LONE STAR REHABILITATION & WELLNESS CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 5.88% based on 2 errors out of 34 opportunities, which involved 2 of 7 residents (Resident #24 & Resident #39) reviewed for medication errors.<BR/>1. The facility failed to ensure LVN B administered potassium chloride liquid diluted with 4-6 oz (ounces) of water prior to administration given for hypokalemia (low potassium) to Resident #24 according to physician orders. <BR/>2. The facility failed to ensure MA A administered the correct dose of Ferrous gluconate (iron) given for anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) to Resident #39 according to physician orders.<BR/>These failures could place residents at risk of inadequate therapeutic outcomes and GI distress.<BR/>Findings included: <BR/>Resident #24<BR/>Review of Resident #24's electronic face sheet dated 08/29/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: aphasia (difficulty swallowing), and gastrostomy status (tube that allows fluid, medication, and formula to be administered into stomach without having to swallow). No evidence that hypokalemia (low potassium) was a diagnosis.<BR/>Review of Resident #24's annual MDS assessment dated [DATE] revealed Resident #24 was rarely or never understood. Further investigation revealed Resident #24 had a feeding tube while a resident. <BR/>Review of Resident #24's comprehensive care plan last reviewed on 06/21/2024 revealed Resident had ADL self-care performance deficit related to impaired mobility. Goal: ADL needs will be anticipated and met by staff through next review. Interventions: Eating: The resident is NPO (nothing by mouth) and is totally dependent on licensed nurse for G-tube (gastric tube) feeding. Further review of care plan revealed Resident #24 had diagnosis of hypokalemia. Goal: The resident will be free from s/sx of complications of cardiac problems through the review date. Interventions: Give meds as ordered by the physician. Monitor and document side effects. Report adverse reactions to MD PRN. <BR/>Review of Resident #24's electronic Physician Orders revealed the following order dated 09/22/2021: Potassium Chloride Solution 20 mEq/15ml (10%) Give 15ml via G-tube three times a day for hypokalemia. Dilute with 4-6 oz of water prior to administration.<BR/>Review of Resident #24's electronic August 2024 MAR revealed Potassium Chloride Solution 20 MEQ/15ML (10%) Give 15ml via G-tube three times a day for Hypokalemia Dilute with 4-6 oz of water prior to administration. Start Date- 09/22/2021<BR/>During an observation on 08/28/2024 at 8:55 a.m., LVN B administered Potassium Chloride Solution 15ml through G-tube after flushing tube with 30cc water before and after administration. LVN B did not dilute Potassium Chloride in 4-6 oz of water prior to administration.<BR/>During an interview on 08/29/2024 at 9:24 a.m., LVN B stated she did not dilute Potassium with 4-6 oz of water prior to administering through G-tube. She stated she did not read the physician's order fully which led to the failure. She stated she did not know what negative effect not diluting medication could have on the resident without looking it up.<BR/>Resident #39<BR/>Record review of Resident #39's electronic face sheet dated 08/29/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues).<BR/>Record review of Resident #39's quarterly MDS assessment dated [DATE] revealed: BIMS score of 15 which indication cognition was intact.<BR/>Record review of Resident #39's comprehensive care plan last reviewed on 07/22/2024 revealed Resident had anemia. Goal: Will remain free of s/sx or complications related to anemia through review date. Interventions: Give medications as ordered.<BR/>Record review of Resident #39's Physician Orders revealed the following order dated 06/11/2024: Ferrous Gluconate Tablet 324 (38Fe) mg Give 1 tablet by mouth two times a day for anemia.<BR/>Review of Resident #39's electronic August 2024 MAR revealed Ferrous Gluconate Tablet 324 (38Fe) MG Give 1 tablet by mouth two times a day for anemia. Start Date- 04/11/2024<BR/>During an observation on 08/28/2024 at 7:50 a.m., MA A put Ferrous Gluconate 240 (27Fe) mg 1 tablet into medication cup. Resident #39 swallowed Ferrous Gluconate 240 (27Fe) mg tablet.<BR/>During an interview on 08/28/2024 at 7:55 a.m., MA A stated she had given 240mg Ferrous Gluconate to Resident #39. She did not state that medication was the wrong dosage.<BR/>During an interview on 08/29/2024 at 8:18 a.m., the DON stated she expected facility staff to follow physician's orders. She stated if OTC (over the counter) medication was not available with correct mg she expected for facility staff to notify herself or ADON so that physician could be notified, and order clarified. She stated that she had been told by MA A wrong dosage of Ferrous Gluconate had been administered to Resident #39 and she notified ordering physician. She stated Resident #39's order has since been updated with correct dosage of 240 mg. She stated the pharmacy monitors that orders are followed by nurses and MAs by performing medication passes with facility staff. She stated the pharmacy monitors that orders are correct in the medical record. She denied any negative effect occurred to Resident #39 from MA administering wrong dosage of medication.<BR/>During a follow up interview on 08/29/2024 at 1:06 p.m., the DON stated she was informed by LVN B of not diluting Potassium Chloride Solution was not diluted during medication pass to Resident #24 on 08/28/2024. She stated MD had been present at facility during lunch time on 08/29/2024 and he did not know why his order stated Potassium Chloride Solution should be diluted. She stated she had reached out the pharmacy and due to Potassium Chloride being administered via G-tube, was not told it had to be diluted. She stated no negative effect occurred to Resident #24 for medication not being diluted but stated that the physician's order should have been followed. She stated that staff should reach out to her or the ADON who would communicate with MD to get order clarified if there was a question on MD's orders.<BR/>Record review of the facility's policy titled Administering Medication revised in December 2012 revealed: Medication shall be administered in a safe and timely manner, and as prescribed .The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related function .Medication must be administered in accordance with the orders, including and required time frame .If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequence, the person preparing or administering the medication call contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns .The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.<BR/>Review of drugs.com accessed on 08/30/2024 at https://www.drugs.com/cdi/potassium-chloride-liquid-and-powder.html revealed: Use potassium chloride liquid and powder as ordered by your doctor. Read all information given to you. Follow all instructions Closely. Take with or right after a meal. Mix with water as you have been told before drinking.<BR/>Review of drugs.com accessed on 08/30/2024 at https://www.drugs.com/mtm/ferrous-gluconate.html revealed: Use this medication exactly as directed on the label, or as prescribed by your doctor. Do not use it in larger amounts or for longer than recommended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for 1 (Resident #1) of 3 residents reviewed for infection control practice.<BR/>CNA A and CNA B failed to perform hand hygiene and change their gloves while providing incontinence care for Resident #1.<BR/>These failures placed residents at risk for the spread of infection. <BR/>Findings included:<BR/>Review of Resident #1's face sheet, dated 01/29/25, revealed the resident was a 78- year- old female admitted to the facility on [DATE] with diagnoses diabetes mellitus and Alzheimer's disease.<BR/>Review of Resident #1's quarterly MDS assessment, dated 01/13/25, revealed she required dependent assistance with most activity of daily living (ADLs) and one-person assist. Resident #1 was always incontinent of bladder and bowel.<BR/>Review of Resident #1's care plan undated revealed the Resident #1 is at risk for skin breakdown due to decreased circulation in the lower extremities relate to peripheral vascular disease.<BR/>Observation of incontinent care for Resident #1 on 01/29/25 at 1:42 p.m. revealed CNA A and CNA B did not wash their hands before the start of care. Both CNAs donned gloves. CNA A and CNA B removed the resident's brief which was completely soiled with urine and fecal matter. CNA A wiped the resident from front to back. Her gloves were visibly soiled, but she continued to use it to clean the resident. CNA A did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #1's clean brief. She placed the clean brief on the resident and fastened it. Meanwhile, CNA B was assisting CNA A to provide care to Resident #1. CNA B wore the same gloves for repositioning including touching the perineal area and fastened the clean brief to the resident. CNA A and CNA B doffed their gloves. Both exited Resident #1's room without washing hands or performing hand hygiene.<BR/>In an interview on 01/29/25 at 1:55p.m with CNA A, she said she had been employed in the facility for 2 years but left and started again today. She could not remember the last time she received infection control training or in-services. CNA A stated cross contamination meant mixing clean with dirty. CNA A stated she should have washed hands and changed gloves before retrieving the clean brief and placing it on Resident #1. CNA A noted the Resident #1 could get sick for not following good infection control practice.<BR/>Interview with CNA B on 01/29/25 at 1:58p.m revealed she had been working for the facility for 3-4 months and received infection control training during orientation. CNA B said cross contamination could be caused by not washing hands or changing gloves. CNA B stated she should have changed her gloves and washed her hands before assisting, after repositioning, and before fastening Resident #1's clean brief.<BR/>During an interview with the DON on 11/29/22 at 3:59 p.m. she acknowledged she was aware of some of the concerns raised about infection control. She stated the staff were expected to wash hands before any care was provided and changed gloves at appropriate times. The DON stated the employee received infection control training annually and periodically as needed. She explained the facility monitored the employees by observing them give care to the residents. <BR/>Review of the facility policy on hand washing/hand hygiene revised August 2015 reflected the following:<BR/>Policy Statement:<BR/>This facility considers hand hygiene the primary means to prevent the spread of infections.<BR/>Policy Interpretation and Implementation<BR/>1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.<BR/>2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.<BR/>3. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and/or other written materials provided at the time of admission and/or posted throughout the facility.<BR/>4. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations:<BR/>a. When hands are visibly soiled; and<BR/>b. After contact with a resident with infectious diarrhea including, but not limited to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents receive meals at regular times comparable to normal mealtimes in the community, for 1 of 1 meal observed for meal service. The facility failed to ensure meals were consistently served at posted mealtimes (lunch meal on 09/02/2025). Posted meal times: Breakfast-Assisted dining room [ROOM NUMBER]:00 PM, Main Dining room [ROOM NUMBER]:05 PM, Hall Trays 12:40 PM This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, unplanned weight loss, and side effects from medication given without food, and diminished quality of life.Findings included: During an observation on 09/02/2025 at 7:30 AM of posted mealtimes in dining room: Lunch Delivery begins at 12:00 PM. The first cart of trays is delivered to the assisted dining room. Assisted Dining room [ROOM NUMBER]:00 PM, Main Dining room [ROOM NUMBER]:05 PM, Hall trays 12:40 PM. During an observation on 09/02/2025 at 12:00 PM the staff began checking the temperature of meal being served. The dietary staff had to keep checking the temperature of tuna salad and other salads being served at the lunch meal and having to place all of the salads back into the refrigerator to obtain safe serving temperatures. During an observation on 09/02/2025 at 12:50 the kitchen staff began plating lunch meal. The last hall try was served on Hall 3 at 2:14 PM. During an interview on 09/04/2025 at 9:26 AM the Dietician stated her expectations were that all meals be served on time per facility's posted times. The Dietician stated the residents could be affected by late meals, by not wanting to eat and being upset that meal was served late. The Dietician stated this failure may have occurred due to the difficulty to keep a cold meal cold and at safe temperatures. The Dietician stated the DM and cook are responsible for ensuring meals are served on time. The Dietician stated she had not been aware of any meals not being served in a timely manner. During an interview on 09/04/2027 at 9:57 AM DM contributed the meal service on Tuesday (9/02/2025) being served late due to the meal consisting of all cold entrees and salads. The DM stated it can be difficult to get salads, tuna fish to appropriate/safe temperature. The DM stated her expectations were that all meals be served on time. The DM stated meals being served late could cause the resident to not want to eat, and this could cause weight loss. The DM stated that the cook and herself are responsible to ensure meals are served on time. The DM stated this failure occurred due to difficulty in obtaining a safe temperature for all salads served for lunch meal. During a review of facility's grievance log on 09/04/2025 at 10:10 AM revealed a grievance on 07/25/2025 was filed due to lunch meal served at 1:00 PM and supper at 6:00 PM. Grievance filed on 06/16/2025 stated food is cold when served to residents. Grievance filed on 03/10/2025 stated meals are cold. During an interview on 09/04/2025 at 12:53 PM ADMN stated her expectations was that all meals be served at posted times. The ADMN stated meals not being served on time can affect quality of life. The ADMN stated it was the responsibility of the DM and cook to ensure meals were served on time. The ADMN stated the nurses and aides monitor for meals being served timely. The ADMN stated this failure occurred due to food temperatures not met for cold foods being served. The ADMN stated that department heads monitored meal service times randomly. Record review of facility's policy titled Frequency of Meals revised 10/2022At least three daily meals will be provided, at regular times comparable to normal mealtimes in the community. The time between a substantial evening and breakfast the following day will not exceed 14 hours, except when a nourishing snack is served at bedtime. The Dining Service Director coordinates with the residents, administrator and/or Director of Nursing Services to establish the meal and snack times that are comparable with the normal times in the community. A schedule of meal service times will be provided to the nursing staff and available in the resident/patient care areas. The Dining Services Director will ensure that each meal is served withing the designated time frame unless there is an emergency situation or a resident request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accommodate residents' needs, preferences and accommodation of needs, for 1 (Resident #6) of 19 residents reviewed for dignity. The facility failed to ensure Resident #6's call light was within reach while he was in bed on 09/02/2025 and 09/03/2025. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.Findings included: Review of Resident #6's face sheet dated 09/04/2025 revealed a [AGE] year-old male admitted on [DATE] with the following diagnosis: aphasia following cerebral infarction (difficulty speaking following a stroke), hemiplegia and hemiparesis following cerebral infarction affecting unspecified side (muscle weakness and inability to move muscles following stroke), and cerebral infarction (stroke). Review of Resident #6's quarterly MDS assessment dated [DATE] revealed: Resident #6 was rarely or never understood, and BIMS was not able to be performed. Section GG: Functional Abilities revealed Resident #6 had impaired range of motion to one side of upper extremities and had impaired range of motion on both sides of lower extremities. He was dependent on staff for bed mobility and helper did all the effort with bed to chair transfer. Section J: Health Conditions revealed Resident #6 had falls since admission with no injury. Review of Resident #6's most recent Care plan reviewed on 09/04/2025 revealed: Resident #6 has had an actual fall: 07/05/25 Fall, no injury 07/11/25 Fall, no injury Date Initiated: 07/07/2025 Revision on: 07/15/2025. During an observation on 09/02/2025 at 10:14 a.m., Resident #6 was lying in bed. He opened eyes to sounds but did not answer questions asked. He had a fall mat to the right of his bed. The call light was hanging on the wall behind and to the right of the head of his bed where the cable exits the wall. No staff were in his room. There were signs on two of the doors in Resident #6's room with message call, don't fall written on them. During an observation and interview on 09/03/2025 at 9:10 a.m., Resident #6 was lying in bed with a fall mat to the right of his bed. The call light was hanging on the wall behind and to the right of the head of his bed where the cable exits the wall. CNA A stated that the call light hanging on the wall was Resident #6's call light. She stated Resident #6 would not be able to reach the call light while it was hanging on the wall. She stated she did not know why the call light was not in Resident #6's reach. She stated she had been helping on another hall this morning and did not realize that the call light was hanging on Resident #6's wall. She stated not having call light in reach could cause Resident #6 to fall. During a telephone interview on 09/03/2025 at 2:26 p.m., Resident #6's representative stated Resident #6 was not able to get out of bed without help. During an interview on 09/03/2025 at 3:58 p.m., LVN B stated she was responsible for Resident #6. She stated Resident #6 could not exit his bed without assistance. She stated if Resident #6 was in bed and the call light was hanging on the wall where the cable exits the wall, Resident #6 would not be able to reach it. She stated all staff were responsible for making sure call lights were in the reach of the residents. She stated not having the call light in reach could interfere with residents being able to call for assistance. During an interview on 09/03/2025 at 4:07 p.m., the DON stated her expectation would be that call lights were in reach of residents when they were in bed. She stated that Resident #6 was not able to exit the bed to reach the call light if the call light was hanging on the cable where it exits the wall behind the head of his bed. She stated not having the call light in reach could interfere with residents calling for assistance. She stated the CNAs were responsible for call lights being in reach and the charge nurse was to monitor that call lights were in reach. During an interview on 09/04/2025 at 12:32 p.m., the ADMN stated it was her expectation that call lights were in reach of residents lying in bed. She stated Resident #6 could not get out of the bed safely to reach a call light if it was handing on the wall behind the head of his bed. She stated Resident #6 would not use his call light and would yell out if he needed assistance but even so, she expected for him to have access to his call light. The ADMN stated the CNAs were responsible for making sure call lights were in residents' reach. She stated the charge nurses were who monitored the CNAs were keeping call lights in reach. She stated the department heads rounded the halls daily during the week to monitor nursing staff. The ADMN added the department head that was assigned to the hall where Resident #6 resided was on vacation and could have led to failure of call light not being in reach. Review of facility document titled Strategies for Reducing the Risk of Falls revised on date December 2007 revealed: Transfer and Ambulation: Remind the resident and family to call as needed for assistance with transfer and ambulation.Room: call light within reach. Review of facility policy titled Answering the Call Light revised date March 2021 revealed: Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident. Ask the resident to return the demonstration.When a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 (cart #1) of 8 medication carts reviewed for medication storage in that:<BR/>The facility failed to ensure medication cart #1 was locked and secured while unattended.<BR/>This failure could result in a drug diversion.<BR/>Findings included:<BR/>During an observation on 08/27/2024 at 12:36 PM, revealed the 200-hall medication cart on 200 hall was unlocked with no staff present or within eyesight. There was also a visitor walking down the hall with unlocked medication cart. Nurse observed toward the end of the hall near the nurses' station checking meal tickets and assisting with passing out lunch trays. The medication cart had medications that included albuterol inhaler, Miralax (laxative), artificial tears, nitroglycerin (vessel dilation), lancets (needles to prick skin during glucometer checks), insulin pens and insulin pen needles, nasal sprays, docusate sodium (for constipation), Bisacodyl (laxative), acetaminophen (pain medication), lactulose (laxative), amiodarone (heart antiarrhythmic medication), Eliquis (anticoagulant), metoprolol (heart antiarrhythmic medication), potassium, Singulair (used to treat asthma), Depakote (anticonvulsant), melatonin, multivitamin, acidophilus (probiotic), Aspirin, cholestyramine (binds to bile to prevent reabsorption in the intestinal tract), and duloxetine (antidepressant). <BR/>During an interview on 08/27/2024 at 12:41 PM, RN C stated she was responsible for unlocked medication cart. She stated the cart should be locked when she was not present. She stated she should have locked the cart. RN C stated she had just given medication to room [ROOM NUMBER] then had to start passing hall lunch trays. She stated that leaving medication cart unlocked could allow resident to have access to medication inside of cart.<BR/>During an observation on 08/28/2024 at 07:11 AM revealed the 200-hall medication cart on 200 hall was unlocked with no staff present or within eyesight. LVN D was in resident's room with door closed. LVN D left out of the room with an insulin pen in her hand. The medication cart had medications that included albuterol inhaler, Miralax (laxative), artificial tears, nitroglycerin (vessel dilation), lancets (needles to prick skin during glucometer checks), insulin pens and insulin pen needles, nasal sprays, docusate sodium (for constipation), Bisacodyl (laxative), acetaminophen (pain medication), lactulose (laxative), amiodarone (heart antiarrhythmic medication), Eliquis (anticoagulant), metoprolol (heart antiarrhythmic medication), potassium, Singulair (used to treat asthma), Depakote (anticonvulsant), melatonin, multivitamin, acidophilus (probiotic), Aspirin, cholestyramine (binds to bile to prevent reabsorption in the intestinal tract), and duloxetine (antidepressant). <BR/>During an interview on 08/28/2024 at 07:13 AM, LVN D stated the medication cart should have been locked. She stated she was responsible for the medication cart and felt the failure occurred due to button on the medication cart needed to be pushed hard. She thought that she had locked the cart when she walked away.<BR/>During an interview on 08/29/2024 at 08:18 AM, the DON stated she expected for medication carts to be locked when not in use by nurse and nurse not within eyeshot of the cart. She stated nurses had been trained on locking medication carts and she did not know why medication cart had been unlocked. She stated nurse managers and pharmacist were responsible for monitoring that medication carts were stored locked. She stated not locking medication cart could lead to medication diversion. <BR/>Review of facility policy titled Storage of Medications dated April 2007 revealed: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/> Based on observation, interview, and record review the facility failed to follow menus for 1 of 1 lunch meal reviewed.<BR/>This facility failed to follow the menu when preparing lunch meal on 08/27/2024.<BR/>This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake.<BR/>The findings included:<BR/>Review of Resident #50's face sheet reflected a [AGE] year-old female who was admitted on [DATE] with diagnoses included Alzheimer's Disease, Hyperlipidemia (an excess of lipids or fats in your blood), Type II Diabetes Meletus.<BR/>During an observation on 08/27/2024 at 12:22 PM revealed Resident #50's pureed diet at the lunch mealtime did not have a dessert or mixed vegetables on her tray.<BR/>During an interview on 08/27/2024 at 4:36 PM, the Dietician stated she expected the facility to follow the recipes. The Dietician stated if an item was on the meal ticket, then it should be provided unless there was a substitution. The Dietician stated the substitution should have been documented before the meal. The Dietician stated if a resident was on a pureed diet, the resident should receive a desert. The dietician stated she and the Dietary Manager would monitor to ensure the menus were followed. The dietician stated since she was not in the building, she did not know why the menu was not followed. The dietician stated the facility had menus that the facility followed due to nutrition and resident's rights. The dietician stated not following the menu could cause residents to be missing proper nutrition if all items were not served. The dietician stated she believed the dietary manager and dietary staff in the kitchen would monitor that the kitchen was serving out meals in a timely manner. The dietician stated cold foods should be served cold, hot foods should be served hot and that French fries should not be served cold and hard. The dietician stated she did not know what effect it could have on residents as she was not in the building at the time. <BR/>During an interview on 08/27/2024 at 2:24 PM, the Dietary manager stated the marinated vegetables did not get made and that was why the resident did not receive them. The dietary manager stated she saw that the desert did not get pureed, and she tried to start making it, but could not get enough made because she kept getting called to other things in the kitchen. The dietary manager stated her expectations were that all the residents receive the food on the menu. The dietary manager stated she personally does the prep work and due to her boss being in the kitchen checking everything, it affected the dietary manager of not seeing that the marinated vegetables had not been prepared. The dietary manager stated the failure could affect the resident's and could cause weight loss.<BR/>During an interview on 08/29/2024 at 8:51 AM, the ADMN stated her expectations were that the menus be followed for all diet types. The ADMN stated mechanical soft diets and puree diets should have gotten a vegetable and a desert. The ADMN stated the failure occurred because the dietary aide missed it. The ADMN stated if the resident were not getting the full meal, it would cause a decreased intake, decreased nutritive value and a decreased calorie intake. The ADMN stated she and the nurses were responsible for ensuring the meal trays have the appropriated diet, and diet consistency. The ADMN stated the menus should be followed. The ADMN stated all but one resident ate meals from the kitchen.<BR/>Review of Week at a Glance menus reflected for lunch on 08/27/2024 was BBQ Cheeseburger on a bun, lettuce and tomato, pickle spear, Confetti Coleslaw, French Fries, Chocolate Chip Cookie. The alternate menu was Tuna Salad Sandwich, lettuce and tomato, broccoli salad, Garden Pasta salad.<BR/>During a review of facility's policy titled Meal Distribution (dated 0/2017) reflected: <BR/>Procedures:<BR/> All meals will be assembled in accordance with the individualized diet order, plan of care and preferences.<BR/>All food items will be transported promptly for appropriated temperature maintenance. <BR/>The nursing staff will be responsible for verifying meal accuracy and the timely delivery. <BR/>During a review of facility's titled Menus (dated revised 9/2017) reflected:<BR/>Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 3 (Resident #80, Resident #63, and Resident #46) of 12 residents reviewed for hospice services.<BR/>The facility failed to maintain required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness to ensure Resident #80, Resident #63, and Resident #46 received adequate end-of-life care.<BR/>The facility failed to have physicians' orders for Hospice Care for Resident #80, Resident #63, and Resident #46. <BR/>This failure could place the residents who receive 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 included: <BR/>Resident #80<BR/>Review of Resident #80's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: anxiety, depression, and dementia. Further review of electronic face sheet revealed resident was on hospice services. <BR/>Review of Resident #80's Quarterly MDS assessment dated [DATE] revealed: BIMS score of 08 which indicated mild cognitive impairment. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed Hospice Care. <BR/>Review of Resident #80's Care plan last reviewed on 06/10/2024 revealed: Focus: The resident has a terminal prognosis. Admit to Hospice Services on 03/19/24. Goal: Dignity and autonomy will be maintained at highest level. Interventions: Observe resident closely for signs of pain, administer pain medication as ordered, and notify physicians immediately if there is breakthrough pain. Work with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social need are met.<BR/>Review of Resident #80's electronic Physicians Orders revealed no evidence of an order for Hospice services. <BR/>Review of Resident #80's electronic record revealed no evidence of the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #80.<BR/>During an interview on 08/28/24 at 10:13 AM, LVN B stated she did not know if Resident #80 was on hospice services or not. She stated the only way to know was to look at the orders. LVN B stated Resident #80 did not have an order for hospice which as to her understanding meant he was not on hospice services. <BR/>Resident #63<BR/>Review of Resident #63's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: depression, anxiety, and dementia, and kidney disease. Further review of electronic face sheet revealed resident was on hospice services. <BR/>Review of Resident #63's Quarterly MDS assessment dated [DATE] revealed: BIMS score of 14 which indicated no cognitive impairment. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed Hospice Care. <BR/>Review of Resident #63's Care plan last reviewed on 06/06/2024 revealed: Focus: The resident has a terminal prognosis. Receiving Hospice Services. Goal: Comfort will be maintained. Interventions: Work with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social need are met.<BR/>Review of Resident #63's electronic Physicians Orders revealed no evidence of an order for Hospice services. <BR/>Review of Resident #63's electronic record revealed initial hospice care plan initiated 05/26/22 with no updates to date. <BR/>Resident #46<BR/>Review of Resident #46's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: depression, anxiety, and dementia. Further review of electronic face sheet revealed resident was on hospice services. <BR/>Review of Resident #46's Quarterly MDS assessment dated [DATE] revealed: BIMS score of 14 which indicated no cognitive impairment. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed Hospice Care. <BR/>Review of Resident #46's Care plan last reviewed on 08/19/2024 revealed: Focus: The resident has a terminal prognosis. Receiving Hospice Services. Goal: Comfort will be maintained. Interventions: Observe resident closely for signs of pain, administer pain medication as ordered, and notify physicians immediately if there is breakthrough pain. Work with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social need are met.<BR/>Review of Resident #46's electronic Physicians Orders revealed no evidence of an order for Hospice services. <BR/>Review of Resident #46's electronic record revealed no evidence of the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #46.<BR/>During an interview on 08/29/24 at 9:50 AM, RN E stated the only way she would know that a resident was on hospice services would be to look at the orders. <BR/>During an interview on 08/29/24 at 2:00 PM, the DON who stated all hospice residents should have an order in the computer and have a binder on cite. DON stated she was not sure what documents were required from hospice, but she could get them at any time. She stated residents did not have to have a binder and nothing in the binder affected the care of hospice residents. DON stated not having an order for hospice did not affect residents care because the nurse would still have contacted the primary doctor and treat the resident the same whether being on hospice services or not. The DON stated her staff needed more training on hospice services. She stated communication with hospice services was not needed because her staff would communicate with the physician if any extra care was needed. <BR/>During an interview on 08/29/2024 at 2:18 PM, the ADON who stated the Hospice records were in the Hospice notebook that was located at the nurse's station. ADON stated the required documents were not in the facility at this time after looking for the Hospice Notebook at the nurses' station without finding it, and that she called Hospice and was faxed the required documents. She stated the documents should have already been in the facility. <BR/>Record review of the facility's Hospice Services Nursing Home Hospice Agreement dated effective April 4, 2023, between the nursing facility and Hospice revealed: .Section III. Services Furnished by The Hospice. Subsection A. Hospice Plan, the hospice is responsible for the professional management of the hospice patient's hospice care. The hospice shall develop, at the time an eligible resident is admitted to the hospice program, a hospice plan for management and palliation of the resident's terminal illness. The hospice plan is in a written document which will be a detailed description of the scope and frequency of hospice services and supplies needed to meet the resident's needs. The hospice plan will specify services and supplies are related to the patient's terminal illness, and therefor, will be furnished by hospice. The hospice shall furnish a copy of the hospice plane to the home within 8 days of being accepted by the hospice into its hospice program. Such hospice plan will be furnished to the home in and will be updated every two weeks or more frequently as deemed necessary by the hospice, and a copy of the updated hospice plan will be furnished every two weeks to the home.<BR/>

Based on interview and record review, the facility failed to ensure resident group meetings were held as scheduled, the residents were made aware of upcoming meetings, and resident group concerns were promptly acted upon for reviewed resident group meeting minutes, in that:<BR/>1. The facility failed to ensure Resident Council Meetings that were scheduled during May 2023 and June 2023 were held as scheduled.<BR/>2. The facility failed to ensure there was documented evidence that residents' concerns, as noted in the Resident Council Minutes dated 4/18/23, regarding not knowing how to use the remote controls for the new televisions in their rooms had been addressed or resolved.<BR/>The facility's failure placed the residents at risk for violation of their right to meet as a group and voice concerns, which could result in decreased feelings of quality of life and well-being within their living environment.<BR/>The findings included:<BR/>Review of the Monthly Activity Calendars for April 2023, May 2023, and June 2023 revealed Resident Council meetings were scheduled for 4/04/23 at 1:00 PM, 5/09/23 at 1:00 PM, and 6/13/23 at 2:00 PM.<BR/>Review of the Resident Council Minutes, dated 4/18/23 at 2:30 PM, revealed documentation that 4 residents had attended. Old business from the previous month's meeting was reviewed, and new business was discussed. The new business documented concerns regarding new televisions in the residents' rooms. The residents could not see them and needed help learning how to use the new remote controls. The Activity Director documented the concern was reported to the appropriate department. There was no further documented follow-up to the concern regarding the new in-room televisions. The meeting was not held on the originally scheduled dated of 4/04/23.<BR/>Review of the Resident Council Minutes, dated 5/09/23 at 2:00 PM, documented no meeting, on floor.<BR/>There were no documented Resident Council Minutes for the meeting scheduled on 6/13/23 at 2:00 PM or for any other date during June 2023. <BR/>Review of the Monthly Grievance Logs and Grievance Report Forms revealed there were no documented grievances from the Resident Council during the past 6 months (December 2022 - June 2023 to date).<BR/>In an interview on 6/27/23 at 3:30 PM, the Activity Director stated if there were Resident Council concerns, she filled out a grievance form and gave it to the department that needed to address it. She stated she followed-up with the residents and asked them questions about the concern. She stated she reviewed old business at the next Resident Council Meeting and reviewed concerns and what was done to correct any problems, such as laundry issues. The Activity Director provided copies of last two Resident Council Meeting Minutes and last three months of activity calendars for review. <BR/>In an interview on 6/27/23 at 3:56 PM, the facility's Social Worker stated she kept a grievance log and would provide the grievance log for 2023 for review. <BR/>In an interview on 6/28/23 at 3:34 PM, the Activity Director stated a Resident Council meeting was not held during May 2023 because she worked the floor as a CNA. <BR/>In a confidential group interview on 6/28/23 on 3:42 PM, during a Resident Council Meeting, the 7 residents in attendance stated Resident Council meetings were not held regularly. One resident stated a meeting during May was not held because the Activity Director had to work the floor as a CNA. A resident stated the Activity Director wears many hats, drives the facility van, and does a lot of other things. The Resident Council President stated the meetings were not held routinely and the last meeting was held in April 2023. One resident stated the previous Activity Director held Resident Council Meetings regularly every month, but she had been gone for almost 2 years. The residents stated they did not attend Resident Council Meetings regularly because the meetings were not held regularly. Some of the residents stated they did not know about the Resident Council Meetings so had not ever attended. The residents stated they did not know they could meet as a group to discuss their concerns without the Activity Director or other staff present. <BR/>In an interview on 6/29/23 at 10:13 AM, the Administrator stated the grievance process started with the Social Worker, who did the tracking log, and initiated the investigation. The Administrator stated anyone could complete the grievance form and give it to the Social Worker. The Administrator stated grievances were discussed in the morning meetings and she assigned the person to address the concern or grievance. The Administrator stated she reviewed and signed the grievance form after verifying the concern has been addressed and resolved. She stated the facility grievance policy was included in the admission packet, as well as resident rights. The Administrator stated maybe she needed to have a meeting with the Resident Council regarding the Grievance Process. She provided a copy of the facility's policy and procedures for filing grievances for review. She stated a copy of the resident rights was included in the admission packet.<BR/>During an interview and record review on 6/29/23 at 10:35 AM, the Payroll Coordinator stated she had started employment in the facility during December 2022 and had not known the prior Activity Director. She reviewed the files for the Activity Department staff and stated she the current Activity Director was hired on 12/09/21 and was also listed as a CNA. She stated the prior Activity Director had given a 30-day notice and left voluntarily during the first part of December 2021. <BR/>In an interview on 6/29/23 at 10:47 AM , the Activity Director stated she had taken nurse aide training and passed the certification test last summer, about 1 year ago, so she could drive the facility van and be the transportation driver for resident appointments and activity outings. She stated she took residents to appointments, which were local and out of town. She stated sometimes she found out the morning of the appointment and other times she found out 1 or 2 days in advance. The Activity Director stated some appointments required her to be gone all day. The Activity Director stated she had been filling in as a CNA on the day shift during May and June. She stated she had not been able to have activities and Resident Council meetings as scheduled . The Activity Director stated there was not a Resident Council meeting held during May 2023 and there had not been a Resident Council Meeting for this month [June] so far.<BR/>In an interview on 6/29/23 at 5:03 PM , the facility's Social Worker and the Administrator stated the stated the Activity Director was good about telling them when the Resident Council had concerns or complaints. The Social Worker stated sometimes she filled out a grievance report form with Resident Council on it and other times she put the resident's name on it. The Administrator stated she did not think there were any grievance forms from the March 2023 and April 2023 Resident Council meetings. The Administrator stated she had not realized the Resident Council meetings were not being held as scheduled. She stated she spoke with the nursing staff and told them that they could not keep pulling the Activity Director from activities and have her work the floor. <BR/>Review of the facility's policy and procedure for Resident Council, not dated, revealed the following [in part]:<BR/>Policy Statement<BR/>The facility supports residents' desires to be involved and have input in the operation of the facility through the Resident Council.<BR/>Policy Interpretation and Implementation<BR/>1. The purpose of the Resident Council is to provide a forum for:<BR/>a. Residents too have input in the operation of the facility;<BR/>b. Discussion of concerns;<BR/>c. Consensus building and communication between residents and facility staff; and<BR/>d. Staff to disseminate information and feedback from interested residents .<BR/>2. Appointment to the council:<BR/>c. The facility will designate, with the approval of the council, and administrative representative. However, the facility representative will only remain in council meetings as requested by the council. Minutes must reflect such requests.<BR/>7. Council meetings are scheduled monthly or more frequently if requested by residents or the Administrator. The date, time, and location of the meetings are noted in the Activities calendar. A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible to address the item(s) of concern.<BR/>8. Minutes include names of the council members and guests present; issues discussed; recommendations from the council to the Administrator; and follow-up on prior issues.<BR/>9. The Administrator reviews the minutes and any responses from departments within the facility. Responses are presented at the next meeting, or sooner, if indicated

Based on interview and record review, the facility failed to make information on how to file a grievance or complaint available to the residents, including notifying residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed for reviewed for resident rights, in that:<BR/>1. The facility failed to ensure residents knew how to file a grievance, as expressed during the Resident Council group meeting held 6/28/23.<BR/>2. The facility failed to ensure residents knew who was responsible for addressing and investigating any complaints or concerns they may have regarding life in the facility.<BR/>The facility's failure placed the residents at risk for concerns not being reported and addressed, decreased quality of life, and a decreased feeling of well-being within their living environment.<BR/>The findings included:<BR/>Review of the Resident Council Minutes, dated 4/18/23 at 2:30 PM, revealed documentation that 4 residents had attended, old business from the last month's minutes was reviewed, and new business was discussed. The new business documented concerns regarding new televisions in the residents' rooms. The residents could not see them and needed help learning how to use the new remote controls. The Activity Director documented the concern was reported to the appropriate department. There was no further documented follow-up to the concern regarding the new in-room televisions. The meeting was not held on the originally scheduled dated of 4/04/23.<BR/>Review of the facility Grievance /Complaint Report form revealed sections to document the date, name of resident and/or representative, nature of the grievance/complaint, documented facility follow-up, and documented resolution of grievance/complaint.<BR/>Review of the Monthly Grievance Logs and Grievance Report Forms revealed there were no documented grievances from the Resident Council during the past 6 months (December 2022 - June 2023 to date).<BR/>In an interview on 6/27/23 at 3:30 PM , the Activity Director stated if there were Resident Council concerns, she filled out a grievance form and gave it to the department that needed to address it. She stated she followed-up with the residents and asked them questions about the concern. She stated she reviewed old business at the next Resident Council Meeting and reviewed concerns and what was done to correct any problems, such as laundry issues. <BR/>In an interview on 6/27/23 at 3:56 PM, the facility's Social Worker stated she kept a grievance log and would provide the grievance log for 2023 for review. <BR/>In a confidential group interview on 6/28/23 on 3:42 PM, during a Resident Council Meeting, the 7 residents in attendance stated they were not sure how to file a complaint or grievance. One resident stated she did not know how to fill out a grievance form and stated some of the residents could not write. The residents did not know who was in charge for addressing complaints. The stated they could tell concerns to the nurse working on their hall. <BR/>Observation of 6/29/23 at 10:04 AM revealed a table desk located in the front lobby against wall outside the door to the Business Office Manager's office. Grievance forms in a tray were located on the upper left hand side corner of the table.<BR/>In an interview on 6/29/23 at 10:13 AM, the Administrator stated the grievance process started with the Social Worker, who did the tracking log and initiated the investigation. The Administrator stated anyone could complete the grievance form and give it to the Social Worker. The Administrator stated grievances were discussed in the morning meetings and she assigned the person to address the concern or grievance. The Administrator stated she reviewed and signed the grievance form after verifying the concern has been addressed and resolved. She stated the facility's grievance policy was included in the admission packet, as well as resident rights. The Administrator stated maybe she needed to have a meeting with the Resident Council regarding the Grievance Process. She provided a copy of the facility's policy and procedure for filing grievances for review. <BR/>In an interview on 6/29/23 at 5:03 PM, the facility's Social Worker and the Administrator stated the stated the Activity Director was good about telling them when the Resident Council had concerns or complaints. The Social Worker stated sometimes she filled out a grievance report form with Resident Council on it and other times she put the resident's name on it. The Administrator stated she did not think there were any grievance forms from the March 2023 and April 2023 Resident Council meetings. <BR/>Review of the facility's policy and procedure for Grievances/Complaints, Filing, dated as revised April 2017, revealed the following [in part]:<BR/>Policy Statement<BR/>Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g. the State Ombudsman).<BR/>The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.<BR/>Policy Interpretation and Implementation<BR/>1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished.<BR/>2. Residents, family and resident representatives have the right to voice or file a grievance without discrimination or reprisal in any form, and without fear of discrimination or reprisal.<BR/>3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response.<BR/>4. Upon admission, residents are provided with written information on how to file a grievance or complaint .<BR/>6. The contact information for the individual(s) with whom a grievance may be filed is provided to the resident and/or representative upon admission .<BR/>8. Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint .<BR/>10. The Grievance Officer, Administrator and Staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated .<BR/>12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems .

Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for 4 of 16 employees (SW, ADMN, CNA C and CNA D) reviewed for employability.The facility failed to ensure record of criminal history check and/or an EMR/NAR check prior to hire were maintained for the SW.The facility failed to ensure record of annual EMR/NAR checks were maintained for the (SW, ADMN, CNA C and CNA D).These findings placed residents at risk of receiving care by someone that was unemployable.The findings included:Record review of the SW's employee file revealed a hire date of 03/28/2022 and no evidence of a criminal history or an EMR/NAR check were completed prior to hire. Further review revealed no evidence of annual EMR/NAR check was completed annually. Record review of the ADMN's employee file revealed a hire date of 02/07/2023 and no evidence of an annual EMR/NAR check completed annually. Record review of the CNA C's employee file revealed a hire date of 03/30/2023 and no evidence of an annual EMR/NAR check completed annually.Record review of the CNA D's employee file revealed a hire date of 11/11/2022 and no evidence of an annual EMR/NAR check completed annually.During an interview on 09/04/2025 at 1:10 PM Payroll E stated she had only been in the position since March 2025. Payroll E stated she was responsible for completing criminal history and EMR/NAR checks. Payroll E stated criminal history checks and EMR/NAR checks were supposed to be completed prior to hire and EMR/NAR checks were supposed to be completed annually. Payroll E stated she had been working since March 2025 and that when she started at the facility, she was told to upload employee files to electronic files. Payroll E stated she uploaded all the documents could find. During an interview on 09/04/2025 at 1:45 PM the ADMN stated her expectation was criminal history checks and EMR/NAR checks were supposed to be ran prior to hire and EMR/NAR check should have been ran annually at date of hire. The ADMN stated Payroll was responsible for ensuring Criminal/EMR NAR checks were to be completed prior to hire and EMR/NAR checks were to be ran annually upon anniversary date. The ADMN stated she was ultimately responsible to ensure checks were completed. The ADMN stated residents could have been affected by being exposed to staff who should not have been hired. The ADMN stated what led to failure was turnover in the payroll in position. The ADMN stated she felt they were completed but the facility had started having employee files uploaded electronically and documents may have been misplaced. Record review of facility policy titled, Personnel Records dated 2/17/2023 revealed: A separate confidential folder will be maintained in conjunction with the personnel contents of payroll record folder and will contain the following confidential information: .a. Criminal History Check (completed prior to hire) . d. Misconduct Registry and Nurse Aide Registry Checks (completed prior to hire and annually)

Based on observation interview and record review, the facility failed to ensure that the daily nurse staffing was posted as required for 2 of 3 days (06/27/23 and 06/28/23) reviewed for nursing services and postings.<BR/>The facility failed to update the daily staffing information posting.<BR/>This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census.<BR/>Findings included:<BR/>Observation with the DON on 06/27/23 at 03:49 PM, concerning staffing posting, revealed the DON showed where it was located. It was on a counter near the front entrance, and it was not prominently posted where everyone could see it. It only had the shift with a number identifying who (which type of staff) was working and did not identify the name of the facility. It did have the date and census. It did not identify the total number of hours worked. <BR/>Interview with the DON on 06/27/2023 at 03:49 PM, The DON said this is the format they have been using for 20 years and did not know of another way to do it. She provided copies of the same form the facility saved that dated back to 06/02/23.<BR/>Interview with the ADM on 06/27/23 at 04:10 PM, The ADM said staff postings should have the date, number of different types of staff, RN, LVN, CNA. She then read the Texas Health and Human Services required postings from her computer. The ADM said her posting did not have the name of the facility on it. And she also said it does not have the hours worked. <BR/>Interview with the ADM and DON on 06/28/23 at 02:31 PM, Interview with the Administrator and the DON about nurse staffing posting. The ADM said that the staff reviewed information that was required to be posted. The ADM said discussions about how the form should have the census for each shift and a column for scheduled hours and actual hours worked were done. The DON stated the facility did not have a policy about staff postings. <BR/>Observation 0n 0627/2023 at 2:55 PM revealed a new posting form for nurse staffing with all required information was presented to the survey team.<BR/>06/27/23 at 04:35 PM, record review of the form used by the facility to show nursing staff working each day revealed an 8.5 x 11 white sheet of paper with the following information on it;<BR/>o <BR/>Upper left corner, the day's date<BR/>o <BR/>Top center of the page, Census<BR/>o <BR/>Single column broken down into Day Shift 6A-6P and below that Night Shift 6P-6A <BR/>o <BR/>Under the 6A-6P heading it had RN:, LVN:, CMA:, and CNA: with total number of staff working that shift only.<BR/>o <BR/>Beneath Night Shift 6P-6a it had RN:, LVN;, CNA: with total number of staff working that shift only.<BR/>The form did not include the facility name, the total number and the actual hours worked for each category listed on form for those categories of both licensed and unlicensed nursing staff who had direct contact with residents<BR/>The facility provided copies of their nurse staffing information for the following dates: 06/02/23, 06/05/23, 06/06/23, 06/09/23, 06/12/23, 06/13/23, 06/14/23, 06/15/23, 06/16/23, 06/19/23, 06/20/23, and 06/23/23.<BR/>The facility did not provide a policy on nursing staff postings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident received food that was palatable, attractive and at a safe and appetizing temperature of 1 of 1 lunch meal in 1 of 1 kitchen tested for nutritive value, flavor, and appearance.<BR/>The facility failed to provide palatable food served at an appetizing temperature to residents, during lunch on 08/27/2024.<BR/>This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of meals served.<BR/>The findings included: <BR/>During an observation on 08/27/2024 at 2:24 PM, the DM obtained temperatures of test tray. The results were: [NAME] slaw vinegary to taste, flavor of burger good but cold; French Fries cold. The temperature of BBQ burger patty was 100.5 degrees Fahrenheit; temperature of [NAME] slaw 54.6 degrees; temperature of French Fries 94.1; and temperature of salad lettuce/tomato/onion 70.1 degrees.<BR/>During an interview on 08/27/2024 at 2:24 PM the DM stated the temperature of the BBQ burger patty should have been at least 165 degrees. The temperature of the [NAME] slaw should have been 41 degrees or lower. The temperature of the French Fries should have been 135 degrees or higher. The temperature of the salad: lettuce/tomato/onion should have been 41 degrees or lower. <BR/>During an interview on 08/27/2024 at 2:32 PM, the DM stated that everything was not reaching correct temperature due to having to use Styrofoam containers. The DM also stated having to wait for trays to be hand washed and waiting for trays to dry before sending out rest of meal prevented the meals to remain at palatable temperature. The DM stated the effect on residents was that they could have weight loss. <BR/>The temperature of the BBQ burger patty should have been at least 165 degrees. The temperature of the [NAME] slaw should have been 41 degrees or lower. The temperature of the French Fries should have been 135 degrees or higher. The temperature of the salad: lettuce/tomato/onion should have been 41 degrees or lower. <BR/>During an interview on 08/27/2024 at 4:36 PM, The dietician stated cold foods should be served cold and hot foods served hot. She stated the French Fires should not be served cold and hard. The dietician did not have an answer to why coleslaw taste like vinegar. <BR/>During an interview on 08/29/2024 at 2:26 PM, ADMN stated all but one resident eats meals from the kitchen. The ADMN stated his expectations were that all food be served to the residents at palatable temperature.<BR/>During a review of facility's policy titled Meal Distribution (dated 0/2017) reflected: <BR/>Procedures:<BR/>All food items will be transported promptly for appropriated temperature maintenance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident received food that was palatable, attractive and at a safe and appetizing temperature of 1 of 1 lunch meal in 1 of 1 kitchen tested for nutritive value, flavor, and appearance.<BR/>The facility failed to provide palatable food served at an appetizing temperature to residents, during lunch on 08/27/2024.<BR/>This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of meals served.<BR/>The findings included: <BR/>During an observation on 08/27/2024 at 2:24 PM, the DM obtained temperatures of test tray. The results were: [NAME] slaw vinegary to taste, flavor of burger good but cold; French Fries cold. The temperature of BBQ burger patty was 100.5 degrees Fahrenheit; temperature of [NAME] slaw 54.6 degrees; temperature of French Fries 94.1; and temperature of salad lettuce/tomato/onion 70.1 degrees.<BR/>During an interview on 08/27/2024 at 2:24 PM the DM stated the temperature of the BBQ burger patty should have been at least 165 degrees. The temperature of the [NAME] slaw should have been 41 degrees or lower. The temperature of the French Fries should have been 135 degrees or higher. The temperature of the salad: lettuce/tomato/onion should have been 41 degrees or lower. <BR/>During an interview on 08/27/2024 at 2:32 PM, the DM stated that everything was not reaching correct temperature due to having to use Styrofoam containers. The DM also stated having to wait for trays to be hand washed and waiting for trays to dry before sending out rest of meal prevented the meals to remain at palatable temperature. The DM stated the effect on residents was that they could have weight loss. <BR/>The temperature of the BBQ burger patty should have been at least 165 degrees. The temperature of the [NAME] slaw should have been 41 degrees or lower. The temperature of the French Fries should have been 135 degrees or higher. The temperature of the salad: lettuce/tomato/onion should have been 41 degrees or lower. <BR/>During an interview on 08/27/2024 at 4:36 PM, The dietician stated cold foods should be served cold and hot foods served hot. She stated the French Fires should not be served cold and hard. The dietician did not have an answer to why coleslaw taste like vinegar. <BR/>During an interview on 08/29/2024 at 2:26 PM, ADMN stated all but one resident eats meals from the kitchen. The ADMN stated his expectations were that all food be served to the residents at palatable temperature.<BR/>During a review of facility's policy titled Meal Distribution (dated 0/2017) reflected: <BR/>Procedures:<BR/>All food items will be transported promptly for appropriated temperature maintenance.