residents that macaroni salad did not get served. She stated not informing the residents could cause residents to have confusion from not receiving all of their food as well as residents not getting their full nutrition for their disease processes and healing. During an observation on 9/15/2025 at 1:16 p.m., trays left the dining room and were served down C hall without macaroni salad for residents with diets other than puree. During an observation on 9/15/2025 at 1:23 p.m., [NAME] B started plating food for the hall that Resident #10 resided on. No pureed roll was added to the plate for Resident #10. During an observation on 9/15/2025 at 1:29 p.m., trays left the dining room and were served down D hall without macaroni salad for residents with diets other than puree. During an observation and interview on 9/15/2025 at 1:30 p.m., Resident #54's tray observed in her room to not have pureed roll. Beside her plate, there was a meal ticket dated 9/15/2025 with items listed that included pureed dinner roll buttered. She stated she had not been given a bread option in the past. She stated she would have added the roll to her broth and drank the broth if the roll were given. During an interview on 9/15/2025 at 1:32 p.m., ADON D stated all residents should get the items on the menu when eating out of the kitchen. She stated she thought that the pureed macaroni salad was a roll and that is why she did not catch the roll was not served to Resident #10 & Resident #54. She stated she would get a pureed roll from the kitchen for Resident #10 after she was asked about items on the plate. During an interview on 9/15/2025 at 1:34 p.m., the DM stated residents on a pureed diet should have gotten a roll served with their meal. She stated she felt the cook being nervous from being watched led to the failure of the roll not being served to the 2 residents with pureed diet. She confirmed both Resident #10 and Resident # 54 had order for pureed diet. She stated macaroni salad not being appropriate temperature was the reason it was not served to the residents with diets other than pureed. She stated residents not getting all of the menu items could cause them to not get all the nutrients with their meal. She stated she monitored that all menu items were served during the meals. During an observation and interview on 9/15/2025 at 4:06 p.m., the DM provided a substitution log for August and September 2025 after she filled in the substitution for lunch service. She stated she had spoken to the dietician after meal service. She stated chips, or mashed potatoes were offered to the residents. She stated she was not responsible for notifying the residents of the substitution and the nursing staff did. Facility document titled Menu Substitution Log reflected on lunch meal 9/15/2025 chips and mashed potatoes were substituted for macaroni salad. During a confidential group interview on an undisclosed date at an undisclosed time, 9 of 9 residents voiced that they did not get macaroni salad with 9/15/2025's lunch. They stated chips or mashed potatoes were offered during the singing activity later that afternoon after 2 p.m. They stated they would have liked to be informed preferably before 2 p.m. if something during the lunch meal was going to be changed. They stated they had brought up missing items from their trays before and it continued to occur. During an interview on 9/17/2025 at 8:33 a.m., the DOO for [dietary staff contracted] stated his expectation would be for the ADON or DON to be notified of food substitution. He stated he did not know the nursing process for notifying the residents but expected for the residents to be notified of food substitution during the meal and given options when the meal was served. He stated that residents on a pureed diet should have gotten all the menu items including a roll with their meal. He stated not getting all the items or offered substitutes could lead to nutritional deficiencies. He stated he heard about items missing after the lunch meal on 9/15/2025 and [NAME] B was most likely nervous causing her to miss the roll on pureed diet trays. During a telephone interview on 9/17/2025, the dietitian stated she expected for residents to get all items on the menu during food service. She stated food offered after 2:00 p.m. would be considered a snack and substitution needed to be offered when it was determined that the macaroni salad was not going to be served. She stated the meal trays should not have been served without substitution on them. She stated all items should be served to residents for them to get nutritional adequacy. She stated the DM monitored that menus were followed, and she would monitor sometimes during her visits to the facility approximately 2-3 times a month. Record review of facility policy titled Menus and Nutritional Adequacy revised on 2/20/2018 reflected: A pre-planned menu is provided to the facility, which has been planned or reviewed by a Registered Dietitian and includes meals that are adequate to meet the average resident's nutritional needs. The meal planning guide in the Facility Diet Manual is used as the basis for menu planning. Record review of facility policy titled Menu Changes and Substitutions revised on 8/2/2017 reflected: Any variation from the planned menu will be properly documented by the Dietary Services Manager (DSM) and reviewed and signed by the Dietitian. Menu changes and substitutions, when necessary, will be made with foods of equivalent nutritive value. Menu substitutions are one time menu changes.Menu substitutions should be of equivalent nutritive value and are recorded on the menu substitution log prior to the meal being served.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that:<BR/>The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods.<BR/>These failures could place residents at risk for food borne illness and cross-contamination. <BR/>Findings included:<BR/>Record Review of facility MDS Resident 672 dated 06/12/2023 revealed, there were 76 out of 76 residents that ate from the kitchen.<BR/>During observation on 06/12/2023 at 10:25 AM, of 1 of 1 dry storage contained:<BR/>1. <BR/>One 5-gallon bucket labeled Beef Broth was open to elements with the lid placed to the side.<BR/>2. <BR/>One gallon of opened Liquid Smoke Beef Marinade with no opened date.<BR/>3. <BR/>One gallon of opened Imitation Vanilla Flavor with no opened date.<BR/>4. <BR/>One gallon of opened White Distilled Vinegar with no opened date, and an expired date of 2020.<BR/>5. <BR/>One gallon of opened Karo with no open date, and an expired date of 01/12/2020.<BR/>6. <BR/>One 32 oz. opened bottle of Seasoning Sauce, with opened date of 2021, and expired date of 12/2022.<BR/>7. <BR/>One storage bin labeled Bulk Cereal,, dated 4/26/21, contained 3 bags of cereal, not labeled, or dated. <BR/>8. <BR/>One 8.1 oz. can of Baking Powder with an expired date of 01/22/2023.<BR/>9. <BR/>Twenty separate opened containers of spices with no opened date.<BR/>During observation on 06/12/2023 at 10:44 AM, freezer #1 of 2 contained:<BR/>1. <BR/>Two unopened bags of what appeared to be, frozen tater tots that had been removed from the original box, not labeled, or dated.<BR/>2. <BR/>One opened bag of what appeared to be, frozen tater tots removed from the original box, not labeled, or dated.<BR/>3. <BR/>Six unopened bags of what appeared to be, frozen French bread that had been removed from the original box, not labeled, or dated.<BR/>4. <BR/>One opened bag of what appeared to be, frozen French Toast that had been removed from the original box, not labeled, or dated<BR/>5. <BR/>Two unopened bags of what appeared to be, frozen French Toast that had been removed from the original box, not labeled, or dated.<BR/>6. <BR/>One bag of what appeared to be, frozen Okra that had been removed from the original box, not labeled, or dated<BR/>During observation on 06/12/2023 at 10:54 AM, refrigerator #2 of 3 contained:<BR/>1. <BR/>One 32 fluid oz. opened bottle of Reconstituted Lemon Juice, with the expired date of 02/21/2022.<BR/>During interview on 06/12/2023 at 12:30 PM, the DM stated all items should have an open date. She stated all products were to have written on the boxes or bags if removed, with a label and received date. The DM stated, once removed from the original box, a label and date should have been placed on that product. She stated, all products should be rotated and used, according to the in date. She stated, there should have been no expired products in the pantry, or refrigerator. She also stated, she was told by her corporate, the spices had not needed an open date so had not proceeded to do so. The DM stated she failed to monitor the dates and rotations of products due to being understaffed. She stated, she felt the failure that led to the products not having not been labeled correctly was, the staff getting in a hurry and her, as DM, had not followed up. She stated, the neg impact to residents was, food could have gone bad and led to residents getting sick. Her expectations were for all products to be labeled and dated when appropriate with no expired dates. <BR/>During an interview on 06/13/2023 at 2:15 PM, the Admin stated, the DM was supposed to had monitored the labeling and storage of products in the kitchen. He stated, not following protocols of label and storing. As well as having had expired food products could have had a negative outcome of possibly causing harm to residents with an adverse reaction to bad food. The Admin stated his expectations were for staff to follow policies and procedures as well as state laws. <BR/>Record Review of facility policy, Dry Food and Supplies Storage dated 07/22/2022, revealed:<BR/>Policy: .<BR/> . Desirable practices include managing the receipt and storage of dry food, regulating foods not safe for consumption, keeping dry food products in closed containers, and rotating supplies.<BR/>Fundamental Information: .<BR/> .All bulk food items (i.e., flour, sugar) That are removed from original containers into food grade containers must have cat fitting lids and must be properly labeled with the common name of the product <BR/>Procedure: .<BR/> .6. <BR/> Expiration or use by dates will be checked and product will be put in order of use by or expiration date. Any product that is found to be out of date will be discarded <BR/> .7. Bulk food products that are removed from original containers must be placed in plastic or metal food grade containers with tight fitting lid. Each container must be labeled with the common name of the food. Plastic food grade storage bags are also acceptable for storage. All storage bags must also be properly sealed and labeled with the common name of the food <BR/> .9. All open products must be resealed effectively and properly labeled, dated and rotated for use <BR/> .10. Use by, Best by Dates should routinely be checked to ensure that items which have expired or discarded appropriately.<BR/>Record Review of facility policy Frozen and Refrigerated Foods Storage with the revised date of 11/16/2017, and a Review Date of 07/22/2022 revealed: .<BR/> .Procedure .<BR/> .10. Package frozen items that are opened and not used in their entirety must be properly sealed, labeled and dated for continued storage. This includes individual bags of frozen vegetables removed from the original storage box unless they have a common name and expiration date on the bag.<BR/> 11. All refrigerated and frozen items in storage will contain a minimum label of common names of products and dated as noted above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program 2 of 2 (CNA-E and CNA-I) staff observed during incontinent care. The facility failed to ensure CNA E, and CNA I performed proper peri-care (incontinent care) and proper hand hygiene during peri-care for Resident #91. These failures placed residents of the facility at risk of infections from improper incontinent care and hand hygiene while performing incontinent care.Findings included: Resident #91Record Review of the Resident #91's Face Sheet dated 09/18/2025, revealed she was a [AGE] year-old female. Her original admission to the facility was on 3/06/2025 with the most recent admission on [DATE]. Resident #91 had diagnoses of metabolic encephalopathy (brain lesions), cystitis (inflammation of the bladder). Record review of Resident #91's MDS assessment Section C, Cognitive Patterns dated 06/02/2025, revealed a BIMS score of 13 (cognitively intact). Record review of Resident #91's Comprehensive Care Plan initiated 09/11/2025 revealed the following focused areas:Incontinence: Resident is incontinent of bowel/bladder related to age related deficits. Goal: The resident will be clean and odor free through next review date . Interventions for the focus on incontinent care included checking frequently for wetness and being soiled, change as needed. During an observation on 09/16/2025 at 09:45 AM, CNA-E and CNA-I both performed peri-care for Resident #91. Neither CNA-E nor CNA-I washed their hands nor used hand sanitizer throughout peri-care. CNA-E was also observed folding a wipe 2 times and wiped resident before being discarded. It was observed that Resident #1 had a BM. During an Interview on 09/16/2025 at 9:55 AM, CNA E stated she knew she had failed the skills of peri-care. She stated she had double wiped as well as not using hand hygiene between the changing of dirty gloves and after incontinent care. CNA E stated she had not used hand hygiene between the changing of gloves because they had not brought hand gel into the room with them. CNA E stated she had done Infection Control/peri-care training about 3 months ago. She stated the negative impact to resident could possibly have been cross contamination, and transferring of bacteria between residents. During an interview on 09/16/2025 at 10:00 AM, the DON stated what staff should had typically followed the facility policy. She stated the facility monitored the staff on a regular basis. The DON stated she felt if the surveyor had not been watching, the CNA E would not have been nervous and would have performed it correctly. The DON stated, It would be hard to tell what the negative impact for the resident would have been on residents for not performing proper peri care. The DON stated, you should observe another incontinent care because we are always monitoring our staff. She stated the potential harm could have possibly been infection and/or cross contamination. The DON stated the facility failure was that the survey team was in the facility watching, which made the staff member nervous. Record review of facility policy Incontinent care dated 4/10/17 and revised 2/14/20 revealed: Purpose: To outline a procedure for cleansing the perineum and buttocks after an incontinence episode. Procedure.8. If feces present, remove with.disposable wipe by wiping from front or perineum toward rectum. Discard soiled materials and gloves. Wash hands. 9. Put on non-sterile, latex free gloves.15. Remove and discard gloves. 16. Wash hands.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that:<BR/>The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods.<BR/>These failures could place residents at risk for food borne illness and cross-contamination. <BR/>Findings included:<BR/>Record Review of facility MDS Resident 672 dated 06/12/2023 revealed, there were 76 out of 76 residents that ate from the kitchen.<BR/>During observation on 06/12/2023 at 10:25 AM, of 1 of 1 dry storage contained:<BR/>1. <BR/>One 5-gallon bucket labeled Beef Broth was open to elements with the lid placed to the side.<BR/>2. <BR/>One gallon of opened Liquid Smoke Beef Marinade with no opened date.<BR/>3. <BR/>One gallon of opened Imitation Vanilla Flavor with no opened date.<BR/>4. <BR/>One gallon of opened White Distilled Vinegar with no opened date, and an expired date of 2020.<BR/>5. <BR/>One gallon of opened Karo with no open date, and an expired date of 01/12/2020.<BR/>6. <BR/>One 32 oz. opened bottle of Seasoning Sauce, with opened date of 2021, and expired date of 12/2022.<BR/>7. <BR/>One storage bin labeled Bulk Cereal,, dated 4/26/21, contained 3 bags of cereal, not labeled, or dated. <BR/>8. <BR/>One 8.1 oz. can of Baking Powder with an expired date of 01/22/2023.<BR/>9. <BR/>Twenty separate opened containers of spices with no opened date.<BR/>During observation on 06/12/2023 at 10:44 AM, freezer #1 of 2 contained:<BR/>1. <BR/>Two unopened bags of what appeared to be, frozen tater tots that had been removed from the original box, not labeled, or dated.<BR/>2. <BR/>One opened bag of what appeared to be, frozen tater tots removed from the original box, not labeled, or dated.<BR/>3. <BR/>Six unopened bags of what appeared to be, frozen French bread that had been removed from the original box, not labeled, or dated.<BR/>4. <BR/>One opened bag of what appeared to be, frozen French Toast that had been removed from the original box, not labeled, or dated<BR/>5. <BR/>Two unopened bags of what appeared to be, frozen French Toast that had been removed from the original box, not labeled, or dated.<BR/>6. <BR/>One bag of what appeared to be, frozen Okra that had been removed from the original box, not labeled, or dated<BR/>During observation on 06/12/2023 at 10:54 AM, refrigerator #2 of 3 contained:<BR/>1. <BR/>One 32 fluid oz. opened bottle of Reconstituted Lemon Juice, with the expired date of 02/21/2022.<BR/>During interview on 06/12/2023 at 12:30 PM, the DM stated all items should have an open date. She stated all products were to have written on the boxes or bags if removed, with a label and received date. The DM stated, once removed from the original box, a label and date should have been placed on that product. She stated, all products should be rotated and used, according to the in date. She stated, there should have been no expired products in the pantry, or refrigerator. She also stated, she was told by her corporate, the spices had not needed an open date so had not proceeded to do so. The DM stated she failed to monitor the dates and rotations of products due to being understaffed. She stated, she felt the failure that led to the products not having not been labeled correctly was, the staff getting in a hurry and her, as DM, had not followed up. She stated, the neg impact to residents was, food could have gone bad and led to residents getting sick. Her expectations were for all products to be labeled and dated when appropriate with no expired dates. <BR/>During an interview on 06/13/2023 at 2:15 PM, the Admin stated, the DM was supposed to had monitored the labeling and storage of products in the kitchen. He stated, not following protocols of label and storing. As well as having had expired food products could have had a negative outcome of possibly causing harm to residents with an adverse reaction to bad food. The Admin stated his expectations were for staff to follow policies and procedures as well as state laws. <BR/>Record Review of facility policy, Dry Food and Supplies Storage dated 07/22/2022, revealed:<BR/>Policy: .<BR/> . Desirable practices include managing the receipt and storage of dry food, regulating foods not safe for consumption, keeping dry food products in closed containers, and rotating supplies.<BR/>Fundamental Information: .<BR/> .All bulk food items (i.e., flour, sugar) That are removed from original containers into food grade containers must have cat fitting lids and must be properly labeled with the common name of the product <BR/>Procedure: .<BR/> .6. <BR/> Expiration or use by dates will be checked and product will be put in order of use by or expiration date. Any product that is found to be out of date will be discarded <BR/> .7. Bulk food products that are removed from original containers must be placed in plastic or metal food grade containers with tight fitting lid. Each container must be labeled with the common name of the food. Plastic food grade storage bags are also acceptable for storage. All storage bags must also be properly sealed and labeled with the common name of the food <BR/> .9. All open products must be resealed effectively and properly labeled, dated and rotated for use <BR/> .10. Use by, Best by Dates should routinely be checked to ensure that items which have expired or discarded appropriately.<BR/>Record Review of facility policy Frozen and Refrigerated Foods Storage with the revised date of 11/16/2017, and a Review Date of 07/22/2022 revealed: .<BR/> .Procedure .<BR/> .10. Package frozen items that are opened and not used in their entirety must be properly sealed, labeled and dated for continued storage. This includes individual bags of frozen vegetables removed from the original storage box unless they have a common name and expiration date on the bag.<BR/> 11. All refrigerated and frozen items in storage will contain a minimum label of common names of products and dated as noted above.

**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 baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 2 (Resident #131) reviewed for baseline care plans.<BR/>The facility failed to develop a baseline careplan that included the needs of Resident #131's foley catheter.<BR/>This failure placed residents that admitted to the facility with a foley catheter of having their needs met.<BR/>Findings included:<BR/>Record review of Resident #131's Facesheet dated 06/14/23 revealed a [AGE] year-old male that admitted to the facility on [DATE]. He had a diagnosis list that included dysuria dated 06/12/23.<BR/>Record review of Resident #131's admission Evaluation dated 06/08/23 revealed that resident was incontinent of urine with no comment regarding Resident #131 had a foley catheter. <BR/>Record review of Resident #131's Bowel and Bladder Program Screener dated 06/08/23 revealed that resident never voided appropriately without incontinence and no comment regarding he had a foley catheter.<BR/>Record review of Resident 131's Physician's Orders dated 06/13/23 revealed:<BR/>Change the BSD bag along with the catheter if visibly soiled, to collect a urine specimen, or if the closed system has been compromised. as needed. Start date of 06/08/23. <BR/>Flush foley catheter with 60ml of sterile water or normal saline. as needed for non-patency. Start date of 06/08/23. <BR/>Provide catheter care every shift for Urinary catheter use. Start date 06/08/23. <BR/>Record fluid intake and output. Review each week for fluid imbalance. every shift. Start date of 06/08/23.<BR/>Urinary catheter FR CC bulb to gravity (BSD). Change the catheter if it becomes occluded, to obtain a urine specimen, or if the closed system has become compromised. every shift for urinary retention. Start date of 06/08/23. <BR/>Record review of Resident #131's Baseline Careplan initiated 06/09/23 revealed no problem regarding resident care needs for a foley catheter. <BR/>During an observation and interview on 06/12/23 at 11:31AM of Resident #131, he had a foley catheter draining to gravity that had a noted blood clot in tubing and pink blood-tinged urine in the drainage bag. Resident #131 was repetitive in his remarks and spoke in a word salad. He was unable to express when and why he came to the facility. <BR/>During an interview on 06/14/23 at 2:38PM with the DON, she said they had a baseline careplan assessment. She said, whatever is on the baseline assessment would be on their baseline careplan. She, or an RN if on weekends, would begin the comprehensive care plan within 24 hours. DON said the baseline careplan would have the ADL needs if any. DON said if a resident had a catheter, then that would be considered as they were incontinent. She said the baseline careplan assessment had a box to check that the resident was continent or incontinent. So, with that, a catheter would mean incontinent, and staff would know they needed to go check on that resident. She said the admission nurse would also put physician orders in to indicate that a resident had a catheter. The physician orders would include what type/size the catheter was, to empty it, monitoring of the catheter. DON said the nurse aides did not have direct access to resident physician orders so the only way they would know if a resident had a catheter would be by going into the resident room and checking on them. She said, the baseline care plan assessment did not have a direct question regarding if a resident had a catheter. DON said there was a section at the bottom of that assessment that the nurse could summarize what was answered in that assessment and nothing more. She said the admission assessment and the bowel and bladder assessment would also have been completed as well. DON review of all 3 assessments did not include an area to checkbox that a resident did or did not have a catheter. It only had a checkbox that they were continent or incontinent of bowel and bladder. She said the reason that Resident #131 did not have a baseline careplan area directly identifying his catheter was due to the system generated assessments not having an area of addressing a catheter directly. DON said that the comprehensive care plan would address the resident catheter with further details, however they had at least 7 days to complete the comprehensive care plan. She said the comprehensive care plan policy should address baseline care plans as well.<BR/>Record review of facility policy labeled Comprehensive Care Plans revised September of 2010 revealed no area specifically addressing baseline careplans.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that:<BR/>The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods.<BR/>These failures could place residents at risk for food borne illness and cross-contamination. <BR/>Findings included:<BR/>Record Review of facility MDS Resident 672 dated 06/12/2023 revealed, there were 76 out of 76 residents that ate from the kitchen.<BR/>During observation on 06/12/2023 at 10:25 AM, of 1 of 1 dry storage contained:<BR/>1. <BR/>One 5-gallon bucket labeled Beef Broth was open to elements with the lid placed to the side.<BR/>2. <BR/>One gallon of opened Liquid Smoke Beef Marinade with no opened date.<BR/>3. <BR/>One gallon of opened Imitation Vanilla Flavor with no opened date.<BR/>4. <BR/>One gallon of opened White Distilled Vinegar with no opened date, and an expired date of 2020.<BR/>5. <BR/>One gallon of opened Karo with no open date, and an expired date of 01/12/2020.<BR/>6. <BR/>One 32 oz. opened bottle of Seasoning Sauce, with opened date of 2021, and expired date of 12/2022.<BR/>7. <BR/>One storage bin labeled Bulk Cereal,, dated 4/26/21, contained 3 bags of cereal, not labeled, or dated. <BR/>8. <BR/>One 8.1 oz. can of Baking Powder with an expired date of 01/22/2023.<BR/>9. <BR/>Twenty separate opened containers of spices with no opened date.<BR/>During observation on 06/12/2023 at 10:44 AM, freezer #1 of 2 contained:<BR/>1. <BR/>Two unopened bags of what appeared to be, frozen tater tots that had been removed from the original box, not labeled, or dated.<BR/>2. <BR/>One opened bag of what appeared to be, frozen tater tots removed from the original box, not labeled, or dated.<BR/>3. <BR/>Six unopened bags of what appeared to be, frozen French bread that had been removed from the original box, not labeled, or dated.<BR/>4. <BR/>One opened bag of what appeared to be, frozen French Toast that had been removed from the original box, not labeled, or dated<BR/>5. <BR/>Two unopened bags of what appeared to be, frozen French Toast that had been removed from the original box, not labeled, or dated.<BR/>6. <BR/>One bag of what appeared to be, frozen Okra that had been removed from the original box, not labeled, or dated<BR/>During observation on 06/12/2023 at 10:54 AM, refrigerator #2 of 3 contained:<BR/>1. <BR/>One 32 fluid oz. opened bottle of Reconstituted Lemon Juice, with the expired date of 02/21/2022.<BR/>During interview on 06/12/2023 at 12:30 PM, the DM stated all items should have an open date. She stated all products were to have written on the boxes or bags if removed, with a label and received date. The DM stated, once removed from the original box, a label and date should have been placed on that product. She stated, all products should be rotated and used, according to the in date. She stated, there should have been no expired products in the pantry, or refrigerator. She also stated, she was told by her corporate, the spices had not needed an open date so had not proceeded to do so. The DM stated she failed to monitor the dates and rotations of products due to being understaffed. She stated, she felt the failure that led to the products not having not been labeled correctly was, the staff getting in a hurry and her, as DM, had not followed up. She stated, the neg impact to residents was, food could have gone bad and led to residents getting sick. Her expectations were for all products to be labeled and dated when appropriate with no expired dates. <BR/>During an interview on 06/13/2023 at 2:15 PM, the Admin stated, the DM was supposed to had monitored the labeling and storage of products in the kitchen. He stated, not following protocols of label and storing. As well as having had expired food products could have had a negative outcome of possibly causing harm to residents with an adverse reaction to bad food. The Admin stated his expectations were for staff to follow policies and procedures as well as state laws. <BR/>Record Review of facility policy, Dry Food and Supplies Storage dated 07/22/2022, revealed:<BR/>Policy: .<BR/> . Desirable practices include managing the receipt and storage of dry food, regulating foods not safe for consumption, keeping dry food products in closed containers, and rotating supplies.<BR/>Fundamental Information: .<BR/> .All bulk food items (i.e., flour, sugar) That are removed from original containers into food grade containers must have cat fitting lids and must be properly labeled with the common name of the product <BR/>Procedure: .<BR/> .6. <BR/> Expiration or use by dates will be checked and product will be put in order of use by or expiration date. Any product that is found to be out of date will be discarded <BR/> .7. Bulk food products that are removed from original containers must be placed in plastic or metal food grade containers with tight fitting lid. Each container must be labeled with the common name of the food. Plastic food grade storage bags are also acceptable for storage. All storage bags must also be properly sealed and labeled with the common name of the food <BR/> .9. All open products must be resealed effectively and properly labeled, dated and rotated for use <BR/> .10. Use by, Best by Dates should routinely be checked to ensure that items which have expired or discarded appropriately.<BR/>Record Review of facility policy Frozen and Refrigerated Foods Storage with the revised date of 11/16/2017, and a Review Date of 07/22/2022 revealed: .<BR/> .Procedure .<BR/> .10. Package frozen items that are opened and not used in their entirety must be properly sealed, labeled and dated for continued storage. This includes individual bags of frozen vegetables removed from the original storage box unless they have a common name and expiration date on the bag.<BR/> 11. All refrigerated and frozen items in storage will contain a minimum label of common names of products and dated as noted above.

Based on interviews and record reviews, the facility failed to follow their written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property 2 of 15 employees (RN J and DM) reviewed for employability.The facility failed to ensure the record of the initial EMR/NAR check was completed and maintained for DM hired on 7/1/2025 per facility policy. The facility failed to ensure the initial EMR check was completed and maintained for the DM hired on 06/2/2025 per facility policy. These findings placed residents at risk of receiving care by someone that was unemployable.The findings included: Record review of the RN J's employee file revealed a hire date of 07/14/2025 and no evidence of an EMR/NAR check was completed prior to hire. Record review of the DM's employee file revealed a hire date of 06/03/2025 and no evidence of an EMR/NAR check was completed prior to hire.During an interview on 09/18/2025 at 2:30 PM the HR stated she was responsible for running EMR checks upon hire and annually. The HR stated she remembered running RN J's but must have put in the shredder because she could not locate a copy of the EMR. The HR stated the only way to prove she ran the EMR was the copy of the EMR. The HR stated she ran an EMR on 9/16/2025 for RN J, which was after the survey team entered the facility. The HR stated DM was contracted and she assumed the company that was contracted was running checks. The HR stated the facility could not provide a copy of EMR check being completed. During an interview on 9/18/2025 at 4:30 PM the ADMN stated his expectation was EMR checks were to be ran prior to hiring for all staff and should have been maintained. The AMDN stated HR was responsible for running and maintaining EMR checks in resident file. The ADMN stated he was ultimately responsible to ensure employee records were maintained. The ADMN stated residents could have been affected because policy was not followed. The ADMN stated what led to failure was a new HR staff. The ADMN stated that the DM was contracted staff, and he was at the mercy of the contracted company. The ADMN stated they should have had an EMR completed for the DM because their policy required all employees to have an EMR check completed, if they had contact with residents. Record review of facility policy titled, Texas Background Screening Procedures dated 04/27/2021 revealed, All offers of employment are contingent upon the prospective Team Member (Applicant) successfully completing a background screening process conducted according to applicable federal and state laws.Employability Status Check.Regardless of position ALL Team Members are subject to this verification.

Based on observation, interview and record review, the facility failed to ensure that a medication cart not being used was secured for 1 of 4 medication carts (Cart Hall D). The facility failed to ensure Cart Hall D was not left unlocked and unsecured while unattended. These failures could place all residents at risk of harm or decline in health due to lack of potency of supplies, medications/biologicals or misappropriation of medications, or drug diversions.The findings included: During an observation and interview on 09/15/2025 between 1:30 PM and 1:50 PM the medication cart on Hall D (Cart Hall D) was left unattended and unlocked from 1:30 PM to 1:35PM. There were three CNA's and residents walking up and down hall D, within arm's reach of the medication cart. The nurse was not in sight of the medication cart. ADON was walking down the hall and stated LVN A was responsible for the medication cart. ADON stated the medication cart should not have been left unlocked and unattended. Contents of the medication cart included: Zoloft (anti-depressant), Trazodone (anti-depressant), Eliquis (blood thinner), Pradaxa (anti-coagulant), Metoprolol (high blood pressure), Lisinopril (high blood pressure), Furosemide (diuretic), Bumex (diuretic), Glargine Insulin Pen (anti-diabetic), Lispro Insulin Pen (anti-diabetic), Lidocaine patches (pain relief), Seroquel (anti-psychotic), Buspar (anti-anxiety), Depakote (used for epilepsy). The medication cart also contained creams, syringes,liquid medications, alcohol pads and over the counter medications. LVN A stated she was distracted by a family member who was upset and followed the family member down the hall. LVN A stated she never left her cart unlocked. LVN A stated medication carts being left unlocked could have had negative effects to residents. During an interview on 09/18/2025 at 4:32 PM the DON stated her expectations was that all medication carts be locked when out of direct vision of the nurse. The DON stated that she was responsible to ensure medications carts are locked when not in use. The DON stated she checks to see if medication carts are locked periodically throughout the day. The DON stated this failure occurred due to poor judgement on the nurse's part. The DON stated residents could be affected if they were to get something out of the medication cart that could potentially cause them harm. Record review of the facility policy titled, Storage Medications dated 09/2018 revealed: Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts and medication supplies are locked when they are not attended by persons with authorized access.

Based on observation and interview, the facility failed to post the HHSC complaint number and a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of a state or federal regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of property in the entire facility observed for required postings reviewed for resident rights.<BR/>The facility failed to ensure the required posting of a HHSC complaint number and statement about how a resident may file a complaint with the State Survey agency.<BR/>This failure placed residents at risk of being unaware of who and how to contact the State Survey Agency and their right to file a complaint with the State Service Agency concerning any suspected violation of state or federal regulation. <BR/>The findings included: <BR/>An observation of the facility's front lobby area on 07/31/24 at 11:30 a.m. revealed there was no HHSC complaint number and statement that the resident may file a complaint with the State Survey Agency posted. <BR/>In a confidential group interview on 07/31/24 at 9:52 a.m. with seven residents revealed residents did not know how to file and contact the State Survey Agency if they have any complaints. They stated they would like to be aware of how to file a complaint with the State Survey Agency. <BR/>An interview with the Administrator on 07/31/24 at 1:30 pm, revealed he did not know why there were no HHSC complaint number and statement that the resident may file a complaint with the State Survey Agency posted. The Administrator said it was important to have this signage posted so residents will know how to file a complaint regarding staff and residents. The Administrator said there was not a policy regarding required postings.

Based on observation, interview, and record review the facility failed to provide food prepared and served on time for 1 of 1 dining room and 4 (A, B, C, and D) of 4 halls. The facility failed to ensure that 1 of 1 lunch observed on 9/15/2025 was served at the posted mealtime 11:45 a.m. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for unplanned weight loss, side effects from medication given without food, and diminished quality of life. Findings included:During an observation on 09/15/2025 at 12:32 p.m., resident mealtimes posted outside of kitchen: Breakfast 7:00AM, Lunch 11:45AM, and Dinner 5:00PM. During an observation on 9/15/2025 at 12:30 p.m., the DON was standing at the door from the kitchen leading into the dining room and asked that the food be served without the macaroni salad since the residents were waiting on the food. She stated that she realized that there were regulations, but the residents needed to eat. During an observation on 9/15/2025 at 12:41 p.m., trays left the dining room and were served down A hall then dining room started to be served. During an observation on 9/15/2025 at 1:04 p.m., trays left the dining room and were served down B hall. During an observation on 9/15/2025 at 1:16 p.m., trays left the dining room and were served down C hall. During an observation on 9/15/2025 at 1:29 p.m., trays left the dining room and were served down D hall. All trays had been served at 1:32 p.m. During a confidential group interview on an undisclosed date at an undisclosed time, 9 of 9 residents voiced meals are not on time and they would like to have food served by 12:30 p.m. They stated they had filed a grievance in the past about mealtimes, but it continued to be late at times. During an interview on 9/15/2025 at 4:06 p.m., the DM stated she had asked her supervisor if there was a policy on meal service timing and there was not one. She did not know if there was a specific time that meals had to be served. She stated not serving meals on time could upset residents. During an interview on 9/17/2025 at 8:33 a.m., the DOO for [dietary staff contracted] stated there was no policy on meal service timing. He stated that if lunch was to be served at 11:45 a.m. and the last resident to receive a tray was at 1:30 p.m., then the meal service was not timely. During a telephone interview on 9/17/2025 at 9:51 a.m., the dietitian stated her expectation would be for meal trays to all be served within 45 minutes of the posted mealtime. She stated the DM was responsible for monitoring meals were served timely. She stated she monitored meal service sometimes when she was in the facility approximately two to three times a month. She did not know why lunch service was not timely on 9/15/2025. She stated more education was needed for the kitchen staff. Record review of facility's grievance log in 2025 reflected: 1/30/2025 grievance about food delivery service being late and food and/or plates cold; 2/3/2025 grievance about resident not getting food tray until 20 minutes after other residents served and having to go get her tray because she didn't get one at all three to four times; 8/4/2025 grievance about meals ran 30 minutes to an hour late; 8/28/2025 grievance about food delivery service more than an hour late.

Based on interviews and record review, the facility failed to ensure a qualified professional directs the activities program for 1 of 1 activity director (AD) reviewed for qualifications. The facility failed to ensure the AD, hired on July 17, 2024, was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements.This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.The findings included:Record review of the AD's employee file revealed the AD was hired, on July 17, 2024, as the activity director. Further review revealed no evidence of certification or training as a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements.During an interview on 09/17/2025 at 2:30 PM the AD stated she was hired July 2024 as the activity director. The AD stated she had difficulty getting signed up for the class due to her finances and time.During an interview on 9/18/2025 at 4:30 PM the ADMN stated his expectation was to have a certified activity director. The ADMN stated he was aware the AD did not have a certification when hired, and that the AD was responsible for completing the required courses. The ADMN stated the AD had difficulty paying for the course. The ADMN stated in September 2025 he was able to get the facility's corporate organization to pay for the course and they were waiting for the AD to receive the course. The ADMN stated he did not feel there was a negative effect on the residents due to the AD not being certified. The ADMN stated the AD was the best AD he had ever worked with, she had residents engaged in activities and residents loved her. The ADMN stated what led to failure was the AD had financial issues which delayed her paying for the program, and then it took time to get the facility's cooperation to pay for the program. Record review of the AD's Job Description signed on July 17, 2024, revealed: Qualifications: Successful completion on a state-approved and certified course of instruction in patient activities.successfully completes the state-approved and Certified Activity Director's course within nine months of beginning employment.

Based on interview, the facility failed to ensure the residents' right to receive their mail for seven of seven (confidential) residents interviewed regarding personal mail.<BR/>The facility failed to distribute mail to residents on Saturdays. <BR/>This failure could place residents at risk of not receiving mail in a timely manner and could result in a decline in resident's psychosocial well-being and quality of life. <BR/>Findings include: <BR/>During a confidential group interview on 07/31/24 at 9:52 am, 7 of 7 residents stated that mail was only delivered Monday through Friday, when the facility's business office was opened and not on weekends. They stated they would like to receive their mail on Saturday when facility receives it. <BR/>An interview with the Business Office Manager on 08/01/24 at 11:40 am, revealed mail was distributed on Saturdays by Resident #1. The Business Office Manager stated Resident #1 volunteered to distribute the mail. The Business Office Manager stated there was a weekend receptionist. <BR/>An interview with Resident #1 on 08/01/24 at 12:00 pm, revealed she does not distribute mail on Saturdays. Resident #1 stated she waited until Mondays to distribute Saturday's mail when she was given the mail to distribute to residents. Resident #1 stated the weekend Receptionist retrieved the Saturday mail and took it to the business office. Resident #1 stated the business office separated the mail and then it was given to her to distribute to residents. <BR/>An interview with the Administrator on 08/01/24 at 2:23 pm, revealed he was not aware the mail was not delivered on Saturdays. The Administrator stated he planned to put a system in place for residents to receive mail on Saturdays. The Administrator revealed there was not a policy regarding mail distribution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 3 of 18 Residents (Resident # 15, Resident # 23, and Resident #20) reviewed for accuracy of assessments, in that: <BR/>1. <BR/>The facility failed to update Resident #15's MDS when the resident had not had COVID since 02/01/2023 or sepsis since 11/01/2022. <BR/>2. <BR/>The facility failed to update Resident #23's MDS when the resident had not had COVID since 01/23/2023. <BR/>3. <BR/>The facility failed to update Resident #20's MDS when the resident had not had pneumonia since 03/11/2023. <BR/>These failures place residents at risk of inaccurate assessments and not receiving appropriate care according to their current status. <BR/>Findings include:<BR/>1. Record review of the electronic face sheet for Resident #15 revealed an admission date of 09/02/2022. Resident was an [AGE] year-old female with diagnoses to include: high blood pressure, diabetes, and urinary tract infection. Further review revealed diagnosis of sepsis on 11/01/2022. Further review of electronic face sheet revealed no evidence of a COVID diagnosis.<BR/>Record review of Quarterly MDS dated [DATE] for Resident #15 revealed a BIMS score of 03 which indicated severely impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed COVID and sepsis. <BR/>Record review of electronic physician's orders from 04/20/2023 to 06/14/20223 for Resident #15 revealed no evidence of any treatments for COVID or sepsis. <BR/>Record review of electronic progress noted from 04/20/2023 to 06/14/2023 for Resident #15 revealed no evidence of COVID or sepsis. <BR/>2. Record review of the electronic face sheet for Resident #23 revealed an admission date of 03/04/2022. Resident was a [AGE] year-old male with diagnoses to include: high blood pressure, depression, and anxiety. Further review revealed diagnosis of COVID on 01/23/2023. <BR/>Record review of Quarterly MDS dated [DATE] for Resident #23 revealed a BIMS score of 14 which indicated no impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed COVID. <BR/>Record review of electronic physician's orders from 05/20/2023 to 06/14/20223 for Resident #23 revealed no evidence of any treatments for COVID.<BR/>Record review of electronic progress noted from 05/20/2023 to 06/14/2023 for Resident #23 revealed no evidence of COVID.<BR/>3. Record review of the electronic face sheet for Resident #20 revealed an admission date of 03/11/2023. Resident was a [AGE] year-old female with diagnoses to include: heart failure and respiratory failure. Further review revealed diagnosis of pneumonia on 03/11/2023. <BR/>Record review of Quarterly MDS dated [DATE] for Resident #20 revealed a BIMS score of 12 which indicated moderately impaired cognitive skills for daily decision making. Further review of MDS Section I Active Diagnoses revealed pneumonia. <BR/>Record review of electronic physician's orders from 05/20/2023 to 06/14/20223 for Resident #20 revealed no evidence of any treatments for pneumonia.<BR/>Record review of electronic progress noted from 05/20/2023 to 06/14/2023 for Resident #20 revealed no evidence of pneumonia.<BR/>During an interview on 06/14/23 at 3:00 PM, MDS nurse stated it was her responsibility to ensure the MDSs are accurate. She stated MDS is how the facility got reimbursed. She stated diagnosis should be removed when they are no longer active diagnosis. MDS nurse stated the MDS is a snapshot of resident during a 7-day lookback period. She stated she just missed them.<BR/>During an interview on 06/14/23 3:20 PM, DON stated diagnosis such as COVID, pneumonia, and sepsis should be removed on the next MDS after they are resolved since they are no longer active. She stated she did not know why the failure occurred. DON stated the facility did not have a policy for MDS. She stated the facility followed the RAI.

Based on interview and record review, the facility failed to ensure each resident received food that accommodated their preferences for seven residents in confidential group interview reviewed for food preferences.<BR/>The facility failed to accommodate the residents' preference of spreading peanut butter on the peanut butter/jelly sandwich when served. <BR/>This failure could place residents at risk for not having their choices and food preferences accommodated, possible weight loss and a diminished quality of life.<BR/>Findings include:<BR/>A confidential group meeting on 07/31/24 at 9:52 am, revealed peanut butter and jelly, as well as chicken salad, are not spread on bread when served. The residents stated the jelly is thick and tore the bread when spread. <BR/>An interview with the Dietary Manager on 07/31/24 at 12:30 pm, revealed the jelly was difficult to spread due to the thickness. The Dietary Manager stated the facility changed to Company D in January, which only provided the thick jelly for residents. The Dietary Manager stated residents have been complaining about the jelly being too thick during monthly Food Committee meetings held with residents. The Dietary Manager stated there was not a policy regarding resident preferences. <BR/>An interview with the Consultant Dietitian on 08/01/24 at 9:01 am revealed the Administrator went out yesterday evening and bought jelly from a local store to meet resident preferences. The Dietitian stated they would look into getting a different jelly that was not thick to meet resident needs. The Consultant Dietitian stated she did not have a specific policy on food preferences. She provided the alternate list which included peanut butter/jelly. <BR/>During an interview on 08/01/24 at 9:13 am, the Administrator stated he would ensure residents have jelly to meet their resident preferences. The Administrator stated it was important to meet resident preferences. The Administrator stated he purchased jelly from the local store since the facility was unable to get the jelly from their vendor, Company D. <BR/>Record Review of the Resident Food Committee Meeting Minutes dated 04/25/24 reflected Resident Topics/Concerns Identified: better jelly for PBJ.