WINDSOR NURSING AND REHABILITATION CENTER OF SEGUI

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 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 disease and infection for 2 of 6 residents (Residents #36 and, #59) reviewed for infection control, in that:<BR/>1. While providing incontinent care for Resident #36 CNA A did not wash or sanitize her hands between change of gloves.<BR/>2. While providing incontinent care for Resident #59 CNA C and CNA D cross contaminated the clean brief of the resident with the soiled incontinent pad. <BR/>These deficient practices could place residents at-risk for infection due to improper care practices. <BR/>The findings include:<BR/>1. Record review of Resident #36's face sheet, dated 03/21/2023, revealed an admission date of 03/02/2015 and, a readmission date of 02/08/2021, with diagnoses which included: Alzheimer's disease (brain disorder that causes problems with memory, thinking and behavior), Chronic kidney disease(gradual loss of kidney function) , Mood disorder (general emotional state or mood is distorted or inconsistent with circumstances and interferes with the ability to function), Hypertension (High blood pressure), Hyperlipidemia (too much lipids (fat) in the blood).<BR/>Record review of Resident #36's Quarterly MDS, dated [DATE], revealed Resident #36 did not have a BIMS score and, had severe cognitive impairment. Resident #36 was indicated to always be incontinent of bladder and bowel and needed extensive assistance to total care with his activities of daily living. <BR/>Review of Resident #36's care plan revealed a problem of The resident has bladder incontinence<BR/>ALWAYS related to dx Alzheimer's / lack of awareness, with an intervention of Monitor/document for s/sx UTI, notify MD for any changes in status<BR/>Observation on 03/21/2023 at 11:34 a.m. revealed while providing incontinent care for Resident #36, CNA A change her gloves after cleaning the resident and before touching the clean brief but did not sanitize or wash her hands. <BR/>During an interview on 03/21/2023 at 11:55 a.m. with CNA A, she confirmed she did not use sanitizer or wash her hands between change of gloves. <BR/>During an interview with the DON on 03/22/2023 at 10:30 a.m., she confirmed the staff should sanitize or wash their hands between change of gloves to prevent infection to the residents, The DON reveled the staff received training on infection control and incontinent care at least annually. The staff skills were check yearly. The facility had a CNA instructor that would train the CNA and would spot check the staff while they provided care for infection control and quality of care. <BR/>2. Record review of Resident #59's face sheet, dated 03/21/2023, revealed an admission date of 07/31/2018 and, a readmission date of 06/25/2019, with diagnoses which included: Dementia(loss of cognitive functioning - thinking, remembering, and reasoning), Wernicke's encephalopathy(Degenerative brain disorder), Psychotic disorder(Mental disorders characterized by disconnection from reality which results in strange behavior)<BR/>Record review of Resident #59's Quarterly MDS, dated [DATE], revealed Resident #59 had a BIMS score of 3 indicating severe cognitive impairment. Resident #59 was indicated to always be incontinent of bladder and bowel and needed extensive assistance with her activities of daily living. <BR/>Review of Resident #59's care plan revealed a problem of The resident has bladder incontinence r/t<BR/>cognitive deficit, with an intervention of Check q 2 hrs and as required for incontinence. Wash, rinse and<BR/>dry perineum (Space between anus and genitals). Change clothing PRN after incontinence episodes.<BR/>Observation on 03/21/2023 at 12:21 a.m. revealed during incontinent care for Resident #59 provided by CNA C and CNA D, the soiled incontinent pad came in contact with the inside of the new brief when the CNAs were changing the brief and incontinent pad for Resident #59. <BR/>During an interview on 03/21/2023 at 11:55 a.m. with CNA C, she confirmed the soiled incontinent pad should not have touched the clean brief. She revealed the brief may get dirty and then touched the resident skin. She confirmed she received infection control from the facility. <BR/>During an interview with the DON on 03/22/2023 at 10:30 a.m., she confirmed the staff should have completely removed the soiled pad and brief before placing the clean pad and brief on the resident to prevent contact and cross contamination. The DON revealed the staff received training on infection control and incontinent care at least annually. The staff skills were check yearly. The facility had a CNA instructor that would train the CNA and would spot check the staff while they provided care for infection control and quality of care. <BR/>Review of facility policy, titled Hand washing - Hand Hygiene, dated January 2018, revealed Use an alcohol based hand rub [ .] for the following situations [ .] Before and after direct contact with resident [ .]<BR/>Before moving from a contaminated body site to a clean body site during resident care [ .] After contact with blood or bodily fluids [ .] After removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 5 residents (Resident #95), reviewed for accommodation of needs.<BR/>Resident #95 could not reach or trigger the call light installed near her bed.<BR/>This failure could result in residents not receiving timely care and nursing interventions; and could result in falls, injuries, and a diminished quality of life.<BR/>The findings included:<BR/>Record review of Resident #95's face sheet, dated 01/17/22, and MR (electronic medical record), revealed, the resident was admitted on [DATE] (hospice admission) with diagnose that included, Alzheimer's disease, hypertension, acute kidney failure, dementia, history of falling, and age related physical debility. The Resident was a female age [AGE]. The responsible party was a family member.<BR/>Record review of Resident # 95's MDS (minimum data set), dated 01/04/22( quarterly), revealed, the resident had a BIMS (brief interview of mental status ) score of 3 (severely impaired in cognition). In the area of ADLs (activities of daily living) the resident required: bed mobility and transfer extensive assistance two staff members, dressing, eating, toilet use, and personal hygiene extensive assistance one staff member. The resident was always incontinent in bowel and bladder.<BR/>Record review of Resident #95's care plan, 02/10/21, revealed, in the problem of risk for falls, an intervention that read, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as need . In the problem of ADL deficit, the care plan's interventions included those listed in the 01/04/22 MDS (found above).<BR/>During an observation and interview on 01/17/22 at 10:00 AM, Resident #95 was sitting on a wheel chair, in her room, not alert or oriented. The television was on. A pressure release call light was present near the resident's bed. Room was homelike; a folded floor mat was present; and the resident revealed no skin tears or bruises. The resident could not answer any direct questions. The resident muttered pain in stomach. The surveyor directed to resident to trigger the call light; the resident did not reach or trigger the call light. [Surveyor alerted staff that resident uttered the phrase pain in stomach.] <BR/>During an interview on 01/17/22 at 12:44 PM, Administrator revealed, the facility did not have a policy on accommodations of need. Instead, the Administrator stated, the surveyor would be provided a policy on falls, which required the assessment of residents.<BR/>During an interview on 01/17/22 3:55 PM, DON stated, .(Resident #95) has a padded call light .she has decline in ADLs .and she is on hospice .and fall prevention measures have put in place to include: scoop mattress .low bed .clutter free room .monitoring every two hours .room in high traffic area I am responsible for accommodations of needs for a resident from a nursing perspective . <BR/>During an interview on 01/17/22 at 4:09 PM , Administrator stated, .(Resident # 95) is not verbal or oriented .we will explore issue of call light to meet the resident's needs .she has not fallen .interventions in place have prevented a fall . we do not have a policy specific to accommodation of needs . <BR/>During an interview on 01/18/22 at 8:40 AM, CAN D stated, .I am aware that Resident (#95) has a pressure release pad that she cannot trigger .she is contracted on both arms and legs .her chair reclines for positioning .she is not alert and not oriented .we anticipate her needs by making rounds every two hours .her habit is to yell if she is in distress or discomfort .she would yell when she is in pain .her call light method is to yell .that is the best way for now . <BR/>During an interview on 01/18/22 10:07 AM, LVN E stated, .I am aware that Resident (#95) is not alert or oriented and cannot trigger the call light .(to meet her needs) I make rounds to anticipate her needs and check with the staff .we use the pressure pad as her call light .I rely on rounds to meet her needs .she would yell if she is in pain .staff is aware of residents that need more monitoring like (Resident #95) .<BR/>Record review of facility's Fall Risk policy, dated December 2017, read, .The staff will identify appropriate interventions to reduce the risk of falls .<BR/>Record review of facility's incident log for the months of November 2021, December 2021, and January 2022 revealed, Resident # 93 had not recorded fall incidents.<BR/>Record review of facility policies did not reveal a policy on accommodation of needs. [On the date and time of exit, 01/19/22 at 5 PM, the Administrator did not provide a policy on accommodations of needs.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 583-Personal Privacy/Confidentiality of Records Scope D [NAME] Trayhan<BR/>Based on observation, interview and record review the facility failed to provide personal privacy for 2 of 23 Residents (Resident #39, #77) observed in that:<BR/>1. Resident #39 did not have a full privacy curtain to provide full visual privacy.<BR/>2. Resident #77 did not have a full privacy curtain to provide full visual privacy.<BR/>This deficient practice could affect residents by not providing private space and being unnecessarily exposed or embarrassed when providing care.<BR/>The findings were:<BR/>1. Record review of Resident #39's face sheet, dated 1/18/2022, revealed an admission date of 10/18/2022, resided in room [ROOM NUMBER]A, and had diagnoses which included paranoid schizophrenia, hypertension (high blood pressure), chronic obstructive pulmonary disease, anxiety disorder, bipolar disorder and cognitive communication deficit.<BR/>Review of Resident #39's annual Minimum Data Set (MDS), dated [DATE], revealed a Basic Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition for daily decision-making skills. Continued review of the MDS revealed Resident #39 was continent.<BR/>Review of Resident #7's face sheet dated 1/18/2022 revealed the resident was admitted on [DATE], assigned resided in room [ROOM NUMBER]B, and had diagnoses that included chronic obstructive pulmonary disease, anxiety disorder, congestive heart failure and type 2 diabetes mellitus.<BR/>Review of Resident #7's admission MDS dated [DATE] revealed she had a BIMS score of 11 which indicated moderately impaired cognition for decision-making. <BR/>Observation on 1/16/2021 at 11:27 a.m. revealed there was not a privacy curtain in room [ROOM NUMBER], bed A, for Resident #39. Further observation of the curtain rod revealed part of the curtain rod had become loss from the ceiling. <BR/>Interview on 1/16/2022 at 11:27 a.m. with Resident #7 and Resident # 39 revealed the privacy curtain had been off for a while. Resident #7 went on to say, they (staff) keep saying they were going to fix it, but nothing happens. <BR/>Interview on 1/17/2022 at 10:01 with the Administrator revealed the maintenance director was out sick and would not be back until the following day. When the Administrator saw the loose curtain rod and missing privacy curtain, he reported he was not aware the curtain rod was loose, and the curtain was missing. <BR/>2. Review of Resident #77's face sheet dated 1/18/2022 revealed the resident resided in room [ROOM NUMBER] and had diagnoses that included Alzheimer's disease, hypertension and dementia without behavioral disturbance. <BR/>Review of Resident #77's Quarterly MDS dated [DATE] revealed she had a BIMS score of 9, moderately impaired cognition for decision-making.<BR/>Observation on 1/17/2022 at 1:44 p.m. revealed the privacy curtain from 501, bed B, where Resident #77 resided, was missing a privacy curtain. <BR/>Interview on 1/17/2022 at 1:44 p.m. with CNA F revealed the curtain had been missing for a while.<BR/>Interview on 1/17/2022 at 1:54 p.m. with the Administrator he reported he knew some privacy curtains had been removed today to be washed and would be returned after cleaned but he was not certain which ones had been removed. He reported staff should notify maintenance if there were any issues with residents' rooms, such as missing curtains, could be reported on the Kios, which creates a work order that was sent to the Maintenance Supervisor. <BR/>Interview on 1/17/2022 at 5:09 p.m. with the Housekeeping Manager Trainee revealed she had removed some of the privacy curtains to be washed. The Housekeeping Manager Trainee reported she had not removed the privacy curtain from room [ROOM NUMBER] bed B. She went on to say she was asked to replace the curtain in room [ROOM NUMBER] bed B because the curtain was missing. She reported she had not removed curtains from 403 either.<BR/>The facility reported they did not have a policy on assuring there was a privacy curtain in place for each bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Citation Text for Tag 0656, Regulation FF11<BR/>[NAME], [NAME]<BR/>Based on observation, interview and record review the facility failed to develop and implement a person-centered comprehensive care plan for the resident, with no interventions to attain or maintain the resident's highest practical physical, mental and psychosocial well-being, for 1 of 6 residents (Resident #37) reviewed for comprehensive care plans in that: <BR/>The facility failed to develop a comprehensive care plan that addressed Resident 37's C-collar (known as a neck brace, is a medical device used to support a person's neck) for C-2 Fracture (The hangman's fracture refers to a break in a bone known as C-2, because it is the second bone down from the skull in your cervical (neck) vertebrae). <BR/>These deficient practices could affect residents at the facility who require a care plan and place them at risk for not receiving the appropriate care and services needed to maintain optimal health.<BR/>The findings were:<BR/>Record review of Resident #37's face sheet, dated 01/18/2022, revealed the resident was readmitted to the facility on [DATE] (original admission [DATE]) with diagnoses that include: unspecified displaced fracture of second cervical vertebra, subsequent encounter for fracture with routine healing. <BR/>Record review of Resident #37's progress notes dated 11/03/2021 that read resident admitted from hospital, A&OX3 (alert and oriented times 3). Neck brace in place.<BR/>Record review of Resident #37's Physician Order Summary, dated 01/18/2022, revealed Physician Order dated 12/02/2021 that read C-Collar to be worn at all times x2 months every shift for C-2 fracture for 2 months. <BR/>Record review of Resident #37's Significant Change MDS (Minimum Data Set), dated 11/15/2021, revealed the resident's BIMS score was 11, which indicated moderate cognitive impairment, with diagnosis of unspecified displace fracture of second cervical vertebra, subsequent encounter for fracture with routine healing.<BR/>Record review of Resident #37's Care Plan, start date 10/22/2021 and completion date 12/01/2021 revealed that it did not address Resident #37's requiring the use of the C-Collar (known as a neck brace, is a medical device used to support a person's neck) for C-2 Fracture (The hangman's fracture refers to a break in a bone known as C-2, because it is the second bone down from the skull in your cervical (neck) vertebrae).<BR/>During observation and interview on 01/17/2022 at 11:48 a.m. Resident #37 she was observed lying in bed with her C-Collar on and Resident #37 stated that she had broken her neck back in about October. Further stated that she was seeing a doctor for the care of her neck and had to wear the neck brace all the time. <BR/>During interview on 01/18/2022 at 4:03 p.m. RCS LVN C stated that Resident #37's neck collar was in place when she returned on 11/3/2021 from the hospital and confirmed that C-Collar was not addressed in the care plan but should have been. RCS LVN C further stated that the collar was for immobilization of the neck due to Resident #37 having had surgery and that she was to wear it for two months. <BR/>During interview on 01/19/2022 at 2:42 p.m. DON stated that it was a little bit of everyone's responsibility to update care plans from the ADON, MDS (RCS LVN), treatment nurse and herself. DON further stated that by not wearing the brace (C-Collar) would put Resident #37 at risk of the fracture not healing and that staff had been in-service on the brace (C-Collar). DON confirmed that the C-Collar should have been care planned and it was definitely important for Resident #37 to wear it. <BR/>Record review of the facility's Nursing Services Policy and Procedure Manual policy, titled Care Planning, revised December 2017, revealed A comprehensive, person-centered care plan is developed and implemented for each resident to meet the resident's physical, psychosocial, and functional needs .A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 (Residents #22 and #64) of 24 residents reviewed for care plans.<BR/>1.Resident #22's comprehensive person-centered care plan was not revised after her quarterly MDS assessment with an ARD of 05/09/24 to reflect she was incontinent of bladder.<BR/>2.Resident #64's comprehensive person-centered care plan was not revised after his quarterly MDS assessment with an ARD of 04/09/2024 to reflect he was always incontinent of bowel and bladder.<BR/>This deficient practice affects residents who require assistance with ADL's and could place residents at risk of missing required care.<BR/>The findings included:<BR/>1.Record review of Resident #22's electronic face sheet dated 05/22/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), dysphagia (difficulty swallowing), asthma (inflamed airways, producing mucous which makes it difficult to breath), vascular dementia (brain damage caused by multiple strokes), and cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area).<BR/>Record review of Resident #22's quarterly MDS assessment with an ARD of 05/09/2024 reflected she was not a candidate for a BIMS which signified she was severely cognitively impaired. She sometimes could understand, but rarely could be understood. She was dependent on staff for her ADL care and was always incontinent of bowel and bladder.<BR/>Record review of Resident #22's comprehensive person-centered care plan revision date of 05/08/2023 reflected has bowel incontinence r/t CVA. The care plan did not address she was always incontinent of bladder.<BR/>During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated Resident #22 was always incontinent of bowel and bladder and that information needed to be reflected on the person-centered care plan. She stated revisions of care plans are completed after the MDS assessment and this one must have been missed, and she did not know why. She stated proper care for a resident was communicated through the care plan and care could be missed.<BR/>During an interview on 05/24/2024 at 2:50 PM with the MDS nurse she stated Resident #22 was always incontinent of bladder and somehow she missed putting that information into her care plan revision. She stated the importance of updating and revising care plans to keep information of care accurate and current to meet the resident's needs.<BR/>During an interview on 05/24/2024 at 03:06 PM with CNA C revealed, she worked on Resident #22's hall and Resident #22 was always incontinent of bowel and bladder.<BR/>2. Record review of Resident #64's electronic face sheet dated 05/22/2024 reflected he was admitted to the facility on [DATE]. His diagnoses included: Alzheimer's disease (a type of dementia that affects memory, thinking and behaviors), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), end stage renal disease (the final permanent stage of chronic kidney disease) and malignant neoplasm of prostate (prostate cancer that can grow and spread to other parts of the body).<BR/>Record review of Resident #64's quarterly MDS assessment with an ARD of 04/09/2024 reflected he scored a 03 out of 15 on his BIMS which signified he was severely cognitively impaired. He could be understood and usually could understand. He required moderate to extensive assistance with his ADL's. He was always incontinent of bowel and bladder. <BR/>Observation on 05/23/2024 at 2:22 PM of CNA D and CNA E perform incontinent care for Resident #64 revealed he was incontinent of bowel and bladder.<BR/>Record review of Resident #64's comprehensive person-centered care plan revised on 01/31/2022 reflected has an ADL self-care performance deficit r/t Alzheimer's disease, Interventions, TOILET USE: The resident requires limited to extensive assistance x1-2 staff for toileting. Resident will need staff assistance on and off toilet and with peri care brief changes daily and as needed. The care plan did not reflect he was always incontinent of bowel and bladder.<BR/>During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated Resident #64 was incontinent of bowel and bladder and that information needed to be updated in his care plan for him to receive the appropriate care needed.<BR/>During an interview on 05/24/2024 at 2:50 PM with the MDS nurse she stated Resident #64 was always incontinent of bowel and bladder and she did not know why she missed updating the information in his care plan. She stated the care plan reflected the care required for residents.<BR/>During an interview on 05/24/2024 at 03:06 PM with CNA C revealed, she worked on Resident #64's hall and stated he was always incontinent of bowel and bladder.<BR/>Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 reflected the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time limits and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from significant medication errors for 3 of 6 residents (Residents #31, #34, and #104) reviewed for significant medication errors.<BR/>1. On 05/23/2024 at 09:42 AM, Medication Aide J administered sodium chloride (salt; is an important mineral that helps balance the amount of fluid (water) in your body. It also helps your nerves and muscles to work properly. When the salt level in your blood is too low, extra water moves into your cells and makes them swell. This can be dangerous, especially in the brain where there is not a lot of room to expand) to Resident #104 late by 42 minutes. <BR/>2. On 05/23/2024 at 09:43 AM, Medication Aide J administered buspirone (primarily used to treat generalized anxiety) 10 mg to Resident #31 late by 43 minutes.<BR/>3. On 05/23/2024 at 09:48 AM, Medication Aide J administered carbidopa- levodopa (a combination medications used to treat symptoms of Parkinson's disease or Parkinson-like symptoms, such as: shakiness, stiffness, and difficulty moving) to Resident #34 late by 48 minutes. <BR/>These deficient practices placed residents at risk for not receiving the therapeutic effects of their prescribed medications. <BR/>The findings include:<BR/>1. <BR/>A record review of Resident #104's admission record dated 5/24/2024 revealed an admission date of 03/28/2024 with diagnoses which included cerebral infarction (stroke) and hypo-osmolality (a condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal) and hyponatremia (a condition that occurs when the level of sodium in the blood is too low). <BR/>A record review of Resident #104's MDS assessment dated [DATE] revealed Resident #104 was a [AGE] year-old male admitted for long term care and was assessed with medically complex conditions which included low blood sodium. Resident #104 was assessed with a BIMS score of 03 out of a possible 15 which indicated severe cognition impairment. <BR/>A record review of Resident #104's care plan dated 05/04/2024 revealed, (Resident #104) has had a cerebral vascular accident, causing weakness, aphasia (difficulty speaking), dysphagia (difficulty swallowing), and impaired cognition .Give medications as ordered by the physician. Monitor/document side effects and effectiveness <BR/>A record review of Resident #104's physician's orders dated 05/24/2024 revealed the physician prescribed Resident #104 sodium chloride 1 gram, three times a day, at 08:00 AM, 02:00 PM, and 08:00 PM, related to low salt in his blood.<BR/>A record review of Resident #104's Medication Adim Audit Report dated 05/24/2024 revealed Medication Aide J administered to Resident #104 his sodium at 09:42 AM when it was scheduled at 08:00 AM, 42 minutes late.<BR/>2. <BR/>A record review of Resident #31's admission record dated 05/24/2024 revealed an admission date of 09/26/2022 with diagnoses which included generalized anxiety disorder.<BR/>A record review of Resident #31's quarterly MDS assessment dated [DATE], revealed Resident #31 was a [AGE] year-old female admitted for long term care and assessed with medically complex diagnoses which included generalized anxiety and a BIMS score of 07 out of a possible of 15 which indicated severe cognitive impairment. <BR/>A record review of Resident #31's care plan revealed, (Resident #31) uses anti-anxiety medications r/t (related to) anxiety . Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT (every shift) <BR/>A record review of Resident #31's physician's orders dated 05/24/2024 revealed Resident #31 was prescribed buspirone 10mg three times a day, at 08:00 AM, 02:00 PM, and 08:00 PM, for generalized anxiety. <BR/>A record review of Resident #31's Medication Adimn Audit Report dated 05/24/2024 revealed Medication Aide J administered to Resident #31 her buspirone at 09:43 AM when it was scheduled at 08:00 AM, 43 minutes late.<BR/>3. <BR/>A record review of Resident #34's admission record dated 05/24/2024 revealed an admission date of 02/16/2018 with diagnoses which included dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination).<BR/>A record review of Resident #34's quarterly MDS assessment dated [DATE], revealed Resident #34 was a [AGE] year-old male admitted for long term care and assessed with medically complex diagnoses which included Parkinson's disease and a BIMS score of 08 out of a possible of 15 which indicated moderate cognitive impairment. <BR/>A record review of Resident #34's physician's orders dated 05/24/2024 revealed Resident #34 was prescribed carbidopa-levodopa 10-100mg three times a day, at 08:00 AM, 02:00 PM, and 08:00 PM, for Parkinson's disease. <BR/>A record review of Resident #34's care plan revealed, (Resident #34) is at risk for pain r/t Parkinson's disease . Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain <BR/>A record review of Resident #34's Medication Adimn Audit Report dated 05/24/2024 revealed Medication Aide J administered to Resident #34 his carbidopa-levodopa at 09:48 AM when it was scheduled at 08:00 AM, 48 minutes late.<BR/>During an observation and interview on 05/23/2024 at 09:35 AM revealed Med Aide J at her medication cart with the electronic medication administration record displayed which revealed a red highlighted medication for Resident 31, Resident #34, and Resident #104. Medication Aide J stated she had yet to administer 08:00 AM scheduled medications for residents #31, #34, and #104 due to her running a little late earlier in the morning. Medication Aide J stated she had to assist a couple of residents prepare for their physicians' appointments. Medication Aide J stated she had not reported the potential late medication administrations to her supervisor or the DON. <BR/>During an interview on 05/24/2024 at 09:17 AM the DON stated nursing staff should administer medications on time as prescribed and staff were expected to communicate with their supervisor and or the DON if they had a potential to administer medications late.<BR/>A record review of the facility's Medication Administration policy dated 10/01/2019, revealed, Policy: medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . the facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions .Procedure: . 10 rights of medication administration-whenever you are preparing to give someone medication, it is important to understand the 10 rights of medication administration. safety should be the first thing on your mind with medications. there is always a risk of giving the wrong pill, the wrong dose, or the wrong person's medication. If this happens, harm to the person can occur and some reactions can be deadly . In the past, you may have heard of the five rights of medication administration: right patient, right drug, right route, right time, and right dose. medical practices have changed to include a few more rights . right time- the time a medication is given is important. check the frequency of the ordered medication. double check that you are giving the ordered dose at the correct time. confirm when the last dose was given <BR/>A record review of The Institute for Safe Medication Practices website, Guidelines for Timely Administration of Scheduled Medications (Acute) | Institute For Safe Medication Practices (ismp.org) , accessed 05/24/2024, titled, Guidelines for Timely Administration of Scheduled Medications revealed, .How to Use the Guidelines: These guidelines are applicable ONLY to scheduled medications (see definition section) . Definitions: 1. Scheduled medications include all maintenance doses administered according to a standard, repeated cycle of frequency (e.g., q4h, QID, TID, BID, daily, weekly, monthly, annually) . 2. Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, q4h, q6h) Administer these medications within 1 hour before or after the scheduled time <BR/>A record review of the National Library of Medicine's website, Nursing Rights of Medication Administration - StatPearls - NCBI Bookshelf (nih.gov) , accessed 05/24/2024 titled Nursing Rights of Medication Administration updated 09/04/2023, revealed, Definition/Introduction: Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration.[1] It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. These 'rights' came into being during an era in medicine in which the precedent was that an error committed by a provider was that provider's sole responsibility and patients did not have as much involvement in their own care.[2]; The five traditional rights in the traditional sequence include: . 'Right time' - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this 'right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 medication cart and 1 Treatment cart of 2 carts observed for secure biologicals and drugs.<BR/>1.LVN F left the medication cart unsecured on 200 Hallway while administering medications.<BR/>2.The Treatment Nurse left the treatment cart unsecured on 05/22/2024 on the 100 Hallway, and on 05/23/2024 on the 300 Hallway prior to wound care for a resident.<BR/>These deficient practices could place residents at risk for misappropriation, misuse or tampering of medications.<BR/>The findings included:<BR/>Observation on 05/22/2024 at 08:29 a.m. on the 200 Hall revealed the medication cart was left unattended and not locked. <BR/>During an interview on 05/22/2024 at 08:30 with LVN F, who returned to the unlocked cart from a resident's room, she stated she had not left the medication cart unlocked before and did not know why she did. She stated she was focused on checking a resident and did not secure the cart. She stated she knew she should have secured the medication cart because there were resident medications on the cart to include insulin. She stated misappropriation, misuse, and harm could happen if someone were to get into the cart and acquire something they should not have.<BR/>Observation on 05/24/2024 at 08:40 am on 100 Hall revealed the treatment cart was left unlocked and unattended. Inside were solutions and ointments for wound care, dressings, and other supplies.<BR/>During an interview on 05/24/2024 at 08:45 a.m. with the Treatment Nurse, she stated she had never left the cart unlocked and unattended. She stated residents and others could have access to the cart, take items, or use them and be harmed.<BR/>Observation on 05/24/2024 at 11:09 a.m., before going to observe a treatment for a resident, the Treatment Nurse gathered her supplies and went into the resident's room. She motioned for the surveyor to follow. The treatment cart was left unlocked. The surveyor lingered to see if the Treatment Nurse would come back to the cart, but she did not. The surveyor stepped inside the resident's room halfway and motioned for the Treatment Nurse to check her cart. <BR/>During an interview on 05/24/2024 at 11:15 a.m. with the Treatment Nurse, she stated she could not believe she left the treatment cart unlocked and unattended again. She stated she did not know why she left the cart unlocked twice in one morning.<BR/>During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated LVN F and the Treatment Nurse were two of her nurses who had worked at the facility the longest, and she could not understand how both could have forgotten to lock the carts. She stated nurses and medication aides were trained to keep the medication carts secure when not in use because of the potential of misappropriation and harm if someone took medications they were not prescribed.<BR/>Record review of the facility's policy and procedure titled Medication Carts and Supplies for Administering Meds revised 10/01/19 reflected The facility maintains equipment and supplies necessary for the preparation and administration of medications to residents. The mobile medication cart will be used to facilitate administration of medications to residents. The purpose of the mobile medication system is to ensure appropriate control and surveillance of resident assigned medications. Procedure, only a licensed nurse or certified medical aide may carry keys to the medication cart, the medication cart is locked at all times when not in use, do not leave the medication cart unlocked or unattended in the resident care areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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, in that: <BR/>1. A large pan of pot roast was not labeled or dated.<BR/>2. A large pan of baked pears was not labeled or dated.<BR/>3. A quart bag with prepared Sloppy [NAME] mix was not labeled or dated<BR/>These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.<BR/>Findings included:<BR/>Observation on 1/16/2022 at 9:38 a.m. in the kitchens walk-in refrigerator revealed:<BR/>1. A large pan of pot roast, covered with foil, was not labeled with name of product and did not have a date when made and when to discard.<BR/>2. A large pan, 1/3 filled with cooked pears, covered with foil, was not labeled with name of product and did not have a date when made and when to discard.<BR/>3. A quart bag, 1/2 filled with Sloppy [NAME] mix, was not labeled with name of product and did not have a date when made and when to discard.<BR/>Interview on 1/16/2022 at 9:40 a.m. with [NAME] H revealed the pot roast was made the day before, 1/15/2022. She reported pot roast had not been listed on the menu to be served that week and assumed the pot roast was made to serve as an alternative for meal service. [NAME] H revealed she was not sure when cooked pears had been on the menu to be served. [NAME] H also revealed the Sloppy [NAME] mix was likely the left-over mix from dinner the evening before. <BR/>Interview on 1/16/2022 at 10:05 a.m. with the Administrator revealed he had hired a new Dietary Supervisor who was expected to start work today had not showed up yet. <BR/>Interview on 1/19/2022 with Dietician G revealed food that was not labeled or dated could result in food being served that was spoiled and result in food-borne illnesses. She reported the Dietary Manager was responsible for training staff and assuring food was label and dated.<BR/>Review of the facility policy, Food Storage, revised 6/1/2019, under the heading, Refrigerators revealed, d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage and e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.<BR/>Record review of the TFER 2015, page 72, section &sect;228.75(g)(4)(B) revealed prepared food was to be marked with the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises or discarded.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, revealed (A) .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 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 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 disease and infection for 2 of 6 residents (Residents #36 and, #59) reviewed for infection control, in that:<BR/>1. While providing incontinent care for Resident #36 CNA A did not wash or sanitize her hands between change of gloves.<BR/>2. While providing incontinent care for Resident #59 CNA C and CNA D cross contaminated the clean brief of the resident with the soiled incontinent pad. <BR/>These deficient practices could place residents at-risk for infection due to improper care practices. <BR/>The findings include:<BR/>1. Record review of Resident #36's face sheet, dated 03/21/2023, revealed an admission date of 03/02/2015 and, a readmission date of 02/08/2021, with diagnoses which included: Alzheimer's disease (brain disorder that causes problems with memory, thinking and behavior), Chronic kidney disease(gradual loss of kidney function) , Mood disorder (general emotional state or mood is distorted or inconsistent with circumstances and interferes with the ability to function), Hypertension (High blood pressure), Hyperlipidemia (too much lipids (fat) in the blood).<BR/>Record review of Resident #36's Quarterly MDS, dated [DATE], revealed Resident #36 did not have a BIMS score and, had severe cognitive impairment. Resident #36 was indicated to always be incontinent of bladder and bowel and needed extensive assistance to total care with his activities of daily living. <BR/>Review of Resident #36's care plan revealed a problem of The resident has bladder incontinence<BR/>ALWAYS related to dx Alzheimer's / lack of awareness, with an intervention of Monitor/document for s/sx UTI, notify MD for any changes in status<BR/>Observation on 03/21/2023 at 11:34 a.m. revealed while providing incontinent care for Resident #36, CNA A change her gloves after cleaning the resident and before touching the clean brief but did not sanitize or wash her hands. <BR/>During an interview on 03/21/2023 at 11:55 a.m. with CNA A, she confirmed she did not use sanitizer or wash her hands between change of gloves. <BR/>During an interview with the DON on 03/22/2023 at 10:30 a.m., she confirmed the staff should sanitize or wash their hands between change of gloves to prevent infection to the residents, The DON reveled the staff received training on infection control and incontinent care at least annually. The staff skills were check yearly. The facility had a CNA instructor that would train the CNA and would spot check the staff while they provided care for infection control and quality of care. <BR/>2. Record review of Resident #59's face sheet, dated 03/21/2023, revealed an admission date of 07/31/2018 and, a readmission date of 06/25/2019, with diagnoses which included: Dementia(loss of cognitive functioning - thinking, remembering, and reasoning), Wernicke's encephalopathy(Degenerative brain disorder), Psychotic disorder(Mental disorders characterized by disconnection from reality which results in strange behavior)<BR/>Record review of Resident #59's Quarterly MDS, dated [DATE], revealed Resident #59 had a BIMS score of 3 indicating severe cognitive impairment. Resident #59 was indicated to always be incontinent of bladder and bowel and needed extensive assistance with her activities of daily living. <BR/>Review of Resident #59's care plan revealed a problem of The resident has bladder incontinence r/t<BR/>cognitive deficit, with an intervention of Check q 2 hrs and as required for incontinence. Wash, rinse and<BR/>dry perineum (Space between anus and genitals). Change clothing PRN after incontinence episodes.<BR/>Observation on 03/21/2023 at 12:21 a.m. revealed during incontinent care for Resident #59 provided by CNA C and CNA D, the soiled incontinent pad came in contact with the inside of the new brief when the CNAs were changing the brief and incontinent pad for Resident #59. <BR/>During an interview on 03/21/2023 at 11:55 a.m. with CNA C, she confirmed the soiled incontinent pad should not have touched the clean brief. She revealed the brief may get dirty and then touched the resident skin. She confirmed she received infection control from the facility. <BR/>During an interview with the DON on 03/22/2023 at 10:30 a.m., she confirmed the staff should have completely removed the soiled pad and brief before placing the clean pad and brief on the resident to prevent contact and cross contamination. The DON revealed the staff received training on infection control and incontinent care at least annually. The staff skills were check yearly. The facility had a CNA instructor that would train the CNA and would spot check the staff while they provided care for infection control and quality of care. <BR/>Review of facility policy, titled Hand washing - Hand Hygiene, dated January 2018, revealed Use an alcohol based hand rub [ .] for the following situations [ .] Before and after direct contact with resident [ .]<BR/>Before moving from a contaminated body site to a clean body site during resident care [ .] After contact with blood or bodily fluids [ .] After removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, in 3 rooms (Rooms #502, #503, #508) out of eleven resident rooms on 500 Hall (Secure Unit) reviewed for accident hazards, in that;<BR/>The facility failed to ensure that the hot water temperatures in the restroom sinks for 3 resident rooms did not exceed the maximum of 110 degrees Fahrenheit.<BR/>This failure could place residents at risk for injuries related to hot water temperatures. <BR/>The findings included:<BR/>Review of Resident #46's face sheet dated 1/18/2022 revealed the resident was admitted to the facility on [DATE], resided in room [ROOM NUMBER], and had diagnoses that included dementia with behavioral disturbance, moderate intellectual disabilities, schizophrenia and anxiety disorder.<BR/>Review of Resident #46's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, moderately impaired cognitive status. Further review of the MDS revealed Resident #46 required limited assistance with toileting and ambulation.<BR/>Observation and interview on 01/17/22 at 10:49 a.m. with Resident #46 in room [ROOM NUMBER] the resident reported to be careful when checking the hot water temperature because the hot water gets really hot. When the surveyor checked the hot water temperature with a thermometer it registered 136 degrees Fahrenheit. <BR/>Observation on 1/17/2022 at 10:51 a.m. the hot water temperature in room [ROOM NUMBER] was 137.4 degrees Fahrenheit. The residents that resided in this room were not interviewable.<BR/>Observation on 1/17/2022 at 10:55 a.m. the hot water temperature in room [ROOM NUMBER] measured 142 degrees Fahrenheit. The residents that resided in this room were not interviewable.<BR/>Interview on 11/17/2022 at 10:59 a.m. with the Administrator he reported the Maintenance Supervisor was out sick but expected to return to work the following day. <BR/>Observation on 1/17/2022 at 11:00 a.m. in room [ROOM NUMBER] with the Administrator, the Administrator checked the hot water temperature using his own thermometer and it measured 134 degrees Fahrenheit.<BR/>Observation on 1/17/2022 at 11:04 a.m. in room [ROOM NUMBER] with the Administrator, the Administrator checked the hot water temperature using his own thermometer and it measured 139 degrees Fahrenheit.<BR/>Review of the temperature logs for the hot water monitoring, provided by the facility, revealed hot water temperature checks from 12/27/2021 to present time. Review of the hot water temperatures that were checked on 500 Hall had ranged in temperatures from 100-110. <BR/>Interview on 1/18/2021 at 9:02 a.m. with the Maintenance Supervisor he revealed he checked hot water temperatures in random rooms on each hall daily. The Maintenance Supervisor reported the requirements for the hot water temperatures in the residents' restroom sinks and shower rooms were to be no less than 100 degrees Fahrenheit and no more than 110 degrees Fahrenheit. The Maintenance Supervisor reported he had some issues with the hot water temperatures being out of range on the 500 Hall about 2 weeks ago, but the problem had been resolved and he did not have any further issues. The Maintenance Supervisor reported if the hot water temperature measure above 110 degrees, it places the residents at risk for burns. <BR/>Record review of the facility's undated TELS Testing and Logging of Hot Water Temperatures documented The dial thermometer is accurate to 1 to 2 degrees F, however it is not precision instrument and should be calibrated on a regular basis As the temperature of the water is taken, hold hand under the running water at about the same time to assess how the water feels on your skin .Test the water at various locations throughout your facility .Ensure patient room temperatures (as specified by Texas requirements) are between 100-110 degrees Fahrenheit.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but no later than 2 hours after the allegation was made, in events that caused the allegation involved abuse or resulted in serious bodily injury to the Administrator of the facility and other officials, which included to the State Survey Agency, for 1 of 9 residents (Resident #3) reviewed for reporting abuse and neglect. <BR/>LVN F failed to report to the administrator and HHSC an allegation of sexual abuse made by Resident #3 on 02/05/24.<BR/>This failure could place residents at risk for harm to include neglect, a diminished quality of life, and possible death.<BR/>Findings include:<BR/>Record review of Resident #3's admission record reflected a [AGE] year-old male initially admitted to the facility on [DATE]. Resident #3 had diagnoses which included Alzheimer's (degenerative brain disorder causing problems with memory, thinking, and behavior), dementia (group of symptoms that affects memory, thinking and interferes with daily life) and schizoaffective disorder (a mental disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). <BR/>Record Review of Resident #3's care plan reflected problem [Resident #3] has a behavior problem . [Resident #3] is apt to hear voices in his head, he will call his [RP] to leave voicemails about the FBI and working for the mafia, he says he is 'losing his mind' . [Resident #3] is apt to make delusions allegations reaching out to attorneys and government officials . [Resident #3] will make false claims against staff members.<BR/>Record Review of Resident #3's MDS assessment, dated 02/22/24, reflected a BIMS score of 11/15, which indicated moderate cognitive impairment. <BR/>Record review of Nurse note, dated 02/05/24 at 02:35 PM, authored by LVN F, reflected, resident was on resident phone south station I heard resident talking stating that [the DON] came to him wanting to have sex .<BR/>During an interview on 04/18/24 at 03:24 PM, ADON E revealed Resident #3 was always making accusations. She further revealed he would use the phone frequently trying to report accusations, but there was not truth to these accusations due to history of hallucinations. She further revealed this was care planned. <BR/>During an interview on 04/19/24 at 12:24 PM, the Administrator revealed Resident #3 would make inappropriate comments to staff members, his RP and providers. <BR/>During an interview on 04/19/24 at 12:55 PM, the DON revealed Resident #3 did not bring up any abuse allegations. She noted the resident had inappropriate behaviors. <BR/>During an interview on 04/19/24 at 02:10 PM, the Administrator revealed he could not recall any allegations made by Resident #3. He read the nursing note, dated 02/05/24 at 02:35 PM, and revealed he would not report this to the state agency but would do an internal investigation to see if the allegation was valid. He further revealed the resident was allowed to have sexual relations with anyone he chooses. He revealed he would report if the resident had an allegation of abuse after internal investigation, but he was not aware of this nursing note. <BR/>During an interview on 04/19/24 at 02:46 PM, the DON was doing some medication changes and behaviors were escalating. She further revealed she did not recall LVN F reporting this allegation of sexual abuse to her. The DON tried to review nursing notes daily but did not recall this specific nursing note. She further revealed had she known about this allegation she would speak with the Administrator and the team. She would have asked the Social Worker to interview the resident and kept her distance. When asked if the DON would report this to the state, she did not say yes. <BR/>Attempted interview on 04/19/24 at 03:52 PM with LVN F was unsuccessful. A voicemail was left. No call back. <BR/>During an interview on 04/19/24 at 02:03 PM, ADON E revealed she reported Resident #3's abuse allegations to the appropriate nursing staff and the Administrator. She further revealed she expected the Administrator to report these allegations to the state agency and do an appropriate investigation. She revealed this needed to be investigated to ensure resident's safety. <BR/>During an interview on 4/19/2024 at 2:30 PM, the SW stated he would report the nurse note on 02/05/24 at 02:35 PM that mentioned the DON, to the Administrator as an alleged sexual abuse. <BR/>Attempted interview with Resident #3's RP was unsuccessful. A voicemail left on 04/19/24 at 01:47 PM. No call back. <BR/>Record review of the facility's policy Abuse, Neglect and Exploitation, dated 08/15/22, reflected the following:<BR/>IV. Identification of Abuse, Neglect and Exploitation<BR/>B. Possible indicators of abuse include, but are not limited to:<BR/>1. Resident, staff or family report of abuse .<BR/>VII. Reporting/Response<BR/>A. The facility will have written procedures that include:<BR/>1. Report of all alleged violations to the Administrator, state agency . a. Immediately, but not later than 2 hours after the allegation is made; if the events that cause the allegation involve abuse or result in serious bodily injury

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Citation Text for Tag 0656, Regulation FF11<BR/>[NAME], [NAME]<BR/>Based on observation, interview and record review the facility failed to develop and implement a person-centered comprehensive care plan for the resident, with no interventions to attain or maintain the resident's highest practical physical, mental and psychosocial well-being, for 1 of 6 residents (Resident #37) reviewed for comprehensive care plans in that: <BR/>The facility failed to develop a comprehensive care plan that addressed Resident 37's C-collar (known as a neck brace, is a medical device used to support a person's neck) for C-2 Fracture (The hangman's fracture refers to a break in a bone known as C-2, because it is the second bone down from the skull in your cervical (neck) vertebrae). <BR/>These deficient practices could affect residents at the facility who require a care plan and place them at risk for not receiving the appropriate care and services needed to maintain optimal health.<BR/>The findings were:<BR/>Record review of Resident #37's face sheet, dated 01/18/2022, revealed the resident was readmitted to the facility on [DATE] (original admission [DATE]) with diagnoses that include: unspecified displaced fracture of second cervical vertebra, subsequent encounter for fracture with routine healing. <BR/>Record review of Resident #37's progress notes dated 11/03/2021 that read resident admitted from hospital, A&OX3 (alert and oriented times 3). Neck brace in place.<BR/>Record review of Resident #37's Physician Order Summary, dated 01/18/2022, revealed Physician Order dated 12/02/2021 that read C-Collar to be worn at all times x2 months every shift for C-2 fracture for 2 months. <BR/>Record review of Resident #37's Significant Change MDS (Minimum Data Set), dated 11/15/2021, revealed the resident's BIMS score was 11, which indicated moderate cognitive impairment, with diagnosis of unspecified displace fracture of second cervical vertebra, subsequent encounter for fracture with routine healing.<BR/>Record review of Resident #37's Care Plan, start date 10/22/2021 and completion date 12/01/2021 revealed that it did not address Resident #37's requiring the use of the C-Collar (known as a neck brace, is a medical device used to support a person's neck) for C-2 Fracture (The hangman's fracture refers to a break in a bone known as C-2, because it is the second bone down from the skull in your cervical (neck) vertebrae).<BR/>During observation and interview on 01/17/2022 at 11:48 a.m. Resident #37 she was observed lying in bed with her C-Collar on and Resident #37 stated that she had broken her neck back in about October. Further stated that she was seeing a doctor for the care of her neck and had to wear the neck brace all the time. <BR/>During interview on 01/18/2022 at 4:03 p.m. RCS LVN C stated that Resident #37's neck collar was in place when she returned on 11/3/2021 from the hospital and confirmed that C-Collar was not addressed in the care plan but should have been. RCS LVN C further stated that the collar was for immobilization of the neck due to Resident #37 having had surgery and that she was to wear it for two months. <BR/>During interview on 01/19/2022 at 2:42 p.m. DON stated that it was a little bit of everyone's responsibility to update care plans from the ADON, MDS (RCS LVN), treatment nurse and herself. DON further stated that by not wearing the brace (C-Collar) would put Resident #37 at risk of the fracture not healing and that staff had been in-service on the brace (C-Collar). DON confirmed that the C-Collar should have been care planned and it was definitely important for Resident #37 to wear it. <BR/>Record review of the facility's Nursing Services Policy and Procedure Manual policy, titled Care Planning, revised December 2017, revealed A comprehensive, person-centered care plan is developed and implemented for each resident to meet the resident's physical, psychosocial, and functional needs .A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, in 3 rooms (Rooms #502, #503, #508) out of eleven resident rooms on 500 Hall (Secure Unit) reviewed for accident hazards, in that;<BR/>The facility failed to ensure that the hot water temperatures in the restroom sinks for 3 resident rooms did not exceed the maximum of 110 degrees Fahrenheit.<BR/>This failure could place residents at risk for injuries related to hot water temperatures. <BR/>The findings included:<BR/>Review of Resident #46's face sheet dated 1/18/2022 revealed the resident was admitted to the facility on [DATE], resided in room [ROOM NUMBER], and had diagnoses that included dementia with behavioral disturbance, moderate intellectual disabilities, schizophrenia and anxiety disorder.<BR/>Review of Resident #46's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, moderately impaired cognitive status. Further review of the MDS revealed Resident #46 required limited assistance with toileting and ambulation.<BR/>Observation and interview on 01/17/22 at 10:49 a.m. with Resident #46 in room [ROOM NUMBER] the resident reported to be careful when checking the hot water temperature because the hot water gets really hot. When the surveyor checked the hot water temperature with a thermometer it registered 136 degrees Fahrenheit. <BR/>Observation on 1/17/2022 at 10:51 a.m. the hot water temperature in room [ROOM NUMBER] was 137.4 degrees Fahrenheit. The residents that resided in this room were not interviewable.<BR/>Observation on 1/17/2022 at 10:55 a.m. the hot water temperature in room [ROOM NUMBER] measured 142 degrees Fahrenheit. The residents that resided in this room were not interviewable.<BR/>Interview on 11/17/2022 at 10:59 a.m. with the Administrator he reported the Maintenance Supervisor was out sick but expected to return to work the following day. <BR/>Observation on 1/17/2022 at 11:00 a.m. in room [ROOM NUMBER] with the Administrator, the Administrator checked the hot water temperature using his own thermometer and it measured 134 degrees Fahrenheit.<BR/>Observation on 1/17/2022 at 11:04 a.m. in room [ROOM NUMBER] with the Administrator, the Administrator checked the hot water temperature using his own thermometer and it measured 139 degrees Fahrenheit.<BR/>Review of the temperature logs for the hot water monitoring, provided by the facility, revealed hot water temperature checks from 12/27/2021 to present time. Review of the hot water temperatures that were checked on 500 Hall had ranged in temperatures from 100-110. <BR/>Interview on 1/18/2021 at 9:02 a.m. with the Maintenance Supervisor he revealed he checked hot water temperatures in random rooms on each hall daily. The Maintenance Supervisor reported the requirements for the hot water temperatures in the residents' restroom sinks and shower rooms were to be no less than 100 degrees Fahrenheit and no more than 110 degrees Fahrenheit. The Maintenance Supervisor reported he had some issues with the hot water temperatures being out of range on the 500 Hall about 2 weeks ago, but the problem had been resolved and he did not have any further issues. The Maintenance Supervisor reported if the hot water temperature measure above 110 degrees, it places the residents at risk for burns. <BR/>Record review of the facility's undated TELS Testing and Logging of Hot Water Temperatures documented The dial thermometer is accurate to 1 to 2 degrees F, however it is not precision instrument and should be calibrated on a regular basis As the temperature of the water is taken, hold hand under the running water at about the same time to assess how the water feels on your skin .Test the water at various locations throughout your facility .Ensure patient room temperatures (as specified by Texas requirements) are between 100-110 degrees Fahrenheit.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 4 residents (Resident #85) reviewed for advanced directives, in that:<BR/>The facility failed to ensure the completed OOH-DNR was in the facility for Resident #85.<BR/>This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.<BR/>Record review of Resident #85's face sheet, dated [DATE], revealed an admission date of [DATE] with diagnoses that included: dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), major depressive disorder (persistent feeling of sadness and loss of interest), hyperlipidemia (abnormally high levels of fats (lipids) in the blood, which include cholesterol and triglycerides) and hypertension (high blood pressure).<BR/>Record review of Resident #85's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 06, which indicated severe cognitive impairment. <BR/>Record review of Resident #85's care plan, date initiated [DATE], revealed a problem area; Resident is a DNR and an intervention Ensure signed DNR is in medical record. <BR/>Record review of Resident #85's electronic medical record revealed active orders as of [DATE], with an order, DNR (Do Not Resuscitate), dated [DATE]. Further review of the EMR revealed there was not an OOH-DNR on file for Resident #85.<BR/>During a record review and interview with the SW on [DATE] at 12:35 p.m., the SW stated he is the one responsible for advanced directives. The SW confirmed Resident #85's OOH-DNR was not found in the electronic medical record. The SW stated he keeps copies of the documents and checked his binder for Resident #85's OOH-DNR and revealed he had only copies of Resident #85's MPOA. The SW revealed due to Resident #85's cognitive status she would be unable to sign another OOH-DNR so he would contact her family/MPOA and get it taken care of right away. The SW added that Resident #85 would have to be changed back to Full Code status in her electronic record until that document was completed and identified the potential harm could be the resident's wishes would not be followed.<BR/>In an interview on [DATE] at 12:54 p.m., the DON stated she would have the Medical Records department search for the document to see if maybe it was never scanned into Resident #85's electronic chart. The DON confirmed Resident #85's code status would have to be changed back to Full Code without the OOH-DNR in place. The OOH-DNR was not located prior to exit.<BR/>Record review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, dated [DATE], revealed, Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 583-Personal Privacy/Confidentiality of Records Scope D [NAME] Trayhan<BR/>Based on observation, interview and record review the facility failed to provide personal privacy for 2 of 23 Residents (Resident #39, #77) observed in that:<BR/>1. Resident #39 did not have a full privacy curtain to provide full visual privacy.<BR/>2. Resident #77 did not have a full privacy curtain to provide full visual privacy.<BR/>This deficient practice could affect residents by not providing private space and being unnecessarily exposed or embarrassed when providing care.<BR/>The findings were:<BR/>1. Record review of Resident #39's face sheet, dated 1/18/2022, revealed an admission date of 10/18/2022, resided in room [ROOM NUMBER]A, and had diagnoses which included paranoid schizophrenia, hypertension (high blood pressure), chronic obstructive pulmonary disease, anxiety disorder, bipolar disorder and cognitive communication deficit.<BR/>Review of Resident #39's annual Minimum Data Set (MDS), dated [DATE], revealed a Basic Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition for daily decision-making skills. Continued review of the MDS revealed Resident #39 was continent.<BR/>Review of Resident #7's face sheet dated 1/18/2022 revealed the resident was admitted on [DATE], assigned resided in room [ROOM NUMBER]B, and had diagnoses that included chronic obstructive pulmonary disease, anxiety disorder, congestive heart failure and type 2 diabetes mellitus.<BR/>Review of Resident #7's admission MDS dated [DATE] revealed she had a BIMS score of 11 which indicated moderately impaired cognition for decision-making. <BR/>Observation on 1/16/2021 at 11:27 a.m. revealed there was not a privacy curtain in room [ROOM NUMBER], bed A, for Resident #39. Further observation of the curtain rod revealed part of the curtain rod had become loss from the ceiling. <BR/>Interview on 1/16/2022 at 11:27 a.m. with Resident #7 and Resident # 39 revealed the privacy curtain had been off for a while. Resident #7 went on to say, they (staff) keep saying they were going to fix it, but nothing happens. <BR/>Interview on 1/17/2022 at 10:01 with the Administrator revealed the maintenance director was out sick and would not be back until the following day. When the Administrator saw the loose curtain rod and missing privacy curtain, he reported he was not aware the curtain rod was loose, and the curtain was missing. <BR/>2. Review of Resident #77's face sheet dated 1/18/2022 revealed the resident resided in room [ROOM NUMBER] and had diagnoses that included Alzheimer's disease, hypertension and dementia without behavioral disturbance. <BR/>Review of Resident #77's Quarterly MDS dated [DATE] revealed she had a BIMS score of 9, moderately impaired cognition for decision-making.<BR/>Observation on 1/17/2022 at 1:44 p.m. revealed the privacy curtain from 501, bed B, where Resident #77 resided, was missing a privacy curtain. <BR/>Interview on 1/17/2022 at 1:44 p.m. with CNA F revealed the curtain had been missing for a while.<BR/>Interview on 1/17/2022 at 1:54 p.m. with the Administrator he reported he knew some privacy curtains had been removed today to be washed and would be returned after cleaned but he was not certain which ones had been removed. He reported staff should notify maintenance if there were any issues with residents' rooms, such as missing curtains, could be reported on the Kios, which creates a work order that was sent to the Maintenance Supervisor. <BR/>Interview on 1/17/2022 at 5:09 p.m. with the Housekeeping Manager Trainee revealed she had removed some of the privacy curtains to be washed. The Housekeeping Manager Trainee reported she had not removed the privacy curtain from room [ROOM NUMBER] bed B. She went on to say she was asked to replace the curtain in room [ROOM NUMBER] bed B because the curtain was missing. She reported she had not removed curtains from 403 either.<BR/>The facility reported they did not have a policy on assuring there was a privacy curtain in place for each bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Citation Text for Tag 0656, Regulation FF11<BR/>[NAME], [NAME]<BR/>Based on observation, interview and record review the facility failed to develop and implement a person-centered comprehensive care plan for the resident, with no interventions to attain or maintain the resident's highest practical physical, mental and psychosocial well-being, for 1 of 6 residents (Resident #37) reviewed for comprehensive care plans in that: <BR/>The facility failed to develop a comprehensive care plan that addressed Resident 37's C-collar (known as a neck brace, is a medical device used to support a person's neck) for C-2 Fracture (The hangman's fracture refers to a break in a bone known as C-2, because it is the second bone down from the skull in your cervical (neck) vertebrae). <BR/>These deficient practices could affect residents at the facility who require a care plan and place them at risk for not receiving the appropriate care and services needed to maintain optimal health.<BR/>The findings were:<BR/>Record review of Resident #37's face sheet, dated 01/18/2022, revealed the resident was readmitted to the facility on [DATE] (original admission [DATE]) with diagnoses that include: unspecified displaced fracture of second cervical vertebra, subsequent encounter for fracture with routine healing. <BR/>Record review of Resident #37's progress notes dated 11/03/2021 that read resident admitted from hospital, A&OX3 (alert and oriented times 3). Neck brace in place.<BR/>Record review of Resident #37's Physician Order Summary, dated 01/18/2022, revealed Physician Order dated 12/02/2021 that read C-Collar to be worn at all times x2 months every shift for C-2 fracture for 2 months. <BR/>Record review of Resident #37's Significant Change MDS (Minimum Data Set), dated 11/15/2021, revealed the resident's BIMS score was 11, which indicated moderate cognitive impairment, with diagnosis of unspecified displace fracture of second cervical vertebra, subsequent encounter for fracture with routine healing.<BR/>Record review of Resident #37's Care Plan, start date 10/22/2021 and completion date 12/01/2021 revealed that it did not address Resident #37's requiring the use of the C-Collar (known as a neck brace, is a medical device used to support a person's neck) for C-2 Fracture (The hangman's fracture refers to a break in a bone known as C-2, because it is the second bone down from the skull in your cervical (neck) vertebrae).<BR/>During observation and interview on 01/17/2022 at 11:48 a.m. Resident #37 she was observed lying in bed with her C-Collar on and Resident #37 stated that she had broken her neck back in about October. Further stated that she was seeing a doctor for the care of her neck and had to wear the neck brace all the time. <BR/>During interview on 01/18/2022 at 4:03 p.m. RCS LVN C stated that Resident #37's neck collar was in place when she returned on 11/3/2021 from the hospital and confirmed that C-Collar was not addressed in the care plan but should have been. RCS LVN C further stated that the collar was for immobilization of the neck due to Resident #37 having had surgery and that she was to wear it for two months. <BR/>During interview on 01/19/2022 at 2:42 p.m. DON stated that it was a little bit of everyone's responsibility to update care plans from the ADON, MDS (RCS LVN), treatment nurse and herself. DON further stated that by not wearing the brace (C-Collar) would put Resident #37 at risk of the fracture not healing and that staff had been in-service on the brace (C-Collar). DON confirmed that the C-Collar should have been care planned and it was definitely important for Resident #37 to wear it. <BR/>Record review of the facility's Nursing Services Policy and Procedure Manual policy, titled Care Planning, revised December 2017, revealed A comprehensive, person-centered care plan is developed and implemented for each resident to meet the resident's physical, psychosocial, and functional needs .A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .<BR/>Based on observations, interviews, and record reviews, the facility failed to provide the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 4 of 13 residents reviewed for ADLs (resident # 86, # 89, #95 and #96) in that: <BR/>The facility failed to ensure staff provided consistent showers/baths to resident # 86 and resident # 89. <BR/>1.) <BR/>Resident # 86 was denied 8 bathing or showers over previous 30 days from 12/21/2021<BR/>through 01/17/2022. <BR/>2.) <BR/>Resident # 89 was denied 11 bathing or showers over previous 30 days from 12/21/2021<BR/>through 01/17/2022. Resident # 89 did not receive extensive assistance x 2 staff with bathing 3 x week and as necessary. <BR/>3.) Resident # 95 was denied 9 bathing or showers from 01/01/22 to 01/12/22.<BR/>4.) Resident # 96 was denied 9 bathing or showers from 01/01/22 to 01/12/22.<BR/>This deficient practice could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, a decline in their highest practicable physical, mental and psychosocial well-being. <BR/>The findings included:<BR/>In a record review of resident # 89's admission record dated 1/19/2022 revealed resident # 89 was a [AGE] year-old female admitted [DATE]. Diagnoses included unspecified heart failure; unspecified dementia without behavioral disturbance; unspecified anxiety disorder; muscle wasting and atrophy; lack of coordination. <BR/>In a record review of resident # 89's Minimum Data Set 3.0 dated 10/04/2021 revealed in Section C - cognitive patterns for Brief Interview for Mental Status indicated a Summary Score of 11 [indicates moderately impaired cognition]. In Section G - indicated 1-person physical assistance for bathing activities.<BR/>In a record review of resident # 89's Care Plan with a revision date of 02/23/2021 revealed resident # 89 had a problem of ADL self-care performance deficit related to heart failure and dementia. With a goal of improved current level of functioning through the review date of 04/06/2022. Interventions included extensive assistance with two staff, three times a week and as necessary for bathing. <BR/>In a record review of an undated Shower Schedule resident # 89 was to receive showers three times a week on Mondays, Wednesdays, and Fridays on the day shift between 6:00 AM and 2:00 PM. <BR/>In a record review of resident # 89's Tasks documentation for the previous 30 days [12/21/21 - 01/17/22] from the electronic health record retrieved 01/18/2022, revealed resident # 89 received showers on 12/23/2021 and 01/17/2022 with Not Applicable indicated on the following dates: 12/21/2021, 12/26/2021, 12/27/2021, 01/01/2022, 01/06/2022, 01/15/2022. Review of Bathing Support Provided revealed resident # 89 received supervision and set up help only on 12/23/2021 and 01/17/2022.<BR/>Extrapolating from preferred shower schedule and available documentation, resident # 89 should have received 11 showers on Wednesday 12/22/2021, Friday 12/24/2021, Monday 12/27/2021, Wednesday 12/29/2021, Friday 12/31/2021, Monday 1/3/2022, Wednesday 1/5 2022, Friday 1/7/2022, Monday 1/10/2022, Wednesday 1/12/2022, and Friday 1/14 2022. <BR/>In a record review of resident # 89's Weekly Skin Assessment from 12/18/2020 - 01/03/2022, did not reveal any entries indicating skin breakdown, rashes, or other issues with the exception of an annotation indicating bruises to both arms, Caesarean section surgical scar to abdomen noted upon admission [DATE]]. <BR/>In a record review of resident # 86's Minimum Data Set 3.0 dated 07/07/2021 revealed resident # 86 was a [AGE] year-old female admitted [DATE]. Diagnoses included cancer; gastroesophageal reflux disease; arthritis; seizure disorder or epilepsy; anxiety disorder; depression; asthma, chronic obstructive pulmonary disease, or chronic lung disease; Crohn's disease with this fistula; female intestinal-genital tract fistulae. In Section C - cognitive patterns for Brief Interview for Mental Status indicated a Summary Score of 10 [indicates moderately impaired cognition]. In Section G - indicated 1-person physical assistance for bathing activities.<BR/>In a record review of resident # 86's Care Plan dated 07/01/2021 revealed resident # 86 had a problem of ADL self-care performance deficit related to tumor. With a goal of improve current level of functioning through the review date of 04/07/2022. Interventions included extensive assistance with one staff, three times a week and as necessary for bathing. <BR/>In a record review of an undated Shower Schedule resident # 86 was to receive showers three times a week on Tuesdays, Thursdays, and Saturdays, on the evening shift between 2:00 PM and 6 PM. <BR/>In a record review of resident # 86's Tasks documentation for the previous 30 days [12/21/21 - 01/17/22] from the electronic health record retrieved 01/18/2022, revealed resident # 86 received eight showers on 12/22/2021, 12/28/2021, 12/30/2021, 1/4/2021, 1/5/2021, 1/6/2021, 1/12/2021, and 1/15/2021 with Not Applicable indicated on the following dates: 12/21/2021, 12/26/2021, 12/27/2021, 1/1/2022, and 1/17/2022. <BR/>Extrapolating from preferred shower schedule and available documentation, resident # 86 should have received showers on Saturday 12/18/2021, Tuesday 12/21/21, Thursday 12/23/21, Saturday 12/25/21, Saturday 1/1/2022, Saturday 1/8/2022, Tuesday 1/11/2022, and Thursday 1/13/2022. <BR/>In a record review of resident # 86's Weekly Skin Assessment from 6/30/2021 - 01/12/2022, did not reveal any entries indicating skin breakdown, rashes, or other issues with the following 3 exceptions indicating ileostomy to the mid lower abd [abdomen] multiple scars to abd [abdomen], scar to the r [right] buttock with 'pain pump non working (sp) noted upon admission [DATE]] and an entry on 10/27/2021 indicating unable to see the ulcer to the colostomy stoma site today. Res. States she will let this LVN know when she changes the bag so the ulcer can be tx [treated]; and finally, an entry on 12/15/2021 indicating will check the colostomy site when bag is changed. <BR/>In an interview on 01/16/2022 at 12:06 PM, Resident # 86 stated that she does not get assistance from facility staff to shower. She stated the hospice staff assist her on the days they come to see her. Resident # 86 stated this was about once a week, but wasn't 100% sure. She stated she has reminded staff on the days she is scheduled for a shower, but they don't always get to it before they leave. Resident #86 stated she has asked staff to assist her with showering on days she is not normally scheduled and has been told by various staff that if they can squeeze her in after the residents scheduled for showers they will, but most times the staff are unable to shower her on the off days. <BR/>In an interview on 01/16/2022 at 12:10 PM, Resident # 89 stated that one thing that bothered her about the care that she receives at this facility is the lack of consistent opportunities for bathing. She stated in the last two weeks she has been offered maybe twice to receive a shower. She stated that on the days she is not afforded the opportunity to have a shower she uses a washcloth at the sink in her restroom to freshen up. Resident # 89 stated she has reminded the aides that she needs a shower on her scheduled days but mostly they do not get around to it before the end of their shift. Resident # 89 stated she has not ever been offered a shower on a day she is not normally scheduled for it. <BR/>In an interview on 01/17/2022 at 2:23 PM, Resident # 89 stated she declined her opportunity to shower today [Monday] due to not feeling well and did not think she would get another opportunity to shower until her next scheduled shower day on Wednesday. Resident # 89 stated she could not remember when her last shower was and reiterated that she keeps a washcloth in her restroom to use between showers. <BR/>In an interview on 01/18/2022 at 9:55 AM, Resident # 86 stated that today was her scheduled shower day, and she expected to get a shower in the afternoon. Resident # 86 stated her last shower was over the weekend, but she could not recall if it was on Friday, Saturday, or Sunday. Resident # 86 stated she usually received a shower weekly with the hospice staff. Resident # 86 stated the shower she received over the weekend was facility staff and she did not think it was on her normally scheduled day [Saturday]. <BR/>In an interview on 01/19/2022 at 12:52 with the Director of Nurses (DON), she stated she had not received any concerns from residents or staff that residents are not getting showers as scheduled. She stated that Resident # 89 does receive some services from hospice, but she thought bathing was an activity normally provided by facility staff. The DON stated she had not heard any concerns regarding Resident #89 and showering. The DON stated she thinks that Resident #89 would occasionally refuse a shower but not frequently. The DON stated that the expectation would be for showers to be documented; that refusals or missed showers is communicated to the oncoming shift; and that showers be offered after the normally scheduled residents were taken care either on the next shift, or on an alternate day. The DON said she would check for a policy. The DON did not state effects on residents not receiving showers. Policy not received prior to exit. <BR/>R#95<BR/>Record review of R#95's face sheet, dated 01/12/22, and EMR revealed, the resident was admitted on [DATE] with diagnoses that included: fracture left rib, lack of coordination, and weakness. Female age [AGE].<BR/>Record review of Physician's order, dated 11/30/21, revealed, skin evaluation weekly and provide showers Monday, Wednesday and Friday 2 PM-10 PM and as needed. <BR/>Record review of R#95's MDS, admissions (12/07/21) revealed, BIMS score of 07 (moderately impaired). ADLs for bed mobility was limited assistance one staff, transfer extensive one staff, toileting and personal hygiene was extensive one staff, bathing was physical help one staff.<BR/>Record review of R#95's CP, undated, revealed, ADLs: goals-will maintain ability at selfcare, anticipate needs; clean and dry free of odors. <BR/>Record review of R#95's skin assessment, dated, 01/11/22, revealed, skin intact.<BR/>Record review of R#95's skin assessment, dated 01/12/22, revealed, skin intact. <BR/>Record review of Nurse Notes for R #95, 01/01/22 to 01/12/22, revealed, no documentation of shower refusals or showers given.<BR/>Record review of R#95's POC, revealed, no entries from 01/01/22 to 01/12/22. <BR/>Observation and interview on 01/12/22 at 10:10 AM , R#95 was in bed taking a nap and awaken for the surveyor. [NAME] present. There were no skin tears or bruises present. The resident did not reveal signs of neglect or abuse. R#95 stated, .I have not taken a shower in about a week .do not know shower days .might have a rash .I feel terrible not having a shower .I complained to the nursing staff .no excuse given .staff is busy so I do not feel angry . <BR/>During an interview on 01/12/22 at 11:02 AM, LVN K stated, .I am aware that residents ( R#96) and( R# 95) have missed showers .it might be a staffing issue .I am responsible that nurse aides shower residents we had problems getting the shower list updated .I became aware yesterday about the residents (R#96 and R#95) missing showers .<BR/>During an interview on 01/12/22 at 11:15 AM, OTA (Occupational Therapy Assistant) C stated, .I have showered both (R#96 and R#95) .one day last week I showered (R#96) .we sadly have a staffing issue .on some days we do not have enough staff in Hall 200, nurse aides, to provide ADLs around showering but ADLs are met .the issue is showering .and time for documentation . <BR/>During an interview on 01/12/22 at 11:28 AM, DON stated, .we do not have shower sheets for (R#96 and R#95) .we have not documented on (R#96 and R#95) for the month of January 2022 .because of a staffing shortage .we need more Nurse Aides about 10; but, we are having difficulties hiring nurse aides .we have a contract service for one aide and one nurse .we have been advertising .and we continue to seek more applicants (R#96 and R#95) have been showered but, I cannot prove it .aides have not found time to document .our POC (point of care) documentation is at 11 % rather than 100% for January 2022 . <BR/>During an interview on 01/12/22 at 11:40 AM, Resident Aide D stated, .I provide showers to all residents and all Halls .we do our best to document .we are short on staff .but I do provide showers .I get lists daily when residents who are schedule to be showered .the list is a guide .and PRN (as needed) showers for residents with accidents are given .we scramble to do showers .there are no other issues with ADLs other than showers .and documentation .in the POC and clinical record . <BR/>During an interview on 01/12/22 at 11:54 AM, Administrator stated, .I started here as the Administrator on November 29, 2021 .there is staffing shortage for nurse aides .we are doing signed on bonuses .contracting with two staffing agencies .difficult to hire nurse aides .we are advertising .the shortage has affected ADLs around showers .not around care .the therapy department is helping with showering .Hospice provides showers as well .we lack oversight of nursing supervisors to ensure we have a system to document in the clinical record; it is an issue I am exploring .they need to follow the POC .and document . <BR/>Record review of facility's, Shower/Tub Bath, policy dated October 20, 2010, read, .Documentation: The following information should be recorded on the resident's ADL record and/or in the resident's medical record:<BR/>1. <BR/>The date and time the shower/tub bath was performed .<BR/>5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken .<BR/>R#96<BR/>Record review of R#1's face sheet, dated 01/12/22, and EMR (electronic medical record) revealed, the resident was admitted [DATE] with diagnoses that included: arthritis, fracture of right patella (knee cap), and constipation. Female age [AGE].<BR/>Record review of Physician's order, dated 11/09/21, revealed, skin evaluation weekly (nothing mentioned on showers).<BR/>Record review of R#96's MDS (minimum data set), admissions (11/16/21) revealed, BIMS (brief interview of mental status) score of 15 (cognitively intact). ADLs (activity of daily living) for bed mobility was extensive one staff, transfer extensive one staff, toileting and personal hygiene was extensive one staff, bathing was physical help one staff.<BR/>Record review of R#96's CP (care plan), undated, revealed, resident frequently refused showers and resident stated not receiving showers. Interventions included: nursing to document<BR/> resident refusal of showers in the POC (point of care)/progress notes; and respect resident wishes. Document ADL performance. Shower schedule not present.<BR/>Record review of R#96's skin assessment, dated 01/05/22, revealed, slight redness to buttocks, barrier cream applied.<BR/>Record review of R#96's skin assessment, dated 01/12/22, revealed, light redness in stomach folds. Improved redness to buttocks.<BR/>Record review of Nurse Notes for R #96, 01/01/22 to 01/12/22, revealed, no documentation of shower refusal or showers given.<BR/>Record review of R#96's POC, revealed, no entries from 01/01/22 to 01/12/22. <BR/>Observation and interview on 01/12/22 at 9:55 AM , R#96 revealed, resident was in room sitting on a recliner .wheelchair and walker present .There were no skin tears or bruises present. The resident did not reveal signs of neglect or abuse. R#1 stated, .I only had three showers in two months .it has been about a week and half since I had my shower .I complained to everybody constantly .I mentioned it to the Administrator .I do not know the shower days .they do not give me any excuse for not showering me .I have a rash based on history from home and not the facility .<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, in 3 rooms (Rooms #502, #503, #508) out of eleven resident rooms on 500 Hall (Secure Unit) reviewed for accident hazards, in that;<BR/>The facility failed to ensure that the hot water temperatures in the restroom sinks for 3 resident rooms did not exceed the maximum of 110 degrees Fahrenheit.<BR/>This failure could place residents at risk for injuries related to hot water temperatures. <BR/>The findings included:<BR/>Review of Resident #46's face sheet dated 1/18/2022 revealed the resident was admitted to the facility on [DATE], resided in room [ROOM NUMBER], and had diagnoses that included dementia with behavioral disturbance, moderate intellectual disabilities, schizophrenia and anxiety disorder.<BR/>Review of Resident #46's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, moderately impaired cognitive status. Further review of the MDS revealed Resident #46 required limited assistance with toileting and ambulation.<BR/>Observation and interview on 01/17/22 at 10:49 a.m. with Resident #46 in room [ROOM NUMBER] the resident reported to be careful when checking the hot water temperature because the hot water gets really hot. When the surveyor checked the hot water temperature with a thermometer it registered 136 degrees Fahrenheit. <BR/>Observation on 1/17/2022 at 10:51 a.m. the hot water temperature in room [ROOM NUMBER] was 137.4 degrees Fahrenheit. The residents that resided in this room were not interviewable.<BR/>Observation on 1/17/2022 at 10:55 a.m. the hot water temperature in room [ROOM NUMBER] measured 142 degrees Fahrenheit. The residents that resided in this room were not interviewable.<BR/>Interview on 11/17/2022 at 10:59 a.m. with the Administrator he reported the Maintenance Supervisor was out sick but expected to return to work the following day. <BR/>Observation on 1/17/2022 at 11:00 a.m. in room [ROOM NUMBER] with the Administrator, the Administrator checked the hot water temperature using his own thermometer and it measured 134 degrees Fahrenheit.<BR/>Observation on 1/17/2022 at 11:04 a.m. in room [ROOM NUMBER] with the Administrator, the Administrator checked the hot water temperature using his own thermometer and it measured 139 degrees Fahrenheit.<BR/>Review of the temperature logs for the hot water monitoring, provided by the facility, revealed hot water temperature checks from 12/27/2021 to present time. Review of the hot water temperatures that were checked on 500 Hall had ranged in temperatures from 100-110. <BR/>Interview on 1/18/2021 at 9:02 a.m. with the Maintenance Supervisor he revealed he checked hot water temperatures in random rooms on each hall daily. The Maintenance Supervisor reported the requirements for the hot water temperatures in the residents' restroom sinks and shower rooms were to be no less than 100 degrees Fahrenheit and no more than 110 degrees Fahrenheit. The Maintenance Supervisor reported he had some issues with the hot water temperatures being out of range on the 500 Hall about 2 weeks ago, but the problem had been resolved and he did not have any further issues. The Maintenance Supervisor reported if the hot water temperature measure above 110 degrees, it places the residents at risk for burns. <BR/>Record review of the facility's undated TELS Testing and Logging of Hot Water Temperatures documented The dial thermometer is accurate to 1 to 2 degrees F, however it is not precision instrument and should be calibrated on a regular basis As the temperature of the water is taken, hold hand under the running water at about the same time to assess how the water feels on your skin .Test the water at various locations throughout your facility .Ensure patient room temperatures (as specified by Texas requirements) are between 100-110 degrees Fahrenheit.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 resident (Resident #36) reviewed for incontinent care, in that: <BR/>While providing incontinent care for Resident #36, CNA A made multiple pass with the same wipe and used a back to front motion to clean Resident #36's genitals. CNA did not clean Resident #36's buttocks. <BR/>This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. <BR/>The findings were:<BR/>Record review of Resident #36's face sheet, dated 03/21/2023, revealed an admission date of 03/02/2015 and, a readmission date of 02/08/2021, with diagnoses which included: Alzheimer's disease (brain disorder that causes problems with memory, thinking and behavior), Chronic kidney disease(gradual loss of kidney function) , Mood disorder (general emotional state or mood is distorted or inconsistent with circumstances and interferes with the ability to function), Hypertension (High blood pressure), Hyperlipidemia (too much lipids (fat) in the blood).<BR/>Record review of Resident #36's Quarterly MDS, dated [DATE], revealed Resident #36 did not have a BIMS score and, had severe cognitive impairment. Resident #36 was indicated to always be incontinent of bladder and bowel and needed extensive assistance to total care with his activities of daily living. <BR/>Review of Resident #36's care plan, dated 10/20/22, revealed a problem of The resident has bladder incontinence<BR/>ALWAYS related to dx Alzheimer's / lack of awareness, with an intervention of Monitor/document for s/sx UTI, notify MD for any changes in status<BR/>Observation on 03/21/2023 at 11:34 a.m. revealed while providing incontinent care for Resident #36, CNA A used the same wipe to do multiple passes to clean the resident's genital. CNA used a back to front motion to wipe the resident's scrotum. CNA A, while cleaning the resident's buttocks, cleaned between the cheeks but not the surface of the cheeks. <BR/>During an interview on 03/21/2023 at 11:55 a.m. with CNA A, she confirmed she had wiped back to front instead of using a front to back motion. She confirmed not changing wipes and using the same wipe to do multiple passes and cleaning only between the buttocks cheeks of the resident. She added she was nervous. <BR/>During an interview with the DON on 03/22/2023 at 10:30 a.m., she confirmed the correct motion to clean the residents during perineal care was front to back to prevent fecal matter to get in contact with the urethra and possibly cause an infection. She confirmed a wipe should be used for one pass and confirmed the buttocks surface should have been cleaned, The DON reveled the staff received training on infection control and incontinent care at least annually. The staff skills were check yearly. The facility had a CNA instructor that would train the CNA and would spot check the staff while they provided care for infection control and quality of care. <BR/>Review of annual skills check for CNA A revealed CNA A passed competency for Perineal care/incontinent care on 01/04/2023. <BR/>Review of facility policy, titled Incontinent care proficiency checklist, undated, revealed [ .] wipe down center front to back with one stroke, then each side with clean side of cloth each time. For men wipe the head of the penis using a circular motion first then down the shaft of the penis and then the scrotum.<BR/>Review of Hartman's Nursing assistant care The basics, Fifth edition, undated, revealed using a clean washcloth, wash and rinse buttocks and anal area. Work from front to back. Clean the anal area without contaminating the perineal area

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; was offered sufficient fluid intake to maintain proper hydration and health; or was offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 1 of 8 residents (Resident #50) reviewed for assisted nutrition and hydration, in that:<BR/>Resident #50 did not receive her supplement, ice cream during lunch service.<BR/>This failure could affect residents with therapeutic diets and could result in residents weight loss. <BR/>The Findings were:<BR/>Record review of Resident # 50's admission Record dated 3/22/2023 revealed she was admitted on [DATE] with diagnoses of Dementia, bipolar disorder, chronic kidney disease, mild cognitive impairment and anemia. <BR/>Record review of Resident # 50's diet order card dated 3/21/2023 revealed ice cream was included as part of her diet; all other food items were on her tray . <BR/>Record review Resident # 50's diet card on the lunch tray, dated 3/20/2023 was documented as regular diet with ice cream .<BR/>Record review of Resident # 50's telephone order dated 11/10/2022 revealed an order for ice cream two times a day with lunch and supper. <BR/>Record review of Resident # 50's Quarterly MDS 1/19/2023 revealed section C cognition patterns BIMS score was 8/15 (moderate cognitive impairment), section K -swallowing/nutritional status- K0200-height/weight-62/136, K0300 weight loss--no or unknown. <BR/>Record review of Resident # 50's care plan dated 2/13/2023 revealed resident #50 is on a regular diet, regular texture, regular, encourage died diet as ordered, offer supplements if intakes is less than 50%.<BR/>Observation on 3/20/2023 at 1:23 PM in Resident # 50's room, during lunch, her lunch tray did not have ice cream.<BR/>Interview on 3/20/2023 at 1:22 PM with Resident #50 stated she did not see ice cream on her lunch tray for today and had not eaten any for her lunch today .<BR/>Interview on 3/20/2023 at 1:27 PM with the Charge nurse for Resident #50's, RN K, verified she did not have no ice cream on her tray and will get some for her.<BR/>Interview on 03/20/23 5:25 PM the Administrator stated will search polices for kitchen, but not sure they will have all of them . The policy below was the policy he provided for resident's therapeutic diet.<BR/>Record review of the Job description of the Certified Dietary Manager (dated) revealed Responsible for the daily operations of the dietary department, according to the facility policy and procedures and federal/state regulations. CDM provided leadership and guidance to ensure the food quality, safety standards, and client expectations are satisfactorily met. Essential Functions: Operations Management-Interview, train, coach and evaluate dietary staff. Food Service Management: participates in menu planning, including responding to client preferences, .therapeutic diets, inspect meals and assure the standards for .serving times are met. Food safety assure safe , storage, preparations, an service of food, protect food in all phases in preparation, .service, , transportation,, ensure proper sanitation and safety practices of staff.<BR/>Record review of Tray Service policy dated October 1, 2018, revised June 1, 2019, was documented, The facility believes that accurate tray service and adequate portion sizes are essential to the residents' well -being and safety. The facility will ensure that diets are served accurately and in the correct portions and that resident preferences are met. 6. The Nutrition and Foodservice Manager or consultant will conduct in-service with the nutrition, foodservice as needed to ensure all serving staff are familiar with the portion sizes and therapeutic and mechanically altered diets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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, in that: <BR/>1. A large pan of pot roast was not labeled or dated.<BR/>2. A large pan of baked pears was not labeled or dated.<BR/>3. A quart bag with prepared Sloppy [NAME] mix was not labeled or dated<BR/>These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.<BR/>Findings included:<BR/>Observation on 1/16/2022 at 9:38 a.m. in the kitchens walk-in refrigerator revealed:<BR/>1. A large pan of pot roast, covered with foil, was not labeled with name of product and did not have a date when made and when to discard.<BR/>2. A large pan, 1/3 filled with cooked pears, covered with foil, was not labeled with name of product and did not have a date when made and when to discard.<BR/>3. A quart bag, 1/2 filled with Sloppy [NAME] mix, was not labeled with name of product and did not have a date when made and when to discard.<BR/>Interview on 1/16/2022 at 9:40 a.m. with [NAME] H revealed the pot roast was made the day before, 1/15/2022. She reported pot roast had not been listed on the menu to be served that week and assumed the pot roast was made to serve as an alternative for meal service. [NAME] H revealed she was not sure when cooked pears had been on the menu to be served. [NAME] H also revealed the Sloppy [NAME] mix was likely the left-over mix from dinner the evening before. <BR/>Interview on 1/16/2022 at 10:05 a.m. with the Administrator revealed he had hired a new Dietary Supervisor who was expected to start work today had not showed up yet. <BR/>Interview on 1/19/2022 with Dietician G revealed food that was not labeled or dated could result in food being served that was spoiled and result in food-borne illnesses. She reported the Dietary Manager was responsible for training staff and assuring food was label and dated.<BR/>Review of the facility policy, Food Storage, revised 6/1/2019, under the heading, Refrigerators revealed, d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage and e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.<BR/>Record review of the TFER 2015, page 72, section &sect;228.75(g)(4)(B) revealed prepared food was to be marked with the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises or discarded.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, revealed (A) .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 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff and obtain the required information for 2 of 3 (Resident #70 and #87) residents reviewed for hospice services, in that:<BR/>1. The facility failed to obtain Resident #70's most recent hospice plan of care, names and contact information for hospice personnel involved in hospice care of each resident, documentation by specific interdisciplinary hospice staff providing services.<BR/>2. The facility failed to obtain Resident #87's most recent hospice plan of care, names and contact information for hospice personnel involved in hospice care of each resident, documentation by specific interdisciplinary hospice staff providing services.<BR/>This failure could place the resident who received hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. <BR/>The findings were:<BR/>1. Record review of Resident #70's face sheet, dated 03/22/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease (type of brain disorder that causes problems with memory, thinking and behavior), peripheral vascular disease (PVD, systemic disorder that involves the narrowing of peripheral blood vessels), hyperparathyroidism of renal origin (complication of kidney disease characterized by elevated parathyroid hormones), and hypertensive chronic kidney disease (damage to the kidney due to chronic high blood pressure).<BR/>Record review of Resident #70's Quarterly MDS dated [DATE] revealed a BIMS of 03, which indicated severe cognitive impairment. Further review revealed the resident had a life expectancy of less than 6 months and had received hospice care while a resident at the facility.<BR/>Record review of Resident #70's comprehensive care plan initiated 08/04/2022 revealed a problem Admit to Hospice Company A Dx. Moderate Protein Calorie Malnutrition/deficiency. Call [phone number] for any changes in condition, questions or concerns. No labs or x-rays without hospice approval. RN Hospice nurse to pronounce.<BR/>Record review of Resident #70's electronic medical record active orders as of 03/22/2023 revealed an order on 06/21/2022 for: Admit to Hospice Company A Dx. Moderate Protein Calorie Malnutrition/deficiency. Call [phone number] for any changes in condition, questions or concerns. No labs or x-rays without hospice approval. RN Hospice nurse to pronounce.<BR/>Record review of Resident #70's electronic medical record, miscellaneous documents section, category Hospice, revealed only a hospice election and physician certification of terminal illness form were uploaded.<BR/>2. Record review of Resident #87's face sheet, dated 03/22/2023, revealed the resident had an initial admission date of 10/08/2021 with a re-admission on [DATE] with diagnoses that included: dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), acute kidney failure (kidneys suddenly become unable to filter waste products from your blood) and cerebrovascular disease (group of disorders that affect the blood vessels and blood supply to the brain).<BR/>Record review of Resident #87's Quarterly MDS, dated [DATE], revealed an unscored BIMS score. Further review revealed the staff assessment for mental status scored Resident #87 as severely impaired - never/rarely made decisions. Continued review of Resident #87's MDS revealed the resident had a life expectancy of less than 6 months and had received hospice care while a resident at the facility.<BR/>Record review of Resident #87's Care Plan with a date initiated 03/15/2022, revealed Admit to Hospice Company B. Dx: End Stage Alzheimer's No labs or X-Rays ordered without Hospice approval. Call Hospice Company B for any changes in condition, concerns, questions or falls @ [phone number] [fax number] RN Hospice Nurse to pronounce.<BR/>Record review of Resident #87's electronic medical record active orders as of 03/22/2023, revealed an order on 03/15/2022 for: Admit to Hospice Company B with DX of Alzheimer's Admit to Hospice Company B. Dx: End Stage Alzheimer's No labs or X-Rays ordered without Hospice approval. Call Hospice Company B for any changes in condition, concerns, questions or falls @ [phone number] [fax number] RN Hospice Nurse to pronounce.<BR/>Record review of Resident #87's electronic medical record, miscellaneous documents section, category Hospice, revealed only a hospice election and physician certification of terminal illness form were uploaded.<BR/>In an interview with LVN O on 03/22/2023 at 11:55 a.m., LVN O revealed all records regarding resident care was kept in the resident's electronic medical record. LVN O revealed that only hospice residents have additional paper records kept in hospice binders. LVN O was unable to locate a hospice binder for Resident #70 or Resident #87. LVN O was asked who is responsible for organizing hospice services for residents and LVN O stated the SW meets with families when the doctor orders hospice so the family can choose which agency they want. LVN O was asked how resident care is coordinated between hospice and nursing staff and LVN O revealed when the hospice nurse is finished with the visit, they stop by the nursing station and give a report.<BR/>In an interview with the SW on 03/22/2023 at 12:35 p.m., the SW revealed that after the resident/family had chosen which hospice agency they wanted to use he wouldn't play a part in the coordination of hospice services unless something was needed.<BR/>In an interview with the DON on 03/22/2023 at 12:54 p.m., the DON was asked who is responsible for the coordination of hospice care for the residents. The DON revealed the ADON staff had been the point of contact at one time for the assigned hospice nurse case manager to update following each visit. The DON added the hospice nurses now communicate more closely with the charge nurses. <BR/>Record review of the facility's hospice services agreement with Hospice Company A, with effective date, August 1, 2012, revealed, in 2.12 Plan of Care .The Hospice and Nursing facility will jointly develop and agree upon a coordinated Plan of Care which is consistent with the hospice philosophy ad is responsive to the unique needs of the Residential Hospice Patient and his/her expressed desire for hospice care. 3.2 (i) Hospice shall furnish Nursing Facility with a copy of the Plan of Care. 3.15 Providing Information. At a minimum Hospice shall provide the following information to Facility for each Hospice Patient residing at Facility: A. Hospice Plan of Care . 6.1. Liaison. On or prior to the execution of this Agreement, Hospice and Nursing Facility shall each designate two (2) representative(s) to serve as designees between them and to facilitate cooperative efforts in performance of their respective obligations under this Agreement. <BR/>Record review of the facility's hospice services agreement with Hospice Company A, with effective date, December 30, 2014, revealed, in 2.12 Plan of Care .The Hospice and Nursing facility will jointly develop and agree upon a coordinated Plan of Care which is consistent with the hospice philosophy ad is responsive to the unique needs of the Residential Hospice Patient and his/her expressed desire for hospice care. 3.2 (i) Hospice shall furnish Nursing Facility with a copy of the Plan of Care. 3.15 Providing Information. At a minimum Hospice shall provide the following information to Facility for each Hospice Patient residing at Facility: A. Hospice Plan of Care . 6.1. Liaison. On or prior to the execution of this Agreement, Hospice and Nursing Facility shall each designate two (2) representative(s) to serve as designees between them and to facilitate cooperative efforts in performance of their respective obligations under this Agreement. <BR/>Record review of the facility's policies revealed the facility did not have a hospice policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Citation Text for Tag 0656, Regulation FF11<BR/>[NAME], [NAME]<BR/>Based on observation, interview and record review the facility failed to develop and implement a person-centered comprehensive care plan for the resident, with no interventions to attain or maintain the resident's highest practical physical, mental and psychosocial well-being, for 1 of 6 residents (Resident #37) reviewed for comprehensive care plans in that: <BR/>The facility failed to develop a comprehensive care plan that addressed Resident 37's C-collar (known as a neck brace, is a medical device used to support a person's neck) for C-2 Fracture (The hangman's fracture refers to a break in a bone known as C-2, because it is the second bone down from the skull in your cervical (neck) vertebrae). <BR/>These deficient practices could affect residents at the facility who require a care plan and place them at risk for not receiving the appropriate care and services needed to maintain optimal health.<BR/>The findings were:<BR/>Record review of Resident #37's face sheet, dated 01/18/2022, revealed the resident was readmitted to the facility on [DATE] (original admission [DATE]) with diagnoses that include: unspecified displaced fracture of second cervical vertebra, subsequent encounter for fracture with routine healing. <BR/>Record review of Resident #37's progress notes dated 11/03/2021 that read resident admitted from hospital, A&OX3 (alert and oriented times 3). Neck brace in place.<BR/>Record review of Resident #37's Physician Order Summary, dated 01/18/2022, revealed Physician Order dated 12/02/2021 that read C-Collar to be worn at all times x2 months every shift for C-2 fracture for 2 months. <BR/>Record review of Resident #37's Significant Change MDS (Minimum Data Set), dated 11/15/2021, revealed the resident's BIMS score was 11, which indicated moderate cognitive impairment, with diagnosis of unspecified displace fracture of second cervical vertebra, subsequent encounter for fracture with routine healing.<BR/>Record review of Resident #37's Care Plan, start date 10/22/2021 and completion date 12/01/2021 revealed that it did not address Resident #37's requiring the use of the C-Collar (known as a neck brace, is a medical device used to support a person's neck) for C-2 Fracture (The hangman's fracture refers to a break in a bone known as C-2, because it is the second bone down from the skull in your cervical (neck) vertebrae).<BR/>During observation and interview on 01/17/2022 at 11:48 a.m. Resident #37 she was observed lying in bed with her C-Collar on and Resident #37 stated that she had broken her neck back in about October. Further stated that she was seeing a doctor for the care of her neck and had to wear the neck brace all the time. <BR/>During interview on 01/18/2022 at 4:03 p.m. RCS LVN C stated that Resident #37's neck collar was in place when she returned on 11/3/2021 from the hospital and confirmed that C-Collar was not addressed in the care plan but should have been. RCS LVN C further stated that the collar was for immobilization of the neck due to Resident #37 having had surgery and that she was to wear it for two months. <BR/>During interview on 01/19/2022 at 2:42 p.m. DON stated that it was a little bit of everyone's responsibility to update care plans from the ADON, MDS (RCS LVN), treatment nurse and herself. DON further stated that by not wearing the brace (C-Collar) would put Resident #37 at risk of the fracture not healing and that staff had been in-service on the brace (C-Collar). DON confirmed that the C-Collar should have been care planned and it was definitely important for Resident #37 to wear it. <BR/>Record review of the facility's Nursing Services Policy and Procedure Manual policy, titled Care Planning, revised December 2017, revealed A comprehensive, person-centered care plan is developed and implemented for each resident to meet the resident's physical, psychosocial, and functional needs .A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .<BR/>Based on observations, interviews, and record reviews, the facility failed to provide the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 4 of 13 residents reviewed for ADLs (resident # 86, # 89, #95 and #96) in that: <BR/>The facility failed to ensure staff provided consistent showers/baths to resident # 86 and resident # 89. <BR/>1.) <BR/>Resident # 86 was denied 8 bathing or showers over previous 30 days from 12/21/2021<BR/>through 01/17/2022. <BR/>2.) <BR/>Resident # 89 was denied 11 bathing or showers over previous 30 days from 12/21/2021<BR/>through 01/17/2022. Resident # 89 did not receive extensive assistance x 2 staff with bathing 3 x week and as necessary. <BR/>3.) Resident # 95 was denied 9 bathing or showers from 01/01/22 to 01/12/22.<BR/>4.) Resident # 96 was denied 9 bathing or showers from 01/01/22 to 01/12/22.<BR/>This deficient practice could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, a decline in their highest practicable physical, mental and psychosocial well-being. <BR/>The findings included:<BR/>In a record review of resident # 89's admission record dated 1/19/2022 revealed resident # 89 was a [AGE] year-old female admitted [DATE]. Diagnoses included unspecified heart failure; unspecified dementia without behavioral disturbance; unspecified anxiety disorder; muscle wasting and atrophy; lack of coordination. <BR/>In a record review of resident # 89's Minimum Data Set 3.0 dated 10/04/2021 revealed in Section C - cognitive patterns for Brief Interview for Mental Status indicated a Summary Score of 11 [indicates moderately impaired cognition]. In Section G - indicated 1-person physical assistance for bathing activities.<BR/>In a record review of resident # 89's Care Plan with a revision date of 02/23/2021 revealed resident # 89 had a problem of ADL self-care performance deficit related to heart failure and dementia. With a goal of improved current level of functioning through the review date of 04/06/2022. Interventions included extensive assistance with two staff, three times a week and as necessary for bathing. <BR/>In a record review of an undated Shower Schedule resident # 89 was to receive showers three times a week on Mondays, Wednesdays, and Fridays on the day shift between 6:00 AM and 2:00 PM. <BR/>In a record review of resident # 89's Tasks documentation for the previous 30 days [12/21/21 - 01/17/22] from the electronic health record retrieved 01/18/2022, revealed resident # 89 received showers on 12/23/2021 and 01/17/2022 with Not Applicable indicated on the following dates: 12/21/2021, 12/26/2021, 12/27/2021, 01/01/2022, 01/06/2022, 01/15/2022. Review of Bathing Support Provided revealed resident # 89 received supervision and set up help only on 12/23/2021 and 01/17/2022.<BR/>Extrapolating from preferred shower schedule and available documentation, resident # 89 should have received 11 showers on Wednesday 12/22/2021, Friday 12/24/2021, Monday 12/27/2021, Wednesday 12/29/2021, Friday 12/31/2021, Monday 1/3/2022, Wednesday 1/5 2022, Friday 1/7/2022, Monday 1/10/2022, Wednesday 1/12/2022, and Friday 1/14 2022. <BR/>In a record review of resident # 89's Weekly Skin Assessment from 12/18/2020 - 01/03/2022, did not reveal any entries indicating skin breakdown, rashes, or other issues with the exception of an annotation indicating bruises to both arms, Caesarean section surgical scar to abdomen noted upon admission [DATE]]. <BR/>In a record review of resident # 86's Minimum Data Set 3.0 dated 07/07/2021 revealed resident # 86 was a [AGE] year-old female admitted [DATE]. Diagnoses included cancer; gastroesophageal reflux disease; arthritis; seizure disorder or epilepsy; anxiety disorder; depression; asthma, chronic obstructive pulmonary disease, or chronic lung disease; Crohn's disease with this fistula; female intestinal-genital tract fistulae. In Section C - cognitive patterns for Brief Interview for Mental Status indicated a Summary Score of 10 [indicates moderately impaired cognition]. In Section G - indicated 1-person physical assistance for bathing activities.<BR/>In a record review of resident # 86's Care Plan dated 07/01/2021 revealed resident # 86 had a problem of ADL self-care performance deficit related to tumor. With a goal of improve current level of functioning through the review date of 04/07/2022. Interventions included extensive assistance with one staff, three times a week and as necessary for bathing. <BR/>In a record review of an undated Shower Schedule resident # 86 was to receive showers three times a week on Tuesdays, Thursdays, and Saturdays, on the evening shift between 2:00 PM and 6 PM. <BR/>In a record review of resident # 86's Tasks documentation for the previous 30 days [12/21/21 - 01/17/22] from the electronic health record retrieved 01/18/2022, revealed resident # 86 received eight showers on 12/22/2021, 12/28/2021, 12/30/2021, 1/4/2021, 1/5/2021, 1/6/2021, 1/12/2021, and 1/15/2021 with Not Applicable indicated on the following dates: 12/21/2021, 12/26/2021, 12/27/2021, 1/1/2022, and 1/17/2022. <BR/>Extrapolating from preferred shower schedule and available documentation, resident # 86 should have received showers on Saturday 12/18/2021, Tuesday 12/21/21, Thursday 12/23/21, Saturday 12/25/21, Saturday 1/1/2022, Saturday 1/8/2022, Tuesday 1/11/2022, and Thursday 1/13/2022. <BR/>In a record review of resident # 86's Weekly Skin Assessment from 6/30/2021 - 01/12/2022, did not reveal any entries indicating skin breakdown, rashes, or other issues with the following 3 exceptions indicating ileostomy to the mid lower abd [abdomen] multiple scars to abd [abdomen], scar to the r [right] buttock with 'pain pump non working (sp) noted upon admission [DATE]] and an entry on 10/27/2021 indicating unable to see the ulcer to the colostomy stoma site today. Res. States she will let this LVN know when she changes the bag so the ulcer can be tx [treated]; and finally, an entry on 12/15/2021 indicating will check the colostomy site when bag is changed. <BR/>In an interview on 01/16/2022 at 12:06 PM, Resident # 86 stated that she does not get assistance from facility staff to shower. She stated the hospice staff assist her on the days they come to see her. Resident # 86 stated this was about once a week, but wasn't 100% sure. She stated she has reminded staff on the days she is scheduled for a shower, but they don't always get to it before they leave. Resident #86 stated she has asked staff to assist her with showering on days she is not normally scheduled and has been told by various staff that if they can squeeze her in after the residents scheduled for showers they will, but most times the staff are unable to shower her on the off days. <BR/>In an interview on 01/16/2022 at 12:10 PM, Resident # 89 stated that one thing that bothered her about the care that she receives at this facility is the lack of consistent opportunities for bathing. She stated in the last two weeks she has been offered maybe twice to receive a shower. She stated that on the days she is not afforded the opportunity to have a shower she uses a washcloth at the sink in her restroom to freshen up. Resident # 89 stated she has reminded the aides that she needs a shower on her scheduled days but mostly they do not get around to it before the end of their shift. Resident # 89 stated she has not ever been offered a shower on a day she is not normally scheduled for it. <BR/>In an interview on 01/17/2022 at 2:23 PM, Resident # 89 stated she declined her opportunity to shower today [Monday] due to not feeling well and did not think she would get another opportunity to shower until her next scheduled shower day on Wednesday. Resident # 89 stated she could not remember when her last shower was and reiterated that she keeps a washcloth in her restroom to use between showers. <BR/>In an interview on 01/18/2022 at 9:55 AM, Resident # 86 stated that today was her scheduled shower day, and she expected to get a shower in the afternoon. Resident # 86 stated her last shower was over the weekend, but she could not recall if it was on Friday, Saturday, or Sunday. Resident # 86 stated she usually received a shower weekly with the hospice staff. Resident # 86 stated the shower she received over the weekend was facility staff and she did not think it was on her normally scheduled day [Saturday]. <BR/>In an interview on 01/19/2022 at 12:52 with the Director of Nurses (DON), she stated she had not received any concerns from residents or staff that residents are not getting showers as scheduled. She stated that Resident # 89 does receive some services from hospice, but she thought bathing was an activity normally provided by facility staff. The DON stated she had not heard any concerns regarding Resident #89 and showering. The DON stated she thinks that Resident #89 would occasionally refuse a shower but not frequently. The DON stated that the expectation would be for showers to be documented; that refusals or missed showers is communicated to the oncoming shift; and that showers be offered after the normally scheduled residents were taken care either on the next shift, or on an alternate day. The DON said she would check for a policy. The DON did not state effects on residents not receiving showers. Policy not received prior to exit. <BR/>R#95<BR/>Record review of R#95's face sheet, dated 01/12/22, and EMR revealed, the resident was admitted on [DATE] with diagnoses that included: fracture left rib, lack of coordination, and weakness. Female age [AGE].<BR/>Record review of Physician's order, dated 11/30/21, revealed, skin evaluation weekly and provide showers Monday, Wednesday and Friday 2 PM-10 PM and as needed. <BR/>Record review of R#95's MDS, admissions (12/07/21) revealed, BIMS score of 07 (moderately impaired). ADLs for bed mobility was limited assistance one staff, transfer extensive one staff, toileting and personal hygiene was extensive one staff, bathing was physical help one staff.<BR/>Record review of R#95's CP, undated, revealed, ADLs: goals-will maintain ability at selfcare, anticipate needs; clean and dry free of odors. <BR/>Record review of R#95's skin assessment, dated, 01/11/22, revealed, skin intact.<BR/>Record review of R#95's skin assessment, dated 01/12/22, revealed, skin intact. <BR/>Record review of Nurse Notes for R #95, 01/01/22 to 01/12/22, revealed, no documentation of shower refusals or showers given.<BR/>Record review of R#95's POC, revealed, no entries from 01/01/22 to 01/12/22. <BR/>Observation and interview on 01/12/22 at 10:10 AM , R#95 was in bed taking a nap and awaken for the surveyor. [NAME] present. There were no skin tears or bruises present. The resident did not reveal signs of neglect or abuse. R#95 stated, .I have not taken a shower in about a week .do not know shower days .might have a rash .I feel terrible not having a shower .I complained to the nursing staff .no excuse given .staff is busy so I do not feel angry . <BR/>During an interview on 01/12/22 at 11:02 AM, LVN K stated, .I am aware that residents ( R#96) and( R# 95) have missed showers .it might be a staffing issue .I am responsible that nurse aides shower residents we had problems getting the shower list updated .I became aware yesterday about the residents (R#96 and R#95) missing showers .<BR/>During an interview on 01/12/22 at 11:15 AM, OTA (Occupational Therapy Assistant) C stated, .I have showered both (R#96 and R#95) .one day last week I showered (R#96) .we sadly have a staffing issue .on some days we do not have enough staff in Hall 200, nurse aides, to provide ADLs around showering but ADLs are met .the issue is showering .and time for documentation . <BR/>During an interview on 01/12/22 at 11:28 AM, DON stated, .we do not have shower sheets for (R#96 and R#95) .we have not documented on (R#96 and R#95) for the month of January 2022 .because of a staffing shortage .we need more Nurse Aides about 10; but, we are having difficulties hiring nurse aides .we have a contract service for one aide and one nurse .we have been advertising .and we continue to seek more applicants (R#96 and R#95) have been showered but, I cannot prove it .aides have not found time to document .our POC (point of care) documentation is at 11 % rather than 100% for January 2022 . <BR/>During an interview on 01/12/22 at 11:40 AM, Resident Aide D stated, .I provide showers to all residents and all Halls .we do our best to document .we are short on staff .but I do provide showers .I get lists daily when residents who are schedule to be showered .the list is a guide .and PRN (as needed) showers for residents with accidents are given .we scramble to do showers .there are no other issues with ADLs other than showers .and documentation .in the POC and clinical record . <BR/>During an interview on 01/12/22 at 11:54 AM, Administrator stated, .I started here as the Administrator on November 29, 2021 .there is staffing shortage for nurse aides .we are doing signed on bonuses .contracting with two staffing agencies .difficult to hire nurse aides .we are advertising .the shortage has affected ADLs around showers .not around care .the therapy department is helping with showering .Hospice provides showers as well .we lack oversight of nursing supervisors to ensure we have a system to document in the clinical record; it is an issue I am exploring .they need to follow the POC .and document . <BR/>Record review of facility's, Shower/Tub Bath, policy dated October 20, 2010, read, .Documentation: The following information should be recorded on the resident's ADL record and/or in the resident's medical record:<BR/>1. <BR/>The date and time the shower/tub bath was performed .<BR/>5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken .<BR/>R#96<BR/>Record review of R#1's face sheet, dated 01/12/22, and EMR (electronic medical record) revealed, the resident was admitted [DATE] with diagnoses that included: arthritis, fracture of right patella (knee cap), and constipation. Female age [AGE].<BR/>Record review of Physician's order, dated 11/09/21, revealed, skin evaluation weekly (nothing mentioned on showers).<BR/>Record review of R#96's MDS (minimum data set), admissions (11/16/21) revealed, BIMS (brief interview of mental status) score of 15 (cognitively intact). ADLs (activity of daily living) for bed mobility was extensive one staff, transfer extensive one staff, toileting and personal hygiene was extensive one staff, bathing was physical help one staff.<BR/>Record review of R#96's CP (care plan), undated, revealed, resident frequently refused showers and resident stated not receiving showers. Interventions included: nursing to document<BR/> resident refusal of showers in the POC (point of care)/progress notes; and respect resident wishes. Document ADL performance. Shower schedule not present.<BR/>Record review of R#96's skin assessment, dated 01/05/22, revealed, slight redness to buttocks, barrier cream applied.<BR/>Record review of R#96's skin assessment, dated 01/12/22, revealed, light redness in stomach folds. Improved redness to buttocks.<BR/>Record review of Nurse Notes for R #96, 01/01/22 to 01/12/22, revealed, no documentation of shower refusal or showers given.<BR/>Record review of R#96's POC, revealed, no entries from 01/01/22 to 01/12/22. <BR/>Observation and interview on 01/12/22 at 9:55 AM , R#96 revealed, resident was in room sitting on a recliner .wheelchair and walker present .There were no skin tears or bruises present. The resident did not reveal signs of neglect or abuse. R#1 stated, .I only had three showers in two months .it has been about a week and half since I had my shower .I complained to everybody constantly .I mentioned it to the Administrator .I do not know the shower days .they do not give me any excuse for not showering me .I have a rash based on history from home and not the facility .<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, in 3 rooms (Rooms #502, #503, #508) out of eleven resident rooms on 500 Hall (Secure Unit) reviewed for accident hazards, in that;<BR/>The facility failed to ensure that the hot water temperatures in the restroom sinks for 3 resident rooms did not exceed the maximum of 110 degrees Fahrenheit.<BR/>This failure could place residents at risk for injuries related to hot water temperatures. <BR/>The findings included:<BR/>Review of Resident #46's face sheet dated 1/18/2022 revealed the resident was admitted to the facility on [DATE], resided in room [ROOM NUMBER], and had diagnoses that included dementia with behavioral disturbance, moderate intellectual disabilities, schizophrenia and anxiety disorder.<BR/>Review of Resident #46's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, moderately impaired cognitive status. Further review of the MDS revealed Resident #46 required limited assistance with toileting and ambulation.<BR/>Observation and interview on 01/17/22 at 10:49 a.m. with Resident #46 in room [ROOM NUMBER] the resident reported to be careful when checking the hot water temperature because the hot water gets really hot. When the surveyor checked the hot water temperature with a thermometer it registered 136 degrees Fahrenheit. <BR/>Observation on 1/17/2022 at 10:51 a.m. the hot water temperature in room [ROOM NUMBER] was 137.4 degrees Fahrenheit. The residents that resided in this room were not interviewable.<BR/>Observation on 1/17/2022 at 10:55 a.m. the hot water temperature in room [ROOM NUMBER] measured 142 degrees Fahrenheit. The residents that resided in this room were not interviewable.<BR/>Interview on 11/17/2022 at 10:59 a.m. with the Administrator he reported the Maintenance Supervisor was out sick but expected to return to work the following day. <BR/>Observation on 1/17/2022 at 11:00 a.m. in room [ROOM NUMBER] with the Administrator, the Administrator checked the hot water temperature using his own thermometer and it measured 134 degrees Fahrenheit.<BR/>Observation on 1/17/2022 at 11:04 a.m. in room [ROOM NUMBER] with the Administrator, the Administrator checked the hot water temperature using his own thermometer and it measured 139 degrees Fahrenheit.<BR/>Review of the temperature logs for the hot water monitoring, provided by the facility, revealed hot water temperature checks from 12/27/2021 to present time. Review of the hot water temperatures that were checked on 500 Hall had ranged in temperatures from 100-110. <BR/>Interview on 1/18/2021 at 9:02 a.m. with the Maintenance Supervisor he revealed he checked hot water temperatures in random rooms on each hall daily. The Maintenance Supervisor reported the requirements for the hot water temperatures in the residents' restroom sinks and shower rooms were to be no less than 100 degrees Fahrenheit and no more than 110 degrees Fahrenheit. The Maintenance Supervisor reported he had some issues with the hot water temperatures being out of range on the 500 Hall about 2 weeks ago, but the problem had been resolved and he did not have any further issues. The Maintenance Supervisor reported if the hot water temperature measure above 110 degrees, it places the residents at risk for burns. <BR/>Record review of the facility's undated TELS Testing and Logging of Hot Water Temperatures documented The dial thermometer is accurate to 1 to 2 degrees F, however it is not precision instrument and should be calibrated on a regular basis As the temperature of the water is taken, hold hand under the running water at about the same time to assess how the water feels on your skin .Test the water at various locations throughout your facility .Ensure patient room temperatures (as specified by Texas requirements) are between 100-110 degrees Fahrenheit.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent potential complications of enteral feeding for 1 of 1 residents reviewed for enteral nutrition (Resident #44).<BR/>The facility failed to ensure Resident #44 was positioned in her bed at 30-45 degrees elevation per physicians' orders during feeding and for one (1) hour after administration of feeding.<BR/>This failure placed Resident #44 at risk for aspiration of enteral feeding which could lead to health decline, infection and hospitalization. <BR/>Findings include: <BR/>Record review of Resident #44's face sheet, dated 1/17/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses that include: Alzheimer's disease with early onset, dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or throat), and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). <BR/>Record review of Resident #44's physician order summary dated 1/17/2022, revealed order Elevate HOB (head of bed) 30 to 45 degrees at all times during feeding and for at least 1 hr. (hour) after administration of feeding every shift.<BR/>Record review of Resident #44's Quarterly MDS (minimum data sheet) dated 11/23/2021 revealed she required extensive assistance to move to and from lying position, turn side to side and position body while in bed with two-person physical assist.<BR/>Record review of Resident #44's Care Plan dated 1/28/2019 and reviewed on 12/06//2021 read The resident needs the HOB elevated 45 degrees during and thirty minutes after tube feed.<BR/>Record review of Resident #44's enteral tube feeding (allow liquid food to enter your stomach or intestine through a tube) administration record on the date of 1/17/2021 revealed resident had been administered her bolus enteral tube feeding (type of feeding where a syringe is used to send formula through your feeding tube) at 1:18 p.m.<BR/>Observation on 1/17/2022 at 1:36 p.m. of Resident #44 lying in bed without the head of bed elevated. CNA B had just exited Resident #44's room after providing patient care. <BR/>During an interview on 01/17/2022 at 1:46 p.m. CNA B confirmed that Resident #44's head of bed should have been elevated and picked up the remote control then elevated the head of Resident #44's bed. <BR/>During an interview on 01/18/2022 at 10:49 a.m. LVN A stated that Resident #44's enteral tube feedings were done at 7 in the morning and around 12:30 in the afternoons. LVN A further stated that the morning tube feeding had to be given by 8:00 a.m. and the second was ordered for 12:30 p.m. and that the tube feedings could be given an hour before or an hour after the ordered times. <BR/>During an interview on 01/18/2022 at 1:06 p.m. LVN A confirmed that Resident #44's 12:30 p.m. enteral tube feeding was given at 1:18 p.m. on 01/17/2022 according to the medication administration record available to the nurse showing the time on the EMR (electronic medical record) at the nurses station. <BR/>During an interview on 01/18/22 at 1:58 p.m. LVN A stated Resident #44's head of bed should have been elevated 30 to 45 degrees for 30 minutes to 1 hour after receiving enteral tube feeding. <BR/>During an interview on 01/18/2022 at 3:55 p.m. the ADON stated that the procedure after a tube (enteral) feeding was the head of bed should be elevated 30 to 45 degrees and that a resident should already be in that position due to tube feedings for all times. ADON further stated that Resident #44's order read that she should have been elevated for at least an hour after administration of feeding. ADON also stated that most of the time the CNAs should already know that the head of bed should be elevated 30 to 45 degrees and CNAs should already know that residents have received their tube feeding. ADON stated that the Task Care Plan should tell CNAs to make sure the head of the bed is elevated, and she then confirmed that Resident #44's Task Care Plan (under the CNA task care plan in the electronic medical record) did say that head of bed was to be elevated at all times. ADON continued to state that the evaluation was to prevent aspiration (when something enters your airway or lungs by accident). <BR/>During an interview on 01/19/2022 at 2:33 p.m. the DON stated that if residents are a bolus fed (a way of receiving a set amount of feed as required, without use of a feeding pump. This is given over a period of time, as advised by your healthcare professional, using an enteral feeding syringe) the resident's head of bed should be elevated and should remain that way. DON further stated that if CNAs provide care during care the CNA may need to lower head of bed but once completed care CNA should position bed back to elevations of 30 to 45 degrees and that by not having resident elevated it could put resident at risk for aspiration. <BR/>During an interview at 01/19/2022 at 2:55 p.m. administrator stated that the facility did not have a tube (enteral) feeding policy. <BR/>Record Review on 01/19/2022 at 3:01 p.m. of the Regency Integrated Health Services Policy and Procedure Nursing Services Manual revealed that there was not a tube feeding policy. <BR/>Review of a CDC article dated March 26, 2004 and titled Guidelines for preventing Health-Care-Associated Pneumonia stated, Prevention of Aspiration associated with enteral feeding: elevate at an angle of 30-45 degrees of the head of the bed of a patient at high risk for aspiration (A person who has an enteral tube in place.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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, in that: <BR/>1. A large pan of pot roast was not labeled or dated.<BR/>2. A large pan of baked pears was not labeled or dated.<BR/>3. A quart bag with prepared Sloppy [NAME] mix was not labeled or dated<BR/>These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.<BR/>Findings included:<BR/>Observation on 1/16/2022 at 9:38 a.m. in the kitchens walk-in refrigerator revealed:<BR/>1. A large pan of pot roast, covered with foil, was not labeled with name of product and did not have a date when made and when to discard.<BR/>2. A large pan, 1/3 filled with cooked pears, covered with foil, was not labeled with name of product and did not have a date when made and when to discard.<BR/>3. A quart bag, 1/2 filled with Sloppy [NAME] mix, was not labeled with name of product and did not have a date when made and when to discard.<BR/>Interview on 1/16/2022 at 9:40 a.m. with [NAME] H revealed the pot roast was made the day before, 1/15/2022. She reported pot roast had not been listed on the menu to be served that week and assumed the pot roast was made to serve as an alternative for meal service. [NAME] H revealed she was not sure when cooked pears had been on the menu to be served. [NAME] H also revealed the Sloppy [NAME] mix was likely the left-over mix from dinner the evening before. <BR/>Interview on 1/16/2022 at 10:05 a.m. with the Administrator revealed he had hired a new Dietary Supervisor who was expected to start work today had not showed up yet. <BR/>Interview on 1/19/2022 with Dietician G revealed food that was not labeled or dated could result in food being served that was spoiled and result in food-borne illnesses. She reported the Dietary Manager was responsible for training staff and assuring food was label and dated.<BR/>Review of the facility policy, Food Storage, revised 6/1/2019, under the heading, Refrigerators revealed, d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage and e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.<BR/>Record review of the TFER 2015, page 72, section &sect;228.75(g)(4)(B) revealed prepared food was to be marked with the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises or discarded.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, revealed (A) .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 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 2 of 5 residents (R#96 and R#95) reviewed for ADLs (activity of daily living).<BR/>R#'96's and R#95's medical records did not contain documentation of showers being given in January 2022.<BR/>This failure could result in the residents not receiving scheduled showers and could lead to a diminished quality of life, and infections associated with lack of showering.<BR/>The findings were:<BR/>R#96<BR/>Record review of R#1's face sheet, dated 01/12/22, and EMR (electronic medical record) revealed, the resident was admitted [DATE] with diagnoses that included: arthritis, fracture of right patella (knee cap), and constipation. Female age [AGE].<BR/>Record review of Physician's order, dated 11/09/21, revealed, skin evaluation weekly (nothing mentioned on showers).<BR/>Record review of R#96's MDS (minimum data set), admissions (11/16/21) revealed, BIMS (brief interview of mental status) score of 15 (cognitively intact). ADLs (activity of daily living) for bed mobility was extensive one staff, transfer extensive one staff, toileting and personal hygiene was extensive one staff, bathing was physical help one staff.<BR/>Record review of R#96's CP (care plan), undated, revealed, resident frequently refused showers and resident stated not receiving showers. Interventions included: nursing to document resident refusal of showers in the POC (point of care)/progress notes; and respect resident wishes. Document ADL performance. Shower schedule revealed the resident's shower days were Tuesday, Thursday, and Saturday.<BR/>Record review of R#96's skin assessment, dated 01/05/22, revealed, slight redness to buttocks, barrier cream applied.<BR/>Record review of R#96's skin assessment, dated 01/12/22, revealed, light redness in stomach folds. Improved redness to buttocks.<BR/>Record review of Nurse Notes for R #96, 01/01/22 to 01/12/22, revealed, no documentation of shower refusal or showers given.<BR/>Record review of R#96's POC, revealed, no entries from 01/01/22 to 01/12/22. <BR/>Observation and interview on 01/12/22 at 9:55 AM , R#96 revealed, resident was in room sitting on a recliner .wheelchair and walker present .There were no skin tears or bruises present. The resident did not reveal signs of neglect or abuse. R#96 stated, .I only had three showers in two months .it has been about a week and half since I had my shower .I complained to everybody constantly .I mentioned it to the Administrator .I do not know the shower days .they do not give me any excuse for not showering me .I have a rash based on history . <BR/>R#95<BR/>Record review of R#95's face sheet, dated 01/12/22, and EMR revealed, the resident was admitted on [DATE] with diagnoses that included: fracture left rib, lack of coordination, and weakness. Female age [AGE].<BR/>Record review of Physician's order, dated 11/30/21, revealed, skin evaluation weekly and provide showers Monday, Wednesday and Friday 2 PM-10 PM and as needed. <BR/>Record review of R#95's MDS, admissions (12/07/21) revealed, BIMS score of 07 (moderately impaired). ADLs for bed mobility was limited assistance one staff, transfer extensive one staff, toileting and personal hygiene was extensive one staff, bathing was physical help one staff.<BR/>Record review of R#95's CP, undated, revealed, ADLs: goals-will maintain ability at selfcare, anticipate needs; clean and dry free of odors. <BR/>Record review of R#95's skin assessment, dated, 01/11/22, revealed, skin intact.<BR/>Record review of R#95's skin assessment, dated 01/12/22, revealed, skin intact. <BR/>Record review of Nurse Notes for R #95, 01/01/22 to 01/12/22, revealed no documentation of shower refusals or showers given.<BR/>Record review of R#95's POC, revealed, no entries from 01/01/22 to 01/12/22. <BR/>Observation and interview on 01/12/22 at 10:10 AM , R#95 was in bed taking a nap and awaken for the surveyor. [NAME] present. There were no skin tears or bruises present. The residents did not reveal signs of neglect or abuse. R#2 stated, .I have not taken a shower in about a week .do not know shower days .might have a rash .I feel terrible not having a shower .I complained to the nursing staff .no excuse given .staff is busy so I do not feel angry . <BR/>During an interview on 01/12/22 at 11:02 AM, LVN K stated, .I am aware that residents ( R#96) and( R# 95) have missed showers .it might be a staffing issue .I am responsible that nurse aides shower residents we had problems getting the shower list updated .I became aware yesterday about residents (R#1 and R#2) missing showers .<BR/>During an interview on 01/12/22 at 11:15 AM, OTA (Occupational Therapy Assistant) C stated, .I have showered both (R#96 and R#95) .one day last week I showered (R#96) .we sadly have a staffing issue .on some days we do not have enough staff in Hall 200, nurse aides, to provide ADLs around showering but ADLs are met .the issue is showering .and time for documentation . <BR/>During an interview on 01/12/22 at 11:28 AM, DON stated, .we do not have shower sheets for (R#96 and R#95) .we have not documented on (R#1 and R#2) for the month of January 2022 .because of a staffing shortage .we need more Nurse Aides about 10; but, we are having difficulties hiring nurse aides .we have a contact service for one aide and one nurse .we have been advertising .and we continue to seek more applicants (R#96 and R#95) have been showered but, I cannot prove it .aides have not found time to document .our POC (point of care) documentation is at 11 % rather than 100% for January 2022 . <BR/>During an interview on 01/12/22 at 11:40 AM, Resident Aide D stated, .I provide showers to all residents and all Halls .we do our best to document .we are short on staff .but I do provide showers .I get lists daily when residents who are schedule to be showered .the list is a guide .and PRN (as needed) showers for residents with accidents are given .we scramble to do showers .there are no other issues with ADLs other than showers .and documentation .in the POC and clinical record . <BR/>During an interview on 01/12/22 at 11:54 AM, Administrator stated, .I started here as the Administrator on November 29, 2021 .there is staffing shortage for nurse aides .we are doing signed on bonuses .contracting with two staffing agencies .difficult to hire nurse aides .we are advertising .the shortage has affected ADLs around showers .not around care .the therapy department is helping with showering .Hospice provides showers as well .we lack oversight of nursing supervisors to ensure we have a system to document in the clinical record .they need to follow the POC .and document . <BR/>Record review of facility's, Shower/Tub Bath, policy dated October 20, 2010, read, .Documentation: The following information should be recorded on the resident's ADL record and/or in the resident's medical record:<BR/>2.The date and time the shower/tub bath was performed .<BR/>5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken .

Based on observations and interviews, the facility failed to post, in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility for 1 of 1 facility reviewed for resident rights.<BR/>The facility did not have the survey results available and accessible to residents and visitors without having to ask for them on 5/21/24, 5/22/24, and 5/23/24 during the survey period.<BR/>This failure resulted in residents, family members, and legal representatives of residents having a lack of knowledge of the facility's past inspections, violating resident rights.<BR/>The findings were:<BR/>In an observation on 05/21/24 at 9:09 a.m., there was no sign indicating where the survey results were located and no survey results were observed at the entrance, lobby area, or at the nursing station.<BR/>In an observation on 5/22/24 at 8:50 a.m., there was no sign indicating where the survey results were located and no survey results were observed at the entrance, lobby area, or at the nursing station.<BR/>In the resident council group meeting on 5/22/24 at 10:00 a.m. the residents stated they were not aware of being able to read previous survey results and denied knowledge of a sign indicating where the survey results were or a binder or book in the facility or an area where they could read the previous survey results. The residents stated they were not aware they could read the results and would like to be able to.<BR/>In an observation and interview on 5/23/24 at 1:15 p.m., the DON stated the results used to be in the lobby area and she was unsure of where the sign was regarding the survey results or where the survey results were located and would check with the Administrator. The Administrator was able to show surveyor an approximately 4-inch x 8-inch piece of paper behind a framed glass case hanging on the wall at the entrance that was typed and indicated the survey results were available for viewing behind the receptionist area and to please see a staff member for assistance. The Administrator stated the reason for them to ask a staff member for assistance to access and read the results was on several occasions pages were torn out and were missing so they were placed behind the receptionist area as a solution but were still available upon request.<BR/>In an observation on 5/23/24 at 6:00 p.m., the survey results were in a binder clearly marked on a conversation table between two chairs in the entrance/lobby area and readily accessible to anyone wishing to view them.<BR/>In an interview on 5/24/24 at 11:05 a.m., the Administrator stated he was unsure of when the survey results had been placed behind the receptionist area. The Administrator stated the consequences could be a knowledge deficit for people who wanted to view them.<BR/>On 5/24/24 at 2:16 p.m., the DON stated they did not have a policy on survey results being readily accessible.

Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 of 1 facility in that:<BR/>The one dumpster side door was open, a trash bag was on the ground near the dumpster and trash was scatted on the ground near the dumpster. <BR/>This could affect all residents and could result in pest in the facility.<BR/>The Findings were:<BR/>Observation on 3/19/2023 at 9:41 AM with [NAME] N revealed the one dumpster side door was open, a trash bag was on the ground near the dumpster and trash was scattered on the ground near the dumpster. <BR/>Interview on 3/19/2023 at 9:42 AM with [NAME] N confirmed the one dumpster side door was open, a trash bag was on the ground near the dumpster and trash was scattered on the ground near the dumpster. [NAME] N picked up trash, threw it in the dumpster and closed the side door. <BR/>Interview on 3/20/2023 at 11:27 PM with the dietary manager listened to the surveyor's concerns in kitchen and stated she will in-service staff. <BR/>Interview on 3/20/2023 at 5:25 PM with the Administrator stated will search for kitchen polices, but not sure they will have all of them. <BR/>Record review of Garbage Receptacles policy dated October 1, 2018, revised on June 1, 2019, revealed, the facility will maintain garbage receptacles in a clean and sanitary manner to minimize the risk if food hazards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide a safe, functional, sanitary, comfortable environment for 1 of 11 resident rooms (room [ROOM NUMBER]) observed on 500 Hall in that:<BR/>1. Resident room [ROOM NUMBER], occupied by Resident #46 and 41, hand a toilet tank cover missing from their toilet. <BR/>This deficient practice could place residents at-risk for injury and a decline in quality of life due to environment. <BR/>The findings were:<BR/>Review of Resident #46's face sheet dated 1/18/2022 revealed the resident was admitted to the facility on [DATE], resided in room [ROOM NUMBER], and had diagnoses that included dementia with behavioral disturbance, moderate intellectual disabilities, schizophrenia and anxiety disorder.<BR/>Review of Resident #46's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, moderately impaired cognitive status. Further review of the MDS revealed Resident #46 required limited assistance with toileting and ambulation.<BR/>Review of Resident #41 face sheet dated 1/18/2022 revealed the resident resided in room [ROOM NUMBER] and had diagnoses that included dementia without behavioral disturbance, hypertension (high blood pressure), heart disease and depressive disorder.<BR/>Review of Resident #41 Quarterly MDS dated [DATE] revealed he had a BIMS score of 11, moderately impaired decision making, and required limited assistance with toileting and ambulation.<BR/> Observation on 1/17/2022 at 3:08 p.m. in room [ROOM NUMBER] restroom revealed there was no tank cover on the commode tank.<BR/>Observation and interview on 1/17/2022 at 11:00 a.m. with the Administrator revealed the Maintenance Director was out sick and expected to return to work the following day. After the Administrator observed the toilet tank was missing a tank cover in room [ROOM NUMBER], he stated he was not aware the toilet in room [ROOM NUMBER] did not have a tank cover.<BR/>Interview with the Administrator revealed the facility did not have a policy that addressed missing or broken parts to residents' commodes.

Based on observation, interview, and record review the facility failed to ensure medication error rates are not 5 percent or greater during observation of two CMAs, one LVN, and one RN administering medication to one of five residents (#19). There were seven errors in 31 opportunities for errors, resulting in a 22 percent medication error rate.<BR/>Resident #19's 09:00 a.m. medications were not administered within one hour before or one hour after the scheduled time by CMA E. <BR/>This failure could affect residents who receive medication and could result in residents not receiving the highest possible therapeutic outcome for the medication regimen. <BR/>The finding were:<BR/>Record review of Resident #19's facesheet dated 03/22/2023 revealed an admission date of 10/21/2022 and diagnoses of Unspecified Dementia, Unspecified Severity, without behavioral disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), Gastroesophageal Reflux Disease without Esophagitis, Anemia, Pain in Left Lower Leg, and Essential Hypertension.<BR/>Record review of resident #19's Physician's order (11/6/2022) and MARs for March 2023 revealed the following medications:<BR/>Meloxicam 15 mg give one tablet by mouth one time a day (scheduled at 09:00 a.m.).<BR/>Ferrous Sulfate Tablet 325 mg give one tablet by mouth one time a day (scheduled at 09:00 a.m.).<BR/>Propanolol 60 mg give 60 mg by mouth one time a day (scheduled at 09:00 a.m.).<BR/>Senokot S oral tablet 8.6-50 mg give two tablets by mouth two times a day (scheduled at 09:00 a.m. and 21:00 p.m.).<BR/>Topiramide 25 mg give 25 mg by mouth one time a day (scheduled at 09:00 a.m.).<BR/>Vitamin C 500 mg one tab give one tablet by mouth two times a day (scheduled at 09:00 a.m. and 21:00 p.m.).<BR/>Record review of Resident #19's MDS (03/02/2023) revealed a BIMS score of 11 (moderately impaired). Further review revealed she was assessed for receiving antipsychotic and opioid medications.<BR/>During an observation on 03/19/2023 at 11:04 a.m., CMA E administered Resident #19's morning medications. Further observation revealed CMA E was pouring Resident #19's medications using the electronic MARS (03/2023). Review of Resident #19's electronic MARs at this time revealed the medications poured to be given were scheduled at 09:00 a.m. (two hours after the scheduled time).<BR/>During an interview with CMA E on 03/19/2023 at 11:04 a.m. CMA E stated, the medications were past due. During further interview CMA E revealed I didn't have time to give Resident #19's medication on time because they had to give 500 hall first then 400 hall. CMA E acknowledged the medications had to be given one hour before or one after the scheduled time. <BR/>During an interview on 03/22/2023 at 2:37 p.m., the DON stated if medications are given after the scheduled time, depending on the medication, it could have a negative effect on the residents.<BR/>Record review of the agency's policy and procedure titled Medication Administration (10/01/2019), read in part, 2. Administration: L. Medications are administered within 60 minutes of scheduled time, except before .routine medications are administered according to the established medication administration scheduled for the facility.

Based on observation, interview, and record review, the facility failed to ensure the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility, reviewed for registered nurse coverage.<BR/>RN 8 hour coverage was not available for 7 days in the time frame 11/01/21 to 01/16/22.<BR/>This deficient practice had the potential to affect all residents in the facility by leaving staff without supervisory coverage for coordination of events such as emergency care; and disasters such as severe weather conditions, COVID-19 outbreak, along with the potential for missed assessments, interventions, care; and treatment requiring the education, skills and judgement of an RN. <BR/>The findings included:<BR/>Record review of facility's RN hour time sheets from November 2021 to January 16, 2022 revealed no 8 hours of RN coverage on the following days:<BR/>11/27/21=0 hours<BR/>11/28/21=1 hour<BR/>12/12/21=7.90 hours <BR/>12/18/21=7.60 hours<BR/>01/08/22=0 hours<BR/>01/09/22=0 hours<BR/>01/15/22=7.32 hours <BR/>During an interview on 01/18/22 at 3:10 PM, HR Coordinator stated, .I confirm that the time sheets reveal no RN coverage up to 8 hours on 11/27/2021, 11/28/2021, 12/12/2021, 12/18/21, 12/26/21, 01/02/22, 01/08/22, 01/09/22, and 01/15/21 .I cannot give an explanation; but I am aware to the requirement of 8 hour RN coverage everyday . <BR/>During an interview on 01/18/22 at 3:17 PM , the Administrator stated, I would like to review the time cards and get back with you .but, I am aware of the regulation of 8 hour RN coverage per day . [Surveyor requested of the Administrator any policy on RN coverage.]<BR/>During an interview on 01/18/22 at 3:26 PM , the DON stated, I will check the time cards for accuracy and to make sure missing hours were recorded .I am aware of the regulation involving 8 RN coverage .it is a shared responsibility between the DON and Administrator to ensure the facility has RN coverage . <BR/>Record review of facility's policies did not reveal a policy on RN coverage 8 hours/7 days and weekly. [On the date and time of exit, 01/19/22 at 5 PM, the Administrator did not provide a policy on RN coverage.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure the MDS assessment must accurately reflect the resident's status for 1 (Resident #3) of 24 residents reviewed for assessments.<BR/>Resident #3 was ordered an RCS diet with pureed texture and fortified foods, and her annual MDS assessment with an ARD of 05/03/2024 did not reflect she was on a therapeutic diet.<BR/>This deficient practice affects residents with specialized care and could result in inaccurate or missed care.<BR/>The findings included: <BR/>Record review of Resident #3's electronic face sheet dated 05/22/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (a type of dementia that affects memory, thinking and behaviors), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine) and anxiety (a feeling of worry, nervousness and unease).<BR/>Record review of Resident #3's annual assessment with an ARD of 05/03/2024 reflected she scored a 03 out of 15 on her BIMS which signified her cognition was severely impaired. She was dependent on staff for ADLs, and she was prescribed a mechanically altered diet and not therapeutic.<BR/>Record review of Resident #3's comprehensive person-centered care plan revised on 04/05/2024 reflected on a reduced concentrated sweets diet, pureed texture, regular liquids.<BR/>Record review of Resident #3's Active Orders as of: 05/23/2024 reflected Diet, Reduced Concentrated Sweets Diet Pureed Texture, regular liquids consistency, start date, 08/27/2023.<BR/>Observation on 05/23/2024 at 08:15 a.m. of Resident #3 revealed she was lying in bed with her food tray on her bedside table. Her food was of a pureed texture.<BR/>Record review on 05/23/2024 at 08:15 a.m. of Resident #3's meal ticket, it read RCS, pureed, regular liquid diet.<BR/>During an interview on 05/24/2024 at 1:27 p.m. with the DON, she stated reduced concentrated sweets was a therapeutic diet and should have been indicated on Resident #3's annual MDS assessment. She stated the accuracy of the MDS assessment was important because it communicated the type of care a resident required. <BR/>During an interview on 05/24/2024 at 2:50 PM with the MDS nurse she stated Resident #3 was on an RCS diet which was therapeutic and she did not know how it was missed on her 05/23/2024 MDS assessment, but that the assessment was inaccurate. She stated accuracy of the MDS assessment was important for communication about care for a resident and the care could be missed or inaccurately provided. She stated she was accountable for the MDS accuracy.<BR/>During an interview on 05/24/2024 at 03:06 PM with CNA C revealed, she worked on Resident #3's hall and delivered her meal trays often. She stated Resident #3 was on an RCS, pureed diet with regular liquids.<BR/>Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 reflected The RAI process has multiple regulatory requirements . (1) the assessment accurately reflects the resident's status.

Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for individuals providing services under a contractual arrangement, consistent with their expected roles, that included but are not limited to the mandatory training topics of communication, resident rights, abuse and neglect, QAPI, infection control, compliance and ethics, and behavioral health for 3 of 3 contract employees (PT P, OT Q and ST R) reviewed for training, in that:<BR/>The facility failed to ensure required trainings were provided for PT P, OT Q and ST R working in the therapy department at the facility under a contractual agreement for the review period of March 2022 to March 2023.<BR/>This failure could place residents at risk of being cared for by staff who have been insufficiently trained. <BR/>The findings were:<BR/>Record review of personnel records for PT P revealed a hire date of 01/02/2015. Further review of a training log, from a web-based training platform used by the facility, from January 2022 to March 2023, and provided by the HR Manager revealed no evidence of communication, ethics, or behavioral health trainings.<BR/>Record review of personnel records for OT Q revealed a hire date of 01/02/2014. Further review of a training log, from a web-based training platform used by the facility, from January 2022 to March 2023, and provided by the HR Manager revealed no evidence of communication, resident rights, QAPI, ethics, or behavioral health trainings.<BR/>Record review of personnel records for ST R revealed a hire date of 07/22/2014. Further review of a training log, from a web-based training platform used by the facility, from January 2022 to March 2023, and provided by the HR Manager revealed no evidence of communication, QAPI, ethics, or behavioral health trainings.<BR/>In an interview with the HR Manager on 03/22/2023 at 9:48 a.m., the HR Manager revealed therapy staff have a different relationship with the facility. The HR Manager added that the therapy staff are contract however owned by the same corporate company as the facility. The HR Manager stated she had provided all training she had for therapy staff however would contact corporate office to asked if any additional training logs were available.<BR/>In a follow-up interview with the HR Manager and DON on 03/22/2023 at 3:14 p.m., the HR Manager revealed no other trainings were available for PT P, OT Q and ST R and confirmed the staff had not received all the required trainings. The HR Manager revealed when corporate added the Phase 3 mandatory training requirements for all facility staff, they didn't get added to the therapy staff's modules to complete.<BR/>Record review of the facility's policy titled, Training Requirements, dated 10/13/22, revealed, It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. 6. Training content includes, at a minimum: a. Effective communication for direct care staff, b. Resident rights and facility responsibilities for caring of residents, c. Elements and goals of the facility's QAPI program, e.facility's compliance and ethics program, f. Behavioral health.

Based on observation, interview, and record review the facility failed to ensure medication error rates are not 5 percent or greater during observation of two CMAs, one LVN, and one RN administering medication to one of five residents (#19). There were seven errors in 31 opportunities for errors, resulting in a 22 percent medication error rate.<BR/>Resident #19's 09:00 a.m. medications were not administered within one hour before or one hour after the scheduled time by CMA E. <BR/>This failure could affect residents who receive medication and could result in residents not receiving the highest possible therapeutic outcome for the medication regimen. <BR/>The finding were:<BR/>Record review of Resident #19's facesheet dated 03/22/2023 revealed an admission date of 10/21/2022 and diagnoses of Unspecified Dementia, Unspecified Severity, without behavioral disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), Gastroesophageal Reflux Disease without Esophagitis, Anemia, Pain in Left Lower Leg, and Essential Hypertension.<BR/>Record review of resident #19's Physician's order (11/6/2022) and MARs for March 2023 revealed the following medications:<BR/>Meloxicam 15 mg give one tablet by mouth one time a day (scheduled at 09:00 a.m.).<BR/>Ferrous Sulfate Tablet 325 mg give one tablet by mouth one time a day (scheduled at 09:00 a.m.).<BR/>Propanolol 60 mg give 60 mg by mouth one time a day (scheduled at 09:00 a.m.).<BR/>Senokot S oral tablet 8.6-50 mg give two tablets by mouth two times a day (scheduled at 09:00 a.m. and 21:00 p.m.).<BR/>Topiramide 25 mg give 25 mg by mouth one time a day (scheduled at 09:00 a.m.).<BR/>Vitamin C 500 mg one tab give one tablet by mouth two times a day (scheduled at 09:00 a.m. and 21:00 p.m.).<BR/>Record review of Resident #19's MDS (03/02/2023) revealed a BIMS score of 11 (moderately impaired). Further review revealed she was assessed for receiving antipsychotic and opioid medications.<BR/>During an observation on 03/19/2023 at 11:04 a.m., CMA E administered Resident #19's morning medications. Further observation revealed CMA E was pouring Resident #19's medications using the electronic MARS (03/2023). Review of Resident #19's electronic MARs at this time revealed the medications poured to be given were scheduled at 09:00 a.m. (two hours after the scheduled time).<BR/>During an interview with CMA E on 03/19/2023 at 11:04 a.m. CMA E stated, the medications were past due. During further interview CMA E revealed I didn't have time to give Resident #19's medication on time because they had to give 500 hall first then 400 hall. CMA E acknowledged the medications had to be given one hour before or one after the scheduled time. <BR/>During an interview on 03/22/2023 at 2:37 p.m., the DON stated if medications are given after the scheduled time, depending on the medication, it could have a negative effect on the residents.<BR/>Record review of the agency's policy and procedure titled Medication Administration (10/01/2019), read in part, 2. Administration: L. Medications are administered within 60 minutes of scheduled time, except before .routine medications are administered according to the established medication administration scheduled for the facility.