HARMONY CARE AT FLORESVILLE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 3 of 6 resident (Residents #64, #87 and, 92) reviewed for privacy, in that:<BR/>1. While providing wound care for Resident # 64, LVN E did not completely close the privacy curtain. <BR/>2. While providing colostomy care for Resident # 87, LVN D did not completely close the privacy curtain <BR/>3. While providing incontinent care for Resident # 92, CNA F and CNA G did not completely close the privacy curtain.<BR/>This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.<BR/>The findings include:<BR/>Record review of Resident #64's face sheet, dated 01/18/2023, revealed an admission date of 07/15/2022, and a readmission date of 10/14/2022, with diagnoses which included: Pressure ulcer of sacral region stage 4 (deep wound that may impact muscle, tendons, ligaments, and bone), Hypertension (high blood pressure), Hyperlipidemia (high level of fat in the blood), Congestive heart failure (heart doesn't pump blood as efficiently as it should).<BR/>Record review of Resident #64's 5 days MDS, dated [DATE], revealed the resident had a BIMS score of 5 indicating severe cognitive impairment. Resident #64 required extensive assistance to total care, had an indwelling catheter and was always incontinent of bowel. <BR/>Observation on 01/18/23 at 09:04 a.m. revealed during wound care the privacy curtain at the end of Resident #64's bed was left completely open by LVN E. Anybody opening the bedroom door would have had a full view of the resident. The wound being on Resident #64's buttocks, the resident's buttocks were fully exposed.<BR/>During an interview with LVN E on 01/18/2023 at 9:13 a.m., LVN E verbally confirmed the privacy curtain was not closed while she provided care for Resident #64 but it should have been to provide privacy and ensure dignity. <BR/>During an interview with the DON on 01/18/2023 at 10:30 a.m., the DON verbally confirmed privacy must be provided during nursing care and Resident #64's privacy curtains should have been closed completely. She confirmed the staff received training about Residents' rights and residents' privacy and they are doing return demonstration to ensure good retention of training<BR/>2. Record review of Resident #87's face sheet, dated 01/17/2023, revealed an admission date of 11/15/2022, and a readmission date of 12/06/2022, with diagnoses which included: Gastrostomy status (opening into the stomach from the abdomen made surgically for the introduction of food), Type 2 diabetes mellitus(high level of sugar in the blood), Dementia (progressive impairments in memory, thinking, and behavior), Parkinson's(long-term degenerative disorder of the central nervous system), Colostomy status(opening in the large intestine), Hypertension(high blood pressure)<BR/>Record review of Resident #87's 5 days MDS, dated [DATE], revealed the resident had a BIMS score of 3 indicating severe cognitive impairment. Resident #87 required extensive assistance to total care, had an indwelling catheter and a colostomy. <BR/>Observation on 01/17/23 at 01:50 p.m. revealed during colostomy care the privacy curtain at the end of Resident #87's bed was left completely open by LVN D. Anybody opening the bedroom door would have had a full view of the resident. <BR/>During an interview with LVN D on 01/17/2023 at 2:05 p.m., LVN D verbally confirmed the privacy curtain was not closed while she provided care for Resident #87 but it should have been to provide privacy and ensure dignity. <BR/>During an interview with the DON on 01/18/2023 at 10:30 a.m., the DON verbally confirmed privacy must be provided during nursing care and Resident #87's privacy curtains should have been closed completely. She confirmed the staff received training about Residents' rights and residents' privacy and they are doing return demonstration to insure good retention of training<BR/>3. Record review of Resident #92's face sheet, dated 01/17/2023, revealed an admission date of 08/23/2022, with diagnoses which included: Epileptic syndrome (seizure), Asthma (Chronic disease of the respiratory system), Down syndrome (A genetic disorder associated with physical growth delays, characteristic facial features and mild to moderate developmental and intellectual disability), Hyperlipidemia (Too much fat in the blood)<BR/>Record review of Resident #92's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating severe cognitive impairment. Resident #92 required extensive assistance, was occasionally incontinent of bladder and frequently incontinent of bowel. <BR/>Observation on 01/17/23 at 10:15 a.m. revealed during incontinent care the privacy curtain was too short to completely surround Resident #92's bed. The resident's roommate was in her bed and Resident #92's genitals were exposed during care. <BR/>During an interview with CNA F and CNA G on 01/17/2023 at 10:25 a.m., the CNAs verbally confirmed the privacy curtain was not completely closed while they provided care for Resident #92 but it should have been to provide privacy and ensure dignity. They confirmed the curtain was too short to completely close around the bed. <BR/>During an interview with the DON on 01/18/2023 at 10:30 a.m., the DON verbally confirmed privacy must be provided during nursing care and Resident #92's privacy curtains should have been closed completely. She confirmed the staff received training about Residents' rights and residents' privacy and they are doing return demonstration to insure good retention of training<BR/>Review of the facility's policy titled Residents Rights, undated, revealed, When providing resident care, always provide privacy [ .] pulling a curtain around the bed, pulling the drapes to windows, closing the door and draping the resident's body appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents hazards and supervision, in that:<BR/>On 01/10/2025 Resident #1 was transferred by CNA A using standing pivot transfer x 1 staff instead of a mechanical lift. During transfer Resident #1 was injured resulting in left tibia /fibula fracture.<BR/>The non-compliance was identified as past non-compliance. The IJ began on 1/10/25 and ended on 1/13/25. The facility had corrected the non-compliance before the survey began.<BR/>This failure could lead to injury or death to residents.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 01/30/2025, reveled an [AGE] year old female admitted to the facility on [DATE] with diagnoses that included right below the knee amputation (surgical procedure that removes the lower leg below the knee joint), Osteoporosis (a bone disease characterized by a disease in bone mineral density and bone mass, resulting in weak and brittle bones that are more prone to fractures), and Vitamin D deficiency (the state of having inadequate amounts of vitamin D in your body). <BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/23/2024, reflected a BIMS of 4 which suggested severe cognition impairment. Section G revealed Resident #1 required extensive assistance with 2 persons for transfers.<BR/>Record review of Resident #1's Care Plan, dated 05/2/2021 and revised on 06/02/2024, revealed Resident #1 required a mechanical lift X 2 staff assist for all transfers.<BR/>Record review of the Provider Investigation Report, dated 01/16/2025, related to the facilty's self-report of Resident #1's injury on 01/10/2025, revealed on 01/10/2025 at 2:00 PM, [CNA A] transferred [Resident #1] from the chair to the bed and heard a popping noise. [Resident #1] voiced her leg hurt. Further review revelaed Resident #1 was noted to have an abnormality to the left shin area., and the resident was transferred to the hospital for treatment. Record review of the Investigation Summary revealed, on 1-13-24 the facility found that [Resident #1's] hospital x-ray revealed an acute left mid tibial diaphyseal fracture with significant anteromedial displacement, acute left proximal and distal fibular diaphyseal minimally displaced olbique fractures, segmental. Extensive diffuse bone demineralization by x-ray/osteoporosis and degenerative changes. Records review confirmed that [Resident #1] is care planned for a [mechanical lift] transfer. Staff interivews revealed no issues with [Resident #1] prior to transfer from chair to bed. Interview with [CNA A] revealed that [CNA A] transferred [Resident #1] without the use of a [mechanical lift] and conducted a single person transfer. [CNA A] stated that she had used the [mechanical lift] previously when transferring [Resident #1] and was aware it was on her plan of care. Further review revealed CNA A's employment with the facility was terminated post-investigation.<BR/>Record review of CNA A's written statement, dated 1/10/25 at 3:00 PM, reflected, I transferred [Resident #1] from her wheelchair to her bed via pivot X 1 staff member, when resident told me her noted abnormality to left shin.<BR/>Record review of Incident Report, dated 01/10/2025 at 1:56 PM, revealed, This nurse was called into residents' room by Charge Nurse, left lower extremity assessed and [Resident #1] was able to state where pain was and 911 was called.<BR/>Record review of hospital records for Resident #1, dated 01/11/2025 at 12:01 PM, revealed Resident #1 had a surgical intervention requiring a left tibia intramedullary nail for shaft fracture and closed management with manipulation left fibula fracture.<BR/>During an Interview with the DON on 01/30/2025 at 10:10 AM, the DON stated CNA A should have transferred Resident #1 using 2 staff members with a mechanical lift as per Resident #1's Care Plan. The DON also stated that by CNA's not following the care plan injury to residents may occur.<BR/>An interview with CNA A was attempted on 01/30/2025 at 11:12 AM but was not successful. A voicemail was left for call a back. CNA A did not call back.<BR/>Record review of the facility's policy titled, Assistive Devises and Equipment, undated, revealed, Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the president's plan of care.<BR/>The Administrator was notified on 01/31/2025 at 12:30 PM, that a past non-compliance IJ situation had been identified due to the above failure and an IJ Template was provided to the Administrator. <BR/>The facility implemented the following interventions prior to the survey entrance on 01/28/2025. <BR/>During an interview with the DON on 1/28/25 at 3:20 PM, the DON stated the facility put a system into place for agency staff / PRN (as needed) to review forms prior to their shift to identify the care needs of each resident.<BR/>Record review of in-service training titled, Always Follow POC (Plan of Care), dated 01/10/2025 to 01/13/2025, revealed 50 of 50 staff members, 1 of 1 agency staff, and 10 of 10 PRN staff (as needed) completed the in-service training. Further revealed the in-service training addressed: CNA's look at [NAME], Hoyer's have to use if indicated 2 person, where to find POC (Plan of Care), competencies and demonstration of mechanical lift transfers. <BR/>Interviews with 12 staff members on 01/30/25 from 10:00 a.m. to 12:00 p.m. the following staff (MA B, LVN C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, LVN K, LVN L, LVN M) confirmed completion of in services/training: Always Follow POC (Plan of Care), CNA's look at [NAME], mechanical lifts have to use if indicated 2 people, where to find POC (Plan of Care. Staff were able to verbalize understanding and information provided in the in-service/training.<BR/>During an Interview with the DON on 1/30/25 at 10:20 AM, the DON confirmed CNA A was terminated from employment at the facility on 1/17/25. <BR/>Observation on 01/31/25 at 7:30 AM confirmed MA B and LVN C transferred Resident #3 using a two-staff mechanical lift transfer.<BR/>Observation on 1/31/25 at 8:30 AM confirmed MA B and LVN C transferred Resident #4 using a two-staff mechanical lift transfer. <BR/>The non-compliance was identified as past non-compliance. The IJ began on 1/10/25 and ended on 1/13/25. The facility had corrected the non-compliance before the survey began.

**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 2 of 20 residents (Resident #20 and #62) reviewed for advanced directives, in that:<BR/>1. Resident #20's DNR was not signed twice by the physician. <BR/>2. Resident #62's DNR was not signed twice by the physician.<BR/>These deficient practices could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.<BR/>The findings were:<BR/>1. Record review of Resident #20's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: fibromyalgia (long-term condition that involves widespread body pain and tiredness), hypothyroidism (condition in which thyroid gland does not produce enough thyroid hormone), and Covid-19. <BR/>Further review of Resident #20's facesheet revealed, Advance Directive: DNR.<BR/>Record review of Resident #20's annual MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. <BR/>Record review of Resident #20's care plan, updated [DATE], revealed, Advance Directive: DNR. <BR/>Record review of Resident #20's physician orders revealed an order dated [DATE], DNR.<BR/>Record review of Resident #20's OOH-DNR form revealed it had been signed twice by the resident and two witnesses, but only signed once by the physician. Further review revealed the physician's signature was missing from the bottom of the form which instructions read All persons who have signed above must sign below, acknowledging that this document has been properly completed.<BR/>2. Record review of Resident #62's face sheet, dated [DATE] revealed an admission date of [DATE] with re-admission on [DATE] and diagnoses which included: Chronic Obstructive Pulmonary Disease with acute Exacerbation (COPD) (a sudden worsening of respiratory symptoms in COPD which is a lung disease that blocks airflow and makes it difficult to breathe); Acute Respiratory Failure; Vascular Dementia (Problems with memory, reasoning, judgement and other though processes caused by brain damage from impaired blood flow to brain).<BR/>Record review of Resident #62's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating intact cognition.<BR/>Record review of Resident #62's Care Plan revised [DATE] revealed a focus area for code status of DNR, and included intervention to Make sure code status is signed by appropriate parties and in the medical record<BR/>Record review of Resident #62's Order Summary Report dated [DATE] revealed order for DNR - No CPR dated [DATE].<BR/>Record review of Resident #62's OOH-DNR revealed the resident signed the form on [DATE], the two witnesses signed the DNR form on [DATE], and the Physician signed the Physician statement on [DATE], but on the bottom of the form which reads All persons who have signed above must sign below, acknowledging that this document has been properly completed the Physician's signature is missing.<BR/>During an interview with the Social Work Designee on [DATE] at 12:27 p.m., the Social Work Designee confirmed Resident #20's DNR was not signed twice by the physician and confirmed Resident #62's DNR was not signed twice by the physician. The Social Work Designee further confirmed that the missing signatures invalidated the documents and could result in the residents' end of life wishes being dishonored. <BR/>Review of the facility policy, DNR, undated, revealed, While we are awaiting all the signature requirements for the OOH DNR . <BR/>Review of the Texas Department of State Health Services (DSHS) website at https://www.dshs.texas.gov/sites/default/files revealed Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to accurately reflect the resident's status for 2 (#27 and #90) of 8 residents reviewed for assessments in that:<BR/>1 Resident #27 was on continuous oxygen therapy and it was not reflected in her MDS assessment during the 7 day lookback.<BR/>2. Resident #90 had a LCS diet ordered and it was not reflected that she was on a therapeutic diet during the 7 day lookback.<BR/>This deficient practice could affect residents who receive assessments and could result in improper care.<BR/>The findings were:<BR/>1. Review of Resident #27's electronic face sheet dated 01/15/2023 revealed she was admitted to the facility on [DATE] with diagnoses of heart failure (a progressive heart disease that affects the pumping action of the heart muscles), myocardial infarction (damage to the heart muscle caused by a loss of blood supply due to blocks in the arteries), chronic obstructive pulmonary disease, (COPD) (persistent respiratory symptoms like progressive breathlessness and cough) atrial fibrillation (abnormal heart rhythm) and cardiac pacemaker (surgical insertion of a small device under the collarbone to control the electrical events of the heart).<BR/>Review of Resident #27's Annual MDS assessment with an ARD of 12/17/2022 revealed she scored a 15/15 on her BIMS which indicated she was cognitively intact. Resident #27 was not coded to be on oxygen therapy.<BR/>Review of Resident #27's comprehensive care plan with a revision date of 09/12/2022 revealed under Focus .has oxygen therapy r/t COPD .Interventions .Oxygen settings: The resident has O2 at 2L continuously.<BR/>Review of Resident #27's Active Orders As Of: 01/16/2023 revealed Continuous O2 at 2L per n/c to maintain O2 sat &gt;92% .with a start date of 09/29/2022.<BR/>Review of Resident #27's vital signs record for the dates of 12/10/2022 to 12/17/2022 revealed she had oxygen saturations taken at least two times a day with oxygen on via nasal cannula.<BR/>Review of Resident #27's MAR dated 12/01/2022 to 12/31/2022 reveaeled nurses initialed off that she had continuous O2 at 2L per n/c every day.<BR/>Observation on 01/15/2023 at 10:56 a.m. of Resident #27 revealed she was sitting in her room in her wheel chair and had oxygen infusing at 3L/NC.<BR/>Observation on 01/16/2023 at 09:55 a.m. of Resident #27 revealed she was sitting in her room in her wheel chair and had oxygen infusing at 3L/NC.<BR/>Interview on 01/15/2023 at 11:00 a.m. with Resident #27, she stated she was on oxygen continuously since she was admitted to the facility. She stated she did not adjust the oxygen, only the nurses did that.<BR/>Interview on 01/18/2023 at 12:40 p.m. with MDS Coordinator B revealed that the Annual MDS assessment with an ARD of 12/17/2022 for Resident #27 was inaccurate and should have had the oxygen coded. She stated I'm not sure what happened, I missed that one completely.<BR/>2. Review of Resident #90's electronic face sheet dated 04/19/2022 revealed she was admitted to the facility with diagnoses of diabetes mellitus (condition that results from insufficient production of insulin, causing high blood sugar), dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and anemia (deficiency of healthy red blood cells, causing fatigue and weakness).<BR/>Review of Resident #90's Quarterly MDS assessment with an ARD of 11/04/2022 revealed she was not a candidate for a BIMS which indicated she was severely cognitively impaired. Review of Section K-Swallowing/Nutritional Status .Nutritional Approaches revealed Resident #90 was on a mechanically altered diet but was not coded for a therapeutic diet.<BR/>Review of Resident #90's comprehensive care plan with a revision date of 05/09/2022 revealed Focus .has the potential for a nutritional problem r/t protein calorie malnutrition .diet: FMP, pureed diet with nectar thin liquids.<BR/>Review of Resident #90's Active Orders As Of: 01/16/2023 revealed Diet: FMP, Pureed, Nectar Consistency, LCS. active as of 04/30/2022. <BR/>Observation on 01/16/2023 at 12:00 p.m. of Resident #90 revealed she was in the dining room and was assisted with eating, her meal ticket read, FMP, Pureed, Nectar Consistency, LCS diet.<BR/>Interview on 01/18/2023 at 12:40 p.m. with MDS Coordinator A revealed that the Quarterly MDS assessment with an ARD of 11/04/2022 for Resident #90 was not accurate, and stated the therapeutic diet, should have been coded since Resident #90 has an LCS diet ordered. MDS Coordinator A further revealed the FSS would have entered the diet information however did confirm the MDS coordinators are responsible for ensuring the assessments for accuracy at each review.<BR/>Review of the facility policy and procedure titled Resident Assessment Instrument Process (undated) revealed The MDS Coordinator and Nursing Staff are key members of the interdisciplinary team in this facility. One of the functions in the RAI/MDS process is to gather data in order to develop comprehensive and individualized care plans that meet the medical, nursing, mental and psychosocial needs of each resident.<BR/>Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 revealed The RAI process has multiple regulatory requirements .(1) the assessment accurately reflects the resident's status .an accurate assessment requires collecting information from multiple sources.

Based on interviews and record reviews, the facility failed to complete the baseline care plan for 1 of 32 residents (Resident #153) reviewed for baseline care plans in that:<BR/>The facility failed to complete (Resident # 153's) baseline care plan within the required time frame.<BR/>This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care.<BR/>The findings were:<BR/>Record review of Resident #153's face sheet dated 02/15/24 with recent admission date of 2/2/24 and diagnoses which included: displaced fracture of the left femur (a left broken thighbone), type 2 diabetes (a condition in which the body has difficulty controlling blood sugar) and atherosclerotic heart disease (an illness in which the heart's arteries are damaged).<BR/>Record review of Resident #153's MDS, completed on 2/10/24, revealed a BIMS score of 10, which indicated moderate cognitive impairment. <BR/>Record review of Resident #153's Baseline Care Plan, shows a completion date of 2/7/24 with a locked finalization date of 2/13/24.<BR/>In an interview with MDS Coordinator B on 02/15/24 at 1:45 p.m., confirmed that the baseline care plan for Resident # 153 was not done within the required time frame of 48 hours after admission. <BR/>In an interview with the ADON on 2/15/24 AT 2:00 p.m., stated that the time frame for completion of the baseline care plan for Resident # 153 was not met. She stated that the baseline care plans were usually completed by the charge nurses. She stated that the completion of the baseline care plan would help staff to understand what is going on with the resident's condition.<BR/>In an interview with the DON on 2/15/24 at 2:20pm confirmed that the baseline care plan for Resident # 153 did not meet the necessary time frames for completion.<BR/>Review of the facility policy and procedure titled, Care Plans-Baseline, (undated), revealed, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 1 resident (#27) out of 2 residents reviewed for oxygen therapy in that:<BR/>Resident #27's oxygen setting was on 3L/min when she was prescribed 2L/min.<BR/>This deficient practice could affect residents who receive oxygen therapy and could result in respiratory distress.<BR/>The findings were:<BR/>Review of Resident #27's electronic face sheet dated 01/15/2023 revealed she was admitted to the facility on [DATE] with diagnoses of heart failure (a progressive heart disease that affects the pumping action of the heart muscles), myocardial infarction (damage to the heart muscle caused by a loss of blood supply due to blocks in the arteries), chronic obstructive pulmonary disease, (COPD) (persistent respiratory symptoms like progressive breathlessness and cough) atrial fibrillation (abnormal heart rhythm) and cardiac pacemaker (surgical insertion of a small device under the collarbone to control the electrical events of the heart).<BR/>Review of Resident #27's Annual MDS assessment with an ARD of 12/17/2022 revealed she scored a 15/15 on her BIMS which indicated she was cognitively intact. Resident #29 was not coded to be on oxygen therapy.<BR/>Review of Resident #27's comprehensive care plan with a revision date of 09/12/2022 revealed under Focus .has oxygen therapy r/t COPD .Interventions .Oxygen settings: The resident has O2 at 2L continuously.<BR/>Review of Resident #27's Active Orders As Of: 01/16/2023 revealed Continuous O2 at 2L per n/c to maintain O2 sat &gt;92% .with a start date of 09/29/2022.<BR/>Review of Resideent #27's MAR dated 01/01/2023 to 01/31/2023 reveaeled she had continuous O2 at 2L per n/c initialed off for each day to include 01/15/2023 and 01/16/2023.<BR/>Observation on 01/15/2023 at 10:56 a.m. of Resident #27 revealed she was sitting in her room in her wheel chair and had oxygen infusing at 3L/min via nasal cannula.<BR/>Observation on 01/16/2023 at 09:55 a.m. of Resident #27 revealed she was sitting in her room in her wheel chair and had oxygen infusing at 3L/min via nasal cannula.<BR/>Observation on 01/16/2023 at 1:00 p.m. of Resident #27 accompanied by LVN A revealed the resident's oxygen concentrator rate setting was 3L/min. LVN C stated the oxygen setting needed to be at 2L/min and that she had not checked it. LVN C stated the correct oxygen rate because too much or too little could cause respiratory distress. <BR/>Interview on 01/15/2023 at 11:00 a.m. with Resident #27, she stated she was on oxygen continuously since she was admitted to the facility. She stated that only the nurses adjusted the oxygen setting.<BR/>Interview on 01/18/2023 at 12:58 p.m. with the DON revealed that she knew about Resident #27's oxygen being set on 3L/min instead of 2L/min as ordered, and stated it is our responsibility to monitor that the rate is correct and we make rounds. She stated that a resident with COPD must have the right amount of O2 or could be harmed.<BR/>Review of the facility policy and procedure titled General Guidelines for Medication Administration dated 09-2018 revealed Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer .Medications are administered in accordance with written orders of the prescriber.

**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. Dietary Aide A was not properly wearing a hair restraint.<BR/>2. A food item in the dry storage area was not properly dated and labeled.<BR/>3. A kitchen drawer had a drawer cover and a drawer surface area that were not cleaned.<BR/>These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness from improper infection control, from a lack of food label date monitoring, and improper sanitation in the kitchen area.<BR/>The findings included:<BR/>Observation on 02/13/2024 from 9:50 a.m. to 11:00 a.m. during the kitchen tour revealed the following:<BR/>a. Dietary Aide A was working in the kitchen wearing a hair restraint that did not fully cover the back of her head with visible exposed hair.<BR/>b. There was a package of 24 blueberry muffins with a sealed plastic cover in the dry storage area that was not dated or labeled.<BR/>c. There was a kitchen drawer in the general kitchen service area which measured 16 x 5 inches that was missing a drawer cover.<BR/>d. There was a kitchen drawer in the general kitchen service area which measured 35 x 17 inches which was covered with dirt particles on the service of the drawer which contained two boxes of jelly packets.<BR/>During an interview with the Dietary Aide A, during the kitchen tour, on 02/13/24 from 9:50 a.m. to 11:00 a.m., Dietary Aide A stated she usually wore a hair [NAME] under her hair restraint to help keep her hair in place but she had forgotten to wear it.<BR/>During an interview with the Dietary Manager during the kitchen tour on 02/13/24 from 9:50 a.m. to 11:00 a.m., the Dietary Manager stated Dietary Aide A not wearing hair restraint properly could allow hair particles to fall on the food preparation area. The Dietrary Manager stated he was responsible for ensuring the food items in dry storage were dated and labeled. The Dietrary Manager further stated the blueberry muffins were being served the previous day and that dating and labeling the food item would prevent staff from using the product after the expiration date. The Dietrary Manager stated the kitchen drawer should have been repaired with a drawer cover for sanitation purposes and the kitchen drawer surface area should have been cleaned. The Dietrary Manager stated he could not advise when the drawer surface area was last cleaned.<BR/>During an interview with the Administrator on 2/15/24 at 9:05 a.m., the Administrator stated staff properly wearing their hair restraints in the kitchen prevents hair particles from falling onto the food, that dating and labeling food products prevents them from being served after their expiration date, and that general kitchen cleaning was necessary for kitchen sanitation.<BR/>Record review of the facility's policy titled, Employee Sanitation, dated 10/1/18, revealed, Hair nets or other effective hair restraints must be worn to keep hair from food and food-contact surfaces.<BR/>Record review of the facility's policy titled, Food Storage, dated 10/1/18, revealed, All containers must be labeled and dated.<BR/>Record review of the facility's policy titled, General Kitchen Sanitation, dated 10/1/18, revealed, Clean non-food-contact surfaces of equipment as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed. 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #3) reviewed for gastrostomy tube management., in that:<BR/>1. LVN A failed to check the placement of Resident #3's PEG tube prior to administering flushes and medications. <BR/>2. LVN A failed to check Resident #3's gastric residual volume prior to administering flushes and medications via Resident #3's PEG tube. <BR/>3. LVN A failed to follow Resident #3's order for flushes when administering flushes and medication via Resident #3's PEG tube. <BR/>4. LVN A failed to administer medications and flushes via Resident #3's PEG tube using gravity. <BR/>These failures could place residents with gastrostomy tubes at risk of aspiration, medical complications, and a decline in health due to inappropriate gastrostomy tube care and management. <BR/>The findings included:<BR/>Record review of Resident #3's Quarterly MDS assessment, dated 7/6/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: stroke (an area of the brain that dies due to lack of blood flow), hypertension (high blood pressure), neurogenic bladder (lack bladder control due to a brain, spinal cord, or nerve problem), type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy) , gastrostomy status (surgical opening into the stomach from the for the introduction of food). Further review of this MDS revealed Resident #3's cognitive skills for daily decision making was severely impaired and was dependent (helper does all the effort. Resident does none of the effort to complete the activity) when eating. <BR/>Record review of Resident #3's Care Plan dated, revised 12/5/23, revealed: [Resident #3] requires tube feeding r/t CVA effecting swallowing abilities/dysphagia .The resident is dependent on staff with tube feeding and water flushes .Check for tube placement and gastric contents/residual volume .<BR/>Record review of Resident #3's Physician Orders revealed the following orders: Baclofen oral tablet 5 mg, give 1 tablet via PEG tube three times a day for muscle spasms; dated 8/1/23; Gabapentin oral capsule 100 mg, give 2 capsules via PEG tube three times a day related to malaise, dated 2/1/24; Reglan oral tablet 5 mg, give 1 tablet via PEG tube five times a day for GERD (digestive disease in which stomach acid or bile irritates the food pipe lining), dated 8/1/23; Levothyroxine tablet 112 mcg, give 1 tablet via PEG tube every 24 hours for low thyroid hormone, dated 7/20/24; Tramadol tablet 50 mg, give 1 tablet via PEG tube two times a day for pain and 1 tablet every 4 hours as needed for pain, dated 4/3/24; Flush enteral tube with 30 mL water pre/post medication administration and 5-10 mL water between each medication, dated 2/15/24. <BR/>During an observation and interview during medication administration on 8/6/24 beginning at 3:31 p.m., LVN A prepared Resident #3's medication. LVN A sanitized her hands, donned gloves, and popped the following medication from the blister packs after verifying each with the eMAR: Baclofen 5 mg, Gabapentin 100 mg (2 capsules), Reglan 5 mg, Levothyroxine 112 mcg, and Tramadol 50 mg. LVN A crushed all the medications and opened the Gabapentin capsules, placing each medication into separate medication cups. LVN A obtained water from the bathroom sink and pushed 30 cc of water into Resident #3's PEG tube using syringe, mixed one of the medications with 20 cc of water, and pushed it into Resident #3's PEG tube, she mixed second medication with 25 cc of water, LVN A said he received 30 cc flush in between each medication, and pushed it into Resident #3's PEG tube, she then pushed 30 cc of water into the PEG tube, LVN A mixed a third medication with 20 cc of water and pushed it into Resident #3's PEG tube, she then pushed 30 cc of water, she mixed forth medication with 25 cc of water and pushed it into Resident #3's PEG tube, she then pushed 30 cc of water, she mixed fifth medication with 20 cc of water and pushed it into Resident #3's PEG tube. LVN A then flushed Resident #3's PEG tube with 200 cc of water by pushing 60 cc of water 3 times and then 20 cc. <BR/>During interview with LVN A on 8/6/24 at 4:21 p.m., LVN A stated she had not received training regarding PEG tubes at the facility because she had been a nurse for 9 years. LVN A further stated it was important to administer medications and water via PEG tubes using gravity because air could be pushed into the resident's stomach causing upset. LVN A stated she did not believe Resident #3 had an order to check residuals/placement, and further stated Resident #3 was not able to verbalize if his stomach was full or felt bloated. LVN A stated the facility currently did not have a DON.<BR/>During interview with LVN B on 8/7/24 at 2:59 p.m., LVN B stated medications and water flushes were administered using gravity and nurses were required to check PEG tubes for placement and residual volume, adding she guessed it was policy. LVN B further stated it was facility policy to check PEG tube placement prior to administering anything via a PEG tube. LVN B stated checking for placement was important because if the tube was not in the proper place the resident may be harmed and it was important to check for residual volume to ensure the residents were digesting properly. LVN B stated the facility currently did not have a DON.<BR/>Record review of facility's policy titled Administering Medications through an Enteral Tube, undated, revealed: .2. Review the resident's care plan to assess for any special needs of the resident .Steps in the Procedure .13. Assess the resident, as indicated .19. Check gastric residual volume (GRV) to assess for tolerance of enteral feeding. 20. When correct tube placement and acceptable GRV have been verified, flush tubing with 15-30 mL warm sterile water (or prescribed amount) .22. Dilute the crushed or split medication with 15-30 mL of water or per physician orders. 23. Reattach [NAME] (without plunger) to the end of the tubing. 24. Administer medication by gravity flow. a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. b. Open the clamp and deliver medication slowly .25. If administering more than one medication, flush with 15 mL (or prescribed amount) warm water between medications. 26. When the last of the medication begins to drain from the tubing, flush the tubing with 15 mL of warm water (or prescribed amount) .<BR/>Roecord review of webite Nursing 2024, article titled Administering medication through a gastrostomy tube, dated December 2022, revealed: .Release the GT clamp. To verify tube placement and patency, aspirate for gastric contents, note the residual volume, and follow your facility's policy for reinstilling it . let the water flow by gravity to flush it .Pour the diluted medication into the syringe and release the tubing to administer it. If you're giving more than one drug, flush between each dose with 15 to 30 ml of water. When finished, flush with 30 ml of water, clamp the GT, and replace the plug .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported 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, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #s 1 and 2) of 5 residents reviewed for abuse, neglect, and misappropriation of property, in that;<BR/>1. The facility failed to report Resident #1's 5/7/2024 elopement to HHSC.<BR/>2. The facility failed to report Resident #2's 5/2/2024 elopement to HHSC.<BR/>This failure could place residents at risk for not having incidents reported as required and continued neglect which could result in diminished quality of life.<BR/>The findings were:<BR/>1. Record review of Resident #1's face sheet revealed she was admitted on [DATE] and was [AGE] years old. Resident #1's diagnoses included: tachycardia (When you have tachycardia, your heart beats too fast -- more than 100 beats per minute when you're at rest), and dementia.<BR/>Record review of Resident #1's MDS (Entry 5/7/2024) revealed no BIMs score. <BR/>Record review of Resident #1's electronic chart, under Assessments, revealed a document titled, Elopement Risk - Change of Status, dated 5/7/2024. Further review revealed Resident #1 was at risk for elopement with a score of 12 (High Risk), specifically that she, Verbalizes desire or plan to leave the facility unauthorized/unsupervised (10 pts.), and, Ambulatory (2 pts.)<BR/>Record review of Resident #1's Progress Note, dated 5/7/2024 at 7:19 PM, stated,**Nurses Note** <BR/>Note Text: Notified RP and Physician of (Resident #1's) elopement. RP was thankful resident is ok and moving to memory care. Resident and belongings moved to memory care per (ADON K).[sic]<BR/>Record review of the facility's Incident's and Accidents report, printed 5/9/2024, revealed no documented incidents related to Resident #1, specific to elopement. <BR/>Interview on 5/10/2024 at 1:38 PM, the Administrator confirmed Resident #1 eloped from the facility on 5/7/2024 and opioned the elopement could have occurred while the front door was left unattended during resident smoking time. The Administrator indicated the person at the front desk was responsible for escorting residents to and from the smoking area during their smoke breaks which could at times leave the entrance unstaffed. The Administrator said facility staff would be instructed to ensure someone would remain at the entrance at all times until the doors locked in the evening in response to Resident #1's elopement. <BR/>Interview on 5/10/2024 at 3:50 PM, CMA B said it was around 6:00 pm on 5/7/2024 when staff discovered Resident #1 was missing. CMA B said LVN K got a phone call and then started pacing around looking out the windows. CMA B said she saw Resident #1 walking through the grass in someone's yard approximately 4 blocks away from the facility near a busy street where 18 wheelers travel at a high rate of speed. CMA B said Resident #1 recognized her and got in the car with her to go back to the facility. CMA B Resident #1 was sweating and looked tired and said she didn't know where she was, that she was lost. Upon returning to the facility, CMA B got the Resident #1 a glass of water. CMA B said a high school-aged family member of one of the dietary staff the reported she saw Resident #1 depart the facility from the front door after she noticed the resident being returned to the facility. When asked if anyone was monitoring the front door at the time of Resident #1's disappearance, CMA B said the front door monitor would take the residents to a different location during their designated smoke break and said that it's always a big hassle. CMA B said it was warm that day and that her .car's temperature gauge showed the temperature was 91 F after her shift ended that day. When asked how staff would be informed of the identity of new residents, CMA B said she was unsure and that some residents are admitted at random times, and stated that it was difficult to identify newly admitted residents. <BR/>2. Record review of Resident #2's facesheet (printed 5/8/2024) revealed she was admitted [DATE] and discharged [DATE] and was [AGE] years of age. Resident #2's diagnoses included: senile degeneration of the brain (also known as Senile dementia is the mental deterioration (loss of intellectual ability), Alzheimer's disease, copd, depression, insomnia, hypertension, gastro-esoph reflux, and an over-active bladder. <BR/>Record review of Resident #2's electronic chart, MDS (entry), dated 4/29/2024) revealed no BIMs Score. <BR/>Record review of Resident #2's progress note on date, 5/3/2024 at 10:00 AM, stated, Late Entry: Note Text: Received call from (biological family member) of (Resident #2) requesting to speak to and come visit resident at facility. This nurse placed call to RP, spouse, whom gave verbal permission for son to speak to and visit resident inside facility.[sic]<BR/>Record review of Resident #2's progress note dated, 5/3/2024 at 5:41 PM, stated, Late Entry: Note Text: Notified by staff that they were unable to locate (Resident #2) after dinner. This nurse along with other ADON and staff attempted to locate (Resident #2). Per charge nurse, (Resident #2's biological family member) was in the facility and given permission by RP to visit with (Resident #2) inside facility. Called RP and informed resident was not able to be located. Called number for (Resident #2's biological family member) given by RP. Was informed it was the wrong number. Police notified and in facility. CNA stated she witnessed son in the facility with a bag of (Resident #2's) belongings. All belongings gone from room. Notified by another staff member that she witnessed (Resident #2) walking down the hall hand in hand with (Resident #2's biological family member). All this information given to RP and police officer in facility. Administrator, PCP, and RP updated on current situation. Late Entry:<BR/>Note Text: (Resident #2) was reported possibly missing at 1715 to this nurse by CNA as she was attempting to serve her dinner. This nurse notified ADON immediately and began checking every room in the north wing. This nurse checked residents closet and clothes were gone.<BR/>Record review of Resident #2's progress note dated 5/3/2024 at 8:42 PM stated, Note Text: Reported to (RN L) regarding incident with (Resident #2). (RN M) Executive Director called to confirm and asked that this facility f/u with any new information.<BR/>Record review of Resident #2's progress note dated 5/4/2024 at 2:34 PM, stated: Late Entry:<BR/>Note Text: At approximately 1:45 PM on 5/4/24 I received a call from (Off N) in regard to (Resident #2). Case # 2400898/ [PHONE NUMBER](phone #). He stated that (Resident #2) is safe and is with (Resident #2's biological family member). (Resident #2) has been checked out by the local EMS personnel and is in good health and spirits. He also stated all missing person's bulletins have been cancelled. There will not be any kidnapping charges filed nor any other charges since she is with (Resident #2's biological family member). Number to Hospice provided per his request. (Off N) stated (Resident #2's biological family member) has already obtained all her medications as well.<BR/>Record review of a document, titled, Medical Power of Attorney Designation of Healthcare Agent, signed by Resident #2 on 11/15/2023, revealed the Resident #2's (biological family member) was designated as First Alternate Agent.<BR/>Record review of the facility's Incident's and Accidents report, printed 5/3/2024, revealed no documented incidents related to Resident #2, specific to elopement. <BR/>Interview on 5/13/2024 at 2:48 PM, the Administrator stated Resident (Resident #2) was removed from the facility by biological family member 5/3/2024, and was subsequently taken to his home. The Administrator indicated there was an ongoing family dynamic between the biological family of Resident #2 and the non-related children of her husband. The Administrator stated the police were called by the facility when they discovered Resident #2 was missing. The Administrator stated Resident #2 was no longer residing at the facility and her RP was issued a reimbursement. <BR/>Interview on 5/13/2024 at 3:40 PM, Witness, LVN C said she was at the facility at the time Resident #2 left the facility. LVN C said she was asked by staff if she had seen Resident #2 pass her as Resident #2 was unable to be located. LVN C said she spoke to the a police officer near (Resident #2's biological family member's home) the following day and said Resident #2 had been assessed by EMS and had no injuries, was not in distress, and was with (Resident #2's biological family member) and was safe. LVN C said police informed her the case was cancelled and asked for the Resident #2's hospice information and spoke to her hospice agency. LVN C said on the day of the incident, (Resident #2's biological family member) was visiting. LVN C said Resident #2's dementia was getting progressively worse which was why she was admitted to the facility. When asked why the (Resident #2's biological family member) wasn't on the resident's face sheet as a contact she said it was likely because her (non-biological family members) were involved with placing Resident #2 at the facility. <BR/>Interview on 5/13/2024 at 3:55 PM, ADON E, stated the facility was contacted by a nurse (name unknown) who said Resident #2 was not in her room and her room was empty. ADON E said staff made all necessary notifications and said one of the staff said they saw Resident #2 walking down the hall, holding hands. ADON E further stated another staff, CNA G, was said to have seen the (Resident #2's biological family member) walking out of the facility with a large bag. <BR/>Telephone interview on 5/13/2024 at 4:02 PM, Resident #2 Emergency Contact said Resident #2 was taken illegally, and was said to still be residing with (Resident #2's biological family member)<BR/>Interview on 5/13/2024 at 4:11 PM, CNA G said she saw (Resident #2's biological family member) come into the facility and was visiting the Resident #2. CNA G said she left Resident #2's room to allow them privacy during their visit and said she later saw (Resident #2's biological family member) leaving the facility with a big blue bag but said she did not think anything of it because residents' families would frequently take their clothing home to wash it. The CNA G said Resident #2 was pretty new at the time and said some staff may not have been aware of her identity. <BR/>Telephone interview on 5/14/2024 at 9:44 AM, (Resident #2's biological family member) confirmed Resident #2 was with him and said she was currently at the hospital because she had blood on her brain, and that doctors are trying to dissolve it. When asked why he took Resident #2 from the nursing home (Resident #2's biological family member) responded, because she didn't want to be there. (Resident #2's biological family member) further stated that Resident #2's RP, .put her in the facility without her (biological family's) consent, and that Resident #2's RP, . took all of her belongings and sold them or gave them away. <BR/>Interview on 5/14/2024 at 10:47 AM, the Administrator confirmed Resident #2 was not signed out of the facility prior to her leaving the facility's property and was unaccounted for during a period of time. <BR/>Telephone interview on 5/14/2024 at 11:35 AM, Resident #2's Responsible Party revealed he had not talked to Resident #2 since she left the facility with (Resident #2's biological family member) The RP said Resident #2's biological family, .are crazy sons' of bitches. The RP further stated Resident #2 had Alzheimer's disease, that she had, good days and bad days, that they had been married over 40 years and, .she is the love of my life. The RP stated Resident #2's hospice agency had filed a report with Adult Protective Services. <BR/>Interview on 5/14/2024 at 4:30 PM, the facility's Social Worker stated the facility had a protocol for residents leaving the facility which included checking with the charge nurse, documenting the time and who the resident is leaving with, and ensuring authorization with the resident's responsible party. <BR/>Interview on 5/14/2024 at 4:32 PM, Health Screener (HS) J stated she was monitoring the facility's front door during the time and date of Resident #2's elopement. HS J said her job was to greet and screen individuals entering and exiting the facility. HS J said that during the time of Resident #2's elopement, she was monitoring residents in a different location, the smoking area, and returning them to their rooms afterward. HS J said the front entrance was not being monitored during this time but said there had been recent changes requiring staff to be at the front door at all times while the entrance is unlocked. <BR/>Interview on 5/14/2024 at 4:50 PM, ADON E was asked where Resident #2 resided on the day of her elopement and stated Resident #2 was on 500 Hall. When asked why Resident #2 was not in a secured unit given her Elopement Assessment indicated she was at risk, ADON E responded that Resident #2 did not present with a history of exit seeking or wandering behaviors. <BR/>Interview on 5/15/2024 at 10:00 AM, the Administrator, accompanied by the DON and ADON K, acknowledged that both Residents #1 and #2 had left the facility without the knowledge of facility staff and without adherence to the facility's policies and procedures. <BR/>Record review of a facility policy, Titled, Abuse and Neglect,(no date), stated, If abuse/neglect is suspected the facility will: 2. Notify the appropriate/designated organization/authority HHSC that an investigation is being initiated immediately following intervention for the resident's safety . Further review stated, Prevention (483.13 (b) and 483.13 (c): Have procedures to: Ensuring health and safety of residents in regards to visitors.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents hazards and supervision, in that:<BR/>On 01/10/2025 Resident #1 was transferred by CNA A using standing pivot transfer x 1 staff instead of a mechanical lift. During transfer Resident #1 was injured resulting in left tibia /fibula fracture.<BR/>The non-compliance was identified as past non-compliance. The IJ began on 1/10/25 and ended on 1/13/25. The facility had corrected the non-compliance before the survey began.<BR/>This failure could lead to injury or death to residents.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 01/30/2025, reveled an [AGE] year old female admitted to the facility on [DATE] with diagnoses that included right below the knee amputation (surgical procedure that removes the lower leg below the knee joint), Osteoporosis (a bone disease characterized by a disease in bone mineral density and bone mass, resulting in weak and brittle bones that are more prone to fractures), and Vitamin D deficiency (the state of having inadequate amounts of vitamin D in your body). <BR/>Record review of Resident #1's Quarterly MDS assessment, dated 10/23/2024, reflected a BIMS of 4 which suggested severe cognition impairment. Section G revealed Resident #1 required extensive assistance with 2 persons for transfers.<BR/>Record review of Resident #1's Care Plan, dated 05/2/2021 and revised on 06/02/2024, revealed Resident #1 required a mechanical lift X 2 staff assist for all transfers.<BR/>Record review of the Provider Investigation Report, dated 01/16/2025, related to the facilty's self-report of Resident #1's injury on 01/10/2025, revealed on 01/10/2025 at 2:00 PM, [CNA A] transferred [Resident #1] from the chair to the bed and heard a popping noise. [Resident #1] voiced her leg hurt. Further review revelaed Resident #1 was noted to have an abnormality to the left shin area., and the resident was transferred to the hospital for treatment. Record review of the Investigation Summary revealed, on 1-13-24 the facility found that [Resident #1's] hospital x-ray revealed an acute left mid tibial diaphyseal fracture with significant anteromedial displacement, acute left proximal and distal fibular diaphyseal minimally displaced olbique fractures, segmental. Extensive diffuse bone demineralization by x-ray/osteoporosis and degenerative changes. Records review confirmed that [Resident #1] is care planned for a [mechanical lift] transfer. Staff interivews revealed no issues with [Resident #1] prior to transfer from chair to bed. Interview with [CNA A] revealed that [CNA A] transferred [Resident #1] without the use of a [mechanical lift] and conducted a single person transfer. [CNA A] stated that she had used the [mechanical lift] previously when transferring [Resident #1] and was aware it was on her plan of care. Further review revealed CNA A's employment with the facility was terminated post-investigation.<BR/>Record review of CNA A's written statement, dated 1/10/25 at 3:00 PM, reflected, I transferred [Resident #1] from her wheelchair to her bed via pivot X 1 staff member, when resident told me her noted abnormality to left shin.<BR/>Record review of Incident Report, dated 01/10/2025 at 1:56 PM, revealed, This nurse was called into residents' room by Charge Nurse, left lower extremity assessed and [Resident #1] was able to state where pain was and 911 was called.<BR/>Record review of hospital records for Resident #1, dated 01/11/2025 at 12:01 PM, revealed Resident #1 had a surgical intervention requiring a left tibia intramedullary nail for shaft fracture and closed management with manipulation left fibula fracture.<BR/>During an Interview with the DON on 01/30/2025 at 10:10 AM, the DON stated CNA A should have transferred Resident #1 using 2 staff members with a mechanical lift as per Resident #1's Care Plan. The DON also stated that by CNA's not following the care plan injury to residents may occur.<BR/>An interview with CNA A was attempted on 01/30/2025 at 11:12 AM but was not successful. A voicemail was left for call a back. CNA A did not call back.<BR/>Record review of the facility's policy titled, Assistive Devises and Equipment, undated, revealed, Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the president's plan of care.<BR/>The Administrator was notified on 01/31/2025 at 12:30 PM, that a past non-compliance IJ situation had been identified due to the above failure and an IJ Template was provided to the Administrator. <BR/>The facility implemented the following interventions prior to the survey entrance on 01/28/2025. <BR/>During an interview with the DON on 1/28/25 at 3:20 PM, the DON stated the facility put a system into place for agency staff / PRN (as needed) to review forms prior to their shift to identify the care needs of each resident.<BR/>Record review of in-service training titled, Always Follow POC (Plan of Care), dated 01/10/2025 to 01/13/2025, revealed 50 of 50 staff members, 1 of 1 agency staff, and 10 of 10 PRN staff (as needed) completed the in-service training. Further revealed the in-service training addressed: CNA's look at [NAME], Hoyer's have to use if indicated 2 person, where to find POC (Plan of Care), competencies and demonstration of mechanical lift transfers. <BR/>Interviews with 12 staff members on 01/30/25 from 10:00 a.m. to 12:00 p.m. the following staff (MA B, LVN C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, LVN K, LVN L, LVN M) confirmed completion of in services/training: Always Follow POC (Plan of Care), CNA's look at [NAME], mechanical lifts have to use if indicated 2 people, where to find POC (Plan of Care. Staff were able to verbalize understanding and information provided in the in-service/training.<BR/>During an Interview with the DON on 1/30/25 at 10:20 AM, the DON confirmed CNA A was terminated from employment at the facility on 1/17/25. <BR/>Observation on 01/31/25 at 7:30 AM confirmed MA B and LVN C transferred Resident #3 using a two-staff mechanical lift transfer.<BR/>Observation on 1/31/25 at 8:30 AM confirmed MA B and LVN C transferred Resident #4 using a two-staff mechanical lift transfer. <BR/>The non-compliance was identified as past non-compliance. The IJ began on 1/10/25 and ended on 1/13/25. The facility had corrected the non-compliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure incontinent bladder residents received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 2 of 12 residents (Residents #82 and #7) reviewed for indwelling catheters and perineal/incontinent care, in that:<BR/>1. The facility failed to ensure Resident #82 indwelling catheter was attached to prevent pulling or tugging to the urethra. <BR/>2. The facility failed to ensure Resident #7's indwelling catheter was attached to prevent pulling or tugging to the urethra and failed to provide a dignity bag.<BR/>These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections due to improper care. <BR/>The findings were:<BR/>1. Record review of Resident #82's face sheet, dated 2/13/24, revealed an admission date of 10/2/23 with the diagnosis that included: [Candidiasis] a fungal infection caused by yeast, [colostomy status] an opening into the colon from the outside of the body provides a new path for waste material to leave the body after removing part of the colon, and [Bladder dysfunction] is the leaking of urine that you can't control.<BR/>Record review of Resident's #82's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition, and under section H Bowel and Bladder, an indwelling catheter was selected.<BR/>Record review of Resident #82's care plan, dated 10/23/23, revealed the resident's care plan addressed the resident's urinary catheter with interventions, Use stabilizer or secure device. <BR/>During an observation on 02/15/24 at 9:47 a.m. revealed Resident #82 had an indwelling foley catheter without a secure device. <BR/>During an interview with Resident #82 on 02/15/24 at 10:45 a.m., the resident stated, They never give me that thing to keep this from pulling out.<BR/>During an interview with RN C on 02/15/24 at 11:30 a.m., RN C stated she was the nurse for Resident #82 and confirmed the resident was supposed to be wearing a secure device to prevent the urinary catheter from pulling on the resident's urethra. RN C stated she did not know why Resident #82 was not wearing a secure device but lack of wearing an [NAME] he risked having foley catheter pulled. <BR/>During an interview with the DON on 02/15/24 at 2:35 p.m., the DON stated Resident #82 should have been wearing a secure device to prevent the urinary catheter from possibly dislodging. The DON stated it was her expectation that all residents with a urinary catheter wore a secure device to prevent the catheter from pulling or possibly becoming dislodged. <BR/>2. Record review of Resident #7's face sheet, dated 2/15/2024, revealed the resident was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: hypotension (low blood pressure), neuromuscular dysfunction of the bladder (nerves and muscles on't work together very well), bladder-neck obstruction, and dementia.<BR/>Record review of Resident #7's MDS, dated [DATE], revealed the resident had a BIMS score of 08, which indicated moderate cognitive impairment. <BR/>Record review of Resident #7's Comprehensive Care Plan, dated 10/24/2023, revealed a focus area related to the resident's catheter dignity bag. <BR/>Record review of Resident #7's orders revealed, Ensurelegstrap/securementdevice and dignity bag tocatheter tubing in place<BR/>During an observation on 2/15/2024 at 8:15 a.m. revealed Resident #7's catheter was hanging on the side of the bed with no dignity bag and not secured to prevent pulling or tugging. <BR/>Record review of the facility's policy titled, Catheter Care, Urinary, undated, revealed, Ensure that catheter remains secured with a leg strap.

**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. Dietary Aide A was not properly wearing a hair restraint.<BR/>2. A food item in the dry storage area was not properly dated and labeled.<BR/>3. A kitchen drawer had a drawer cover and a drawer surface area that were not cleaned.<BR/>These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness from improper infection control, from a lack of food label date monitoring, and improper sanitation in the kitchen area.<BR/>The findings included:<BR/>Observation on 02/13/2024 from 9:50 a.m. to 11:00 a.m. during the kitchen tour revealed the following:<BR/>a. Dietary Aide A was working in the kitchen wearing a hair restraint that did not fully cover the back of her head with visible exposed hair.<BR/>b. There was a package of 24 blueberry muffins with a sealed plastic cover in the dry storage area that was not dated or labeled.<BR/>c. There was a kitchen drawer in the general kitchen service area which measured 16 x 5 inches that was missing a drawer cover.<BR/>d. There was a kitchen drawer in the general kitchen service area which measured 35 x 17 inches which was covered with dirt particles on the service of the drawer which contained two boxes of jelly packets.<BR/>During an interview with the Dietary Aide A, during the kitchen tour, on 02/13/24 from 9:50 a.m. to 11:00 a.m., Dietary Aide A stated she usually wore a hair [NAME] under her hair restraint to help keep her hair in place but she had forgotten to wear it.<BR/>During an interview with the Dietary Manager during the kitchen tour on 02/13/24 from 9:50 a.m. to 11:00 a.m., the Dietary Manager stated Dietary Aide A not wearing hair restraint properly could allow hair particles to fall on the food preparation area. The Dietrary Manager stated he was responsible for ensuring the food items in dry storage were dated and labeled. The Dietrary Manager further stated the blueberry muffins were being served the previous day and that dating and labeling the food item would prevent staff from using the product after the expiration date. The Dietrary Manager stated the kitchen drawer should have been repaired with a drawer cover for sanitation purposes and the kitchen drawer surface area should have been cleaned. The Dietrary Manager stated he could not advise when the drawer surface area was last cleaned.<BR/>During an interview with the Administrator on 2/15/24 at 9:05 a.m., the Administrator stated staff properly wearing their hair restraints in the kitchen prevents hair particles from falling onto the food, that dating and labeling food products prevents them from being served after their expiration date, and that general kitchen cleaning was necessary for kitchen sanitation.<BR/>Record review of the facility's policy titled, Employee Sanitation, dated 10/1/18, revealed, Hair nets or other effective hair restraints must be worn to keep hair from food and food-contact surfaces.<BR/>Record review of the facility's policy titled, Food Storage, dated 10/1/18, revealed, All containers must be labeled and dated.<BR/>Record review of the facility's policy titled, General Kitchen Sanitation, dated 10/1/18, revealed, Clean non-food-contact surfaces of equipment as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed. 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' records were complete and accurate for 3 of 32 residents (Resident #5, #73, and #82) reviewed for clinical records, in that: <BR/>1. Resident #5's clinical record included a progress note which was inaccurate and appeared to have been written about a different resident. <BR/>2. Resident #73's diagnosis of Bipolar Disorder was not included on her face sheet. <BR/>3. Resident #82's colostomy care was completed by the resident not nursing staff, but nurses were signing off on the TAR as if they were completing care. <BR/>These deficient practices could result in inadequate care due to incomplete and inaccurate medical records.<BR/>The findings were: <BR/>1. Record review of Resident #5's face sheet, dated 02/15/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including Hypertensive Heart Disease Without Heart Failure, Other Developmental Disorders of Scholastic Skills, and Anxiety Disorder. <BR/>Record review of Resident #5's Quarterly MDS assessment, dated 01/15/2024, revealed a BIMS score of 15 which indicated intact cognition. Further review revealed the resident was a male who utilized a walker for mobility. <BR/>Record review of Resident #5's care plan, revised 12/12/2023, revealed [Resident #5] is PASRR positive d/t [due to] OTHER DEVELOPMENTAL DISORDERS OF SCHOLASTIC SKILLS . Further review revealed the resident was able to make his needs known and frequently participates with facility activities. <BR/>Record review of Resident #5's clinical record revealed a progress note, dated 5/27/2023, revealed a note which read, Resident utilizes a wheelchair for mobility. Staff assist with ADLs. Resident is able to make simple needs known to staff. She is HOH and wears glasses for vision. Resident scored a 4 on BIMS. She is able to repeat 3 words and recall 1 word with cues. Resident reports having some trouble sleeping and has little interest in doing things. Resident is a Full Code. Resident is LTC.<BR/>During an interview with the DON on 02/16/2024 at 2:30 p.m., the DON confirmed the progress note, dated 5/27/2023, had been entered into Resident #5's clinical record in error. The DON further stated she expected staff members to accurate record resident data to avoid confusion about residents' care or condition. <BR/>2. Record review of Resident #73's face sheet, dated 02/15/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Unspecified Esotropia, and Personal History of Covid-19. Further review revealed Bipolar Disorder was not a listed diagnosis. <BR/>Record review of Resident #73's Quarterly MDS assessment, dated 12/10/2023, revealed a BIMS score of 15 which indicated intact cognition. <BR/>Record review of Resident #73's care plan, revised 03/10/2022, revealed, [Resident #73 has a behavior problem r/t [related to] mood disorders and bipolar disorder.<BR/>Record review of Resident #73's clinical record revealed a physician note, dated 11/30/2023, which read, Patient presents with bipolar disorder . Further review of Resident #73's clinical record revealed a physician order, dated 11/2022, which read, QUEtiapine Fumarate Tablet 300 MG [milligrams]. Give 1 tablet by mouth at bedtime for Bipolar. <BR/>During an interview with RN B on 02/14/2024 at 4:40 p.m., RN B confirmed Resident #73's diagnosis of Bipolar Disorder was not listed on the resident's face sheet. <BR/>During an interview with the DON on 02/16/2024 at 2:30 p.m., the DON confirmed she expected staff members to accurate record resident data to avoid confusion about residents' care or condition. <BR/>3. Record review of Resident #82's face sheet, dated 2/15/23, revealed the resident was admitted to the facility on [DATE] with diagnoses including: [Candidiasis] a fungal infection caused by a yeast, [colostomy status] an opening into the colon from the outside of the body which provides a new path for waste material to leave the body after part of the colon has been removed, and [Bladder dysfunction] is the leaking of urine that you can't control.<BR/>Record review of Resident's #82's Quarterly MDS addessment, dated 1/4/24, revealed a BIMS score of 15 which indicated intact cognition, and under under section H Bowel and Bladder section C selected indicating colostomy status.<BR/>Record review of Physician Orders for February 2024 revealed an order for, Change colostomy bag every three days and PRN (as needed).<BR/>Record review of Resident #82's (TAR) Treatment Administration Record for February 2024 revealed a staff nurse was signing TAR and was not completing the treatment. <BR/>During an interview with Resident #82 on 2/15/24 at 1:35 p.m., the resdient stated he was educated on colostomy care at [Name of Hospital] and completed his own colostomy care at the facility. <BR/>During an interview with RN C on 2/15/24 at 1:44 p.m., RN C stated she signs the TAR as per the facility culture, and she had not been trained otherwise.<BR/>During an interview with the DON on 2/15/24 at 210 p.m., the DON stated she did not believe there were any negative consequences for Resident #82 to be untrained by the facility. The DON stated she was unaware nursing staff were signing the TAR and having the resident complete self colostomy care. The DON stated it was her expectation that nursing staff compete the ordered task and then sign the TAR. The DON stated the facility did not have a policy for this issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 3 of 6 resident (Residents #64, #87 and, 92) reviewed for privacy, in that:<BR/>1. While providing wound care for Resident # 64, LVN E did not completely close the privacy curtain. <BR/>2. While providing colostomy care for Resident # 87, LVN D did not completely close the privacy curtain <BR/>3. While providing incontinent care for Resident # 92, CNA F and CNA G did not completely close the privacy curtain.<BR/>This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.<BR/>The findings include:<BR/>Record review of Resident #64's face sheet, dated 01/18/2023, revealed an admission date of 07/15/2022, and a readmission date of 10/14/2022, with diagnoses which included: Pressure ulcer of sacral region stage 4 (deep wound that may impact muscle, tendons, ligaments, and bone), Hypertension (high blood pressure), Hyperlipidemia (high level of fat in the blood), Congestive heart failure (heart doesn't pump blood as efficiently as it should).<BR/>Record review of Resident #64's 5 days MDS, dated [DATE], revealed the resident had a BIMS score of 5 indicating severe cognitive impairment. Resident #64 required extensive assistance to total care, had an indwelling catheter and was always incontinent of bowel. <BR/>Observation on 01/18/23 at 09:04 a.m. revealed during wound care the privacy curtain at the end of Resident #64's bed was left completely open by LVN E. Anybody opening the bedroom door would have had a full view of the resident. The wound being on Resident #64's buttocks, the resident's buttocks were fully exposed.<BR/>During an interview with LVN E on 01/18/2023 at 9:13 a.m., LVN E verbally confirmed the privacy curtain was not closed while she provided care for Resident #64 but it should have been to provide privacy and ensure dignity. <BR/>During an interview with the DON on 01/18/2023 at 10:30 a.m., the DON verbally confirmed privacy must be provided during nursing care and Resident #64's privacy curtains should have been closed completely. She confirmed the staff received training about Residents' rights and residents' privacy and they are doing return demonstration to ensure good retention of training<BR/>2. Record review of Resident #87's face sheet, dated 01/17/2023, revealed an admission date of 11/15/2022, and a readmission date of 12/06/2022, with diagnoses which included: Gastrostomy status (opening into the stomach from the abdomen made surgically for the introduction of food), Type 2 diabetes mellitus(high level of sugar in the blood), Dementia (progressive impairments in memory, thinking, and behavior), Parkinson's(long-term degenerative disorder of the central nervous system), Colostomy status(opening in the large intestine), Hypertension(high blood pressure)<BR/>Record review of Resident #87's 5 days MDS, dated [DATE], revealed the resident had a BIMS score of 3 indicating severe cognitive impairment. Resident #87 required extensive assistance to total care, had an indwelling catheter and a colostomy. <BR/>Observation on 01/17/23 at 01:50 p.m. revealed during colostomy care the privacy curtain at the end of Resident #87's bed was left completely open by LVN D. Anybody opening the bedroom door would have had a full view of the resident. <BR/>During an interview with LVN D on 01/17/2023 at 2:05 p.m., LVN D verbally confirmed the privacy curtain was not closed while she provided care for Resident #87 but it should have been to provide privacy and ensure dignity. <BR/>During an interview with the DON on 01/18/2023 at 10:30 a.m., the DON verbally confirmed privacy must be provided during nursing care and Resident #87's privacy curtains should have been closed completely. She confirmed the staff received training about Residents' rights and residents' privacy and they are doing return demonstration to insure good retention of training<BR/>3. Record review of Resident #92's face sheet, dated 01/17/2023, revealed an admission date of 08/23/2022, with diagnoses which included: Epileptic syndrome (seizure), Asthma (Chronic disease of the respiratory system), Down syndrome (A genetic disorder associated with physical growth delays, characteristic facial features and mild to moderate developmental and intellectual disability), Hyperlipidemia (Too much fat in the blood)<BR/>Record review of Resident #92's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating severe cognitive impairment. Resident #92 required extensive assistance, was occasionally incontinent of bladder and frequently incontinent of bowel. <BR/>Observation on 01/17/23 at 10:15 a.m. revealed during incontinent care the privacy curtain was too short to completely surround Resident #92's bed. The resident's roommate was in her bed and Resident #92's genitals were exposed during care. <BR/>During an interview with CNA F and CNA G on 01/17/2023 at 10:25 a.m., the CNAs verbally confirmed the privacy curtain was not completely closed while they provided care for Resident #92 but it should have been to provide privacy and ensure dignity. They confirmed the curtain was too short to completely close around the bed. <BR/>During an interview with the DON on 01/18/2023 at 10:30 a.m., the DON verbally confirmed privacy must be provided during nursing care and Resident #92's privacy curtains should have been closed completely. She confirmed the staff received training about Residents' rights and residents' privacy and they are doing return demonstration to insure good retention of training<BR/>Review of the facility's policy titled Residents Rights, undated, revealed, When providing resident care, always provide privacy [ .] pulling a curtain around the bed, pulling the drapes to windows, closing the door and draping the resident's body appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to accurately reflect the resident's status for 2 (#27 and #90) of 8 residents reviewed for assessments in that:<BR/>1 Resident #27 was on continuous oxygen therapy and it was not reflected in her MDS assessment during the 7 day lookback.<BR/>2. Resident #90 had a LCS diet ordered and it was not reflected that she was on a therapeutic diet during the 7 day lookback.<BR/>This deficient practice could affect residents who receive assessments and could result in improper care.<BR/>The findings were:<BR/>1. Review of Resident #27's electronic face sheet dated 01/15/2023 revealed she was admitted to the facility on [DATE] with diagnoses of heart failure (a progressive heart disease that affects the pumping action of the heart muscles), myocardial infarction (damage to the heart muscle caused by a loss of blood supply due to blocks in the arteries), chronic obstructive pulmonary disease, (COPD) (persistent respiratory symptoms like progressive breathlessness and cough) atrial fibrillation (abnormal heart rhythm) and cardiac pacemaker (surgical insertion of a small device under the collarbone to control the electrical events of the heart).<BR/>Review of Resident #27's Annual MDS assessment with an ARD of 12/17/2022 revealed she scored a 15/15 on her BIMS which indicated she was cognitively intact. Resident #27 was not coded to be on oxygen therapy.<BR/>Review of Resident #27's comprehensive care plan with a revision date of 09/12/2022 revealed under Focus .has oxygen therapy r/t COPD .Interventions .Oxygen settings: The resident has O2 at 2L continuously.<BR/>Review of Resident #27's Active Orders As Of: 01/16/2023 revealed Continuous O2 at 2L per n/c to maintain O2 sat &gt;92% .with a start date of 09/29/2022.<BR/>Review of Resident #27's vital signs record for the dates of 12/10/2022 to 12/17/2022 revealed she had oxygen saturations taken at least two times a day with oxygen on via nasal cannula.<BR/>Review of Resident #27's MAR dated 12/01/2022 to 12/31/2022 reveaeled nurses initialed off that she had continuous O2 at 2L per n/c every day.<BR/>Observation on 01/15/2023 at 10:56 a.m. of Resident #27 revealed she was sitting in her room in her wheel chair and had oxygen infusing at 3L/NC.<BR/>Observation on 01/16/2023 at 09:55 a.m. of Resident #27 revealed she was sitting in her room in her wheel chair and had oxygen infusing at 3L/NC.<BR/>Interview on 01/15/2023 at 11:00 a.m. with Resident #27, she stated she was on oxygen continuously since she was admitted to the facility. She stated she did not adjust the oxygen, only the nurses did that.<BR/>Interview on 01/18/2023 at 12:40 p.m. with MDS Coordinator B revealed that the Annual MDS assessment with an ARD of 12/17/2022 for Resident #27 was inaccurate and should have had the oxygen coded. She stated I'm not sure what happened, I missed that one completely.<BR/>2. Review of Resident #90's electronic face sheet dated 04/19/2022 revealed she was admitted to the facility with diagnoses of diabetes mellitus (condition that results from insufficient production of insulin, causing high blood sugar), dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and anemia (deficiency of healthy red blood cells, causing fatigue and weakness).<BR/>Review of Resident #90's Quarterly MDS assessment with an ARD of 11/04/2022 revealed she was not a candidate for a BIMS which indicated she was severely cognitively impaired. Review of Section K-Swallowing/Nutritional Status .Nutritional Approaches revealed Resident #90 was on a mechanically altered diet but was not coded for a therapeutic diet.<BR/>Review of Resident #90's comprehensive care plan with a revision date of 05/09/2022 revealed Focus .has the potential for a nutritional problem r/t protein calorie malnutrition .diet: FMP, pureed diet with nectar thin liquids.<BR/>Review of Resident #90's Active Orders As Of: 01/16/2023 revealed Diet: FMP, Pureed, Nectar Consistency, LCS. active as of 04/30/2022. <BR/>Observation on 01/16/2023 at 12:00 p.m. of Resident #90 revealed she was in the dining room and was assisted with eating, her meal ticket read, FMP, Pureed, Nectar Consistency, LCS diet.<BR/>Interview on 01/18/2023 at 12:40 p.m. with MDS Coordinator A revealed that the Quarterly MDS assessment with an ARD of 11/04/2022 for Resident #90 was not accurate, and stated the therapeutic diet, should have been coded since Resident #90 has an LCS diet ordered. MDS Coordinator A further revealed the FSS would have entered the diet information however did confirm the MDS coordinators are responsible for ensuring the assessments for accuracy at each review.<BR/>Review of the facility policy and procedure titled Resident Assessment Instrument Process (undated) revealed The MDS Coordinator and Nursing Staff are key members of the interdisciplinary team in this facility. One of the functions in the RAI/MDS process is to gather data in order to develop comprehensive and individualized care plans that meet the medical, nursing, mental and psychosocial needs of each resident.<BR/>Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 revealed The RAI process has multiple regulatory requirements .(1) the assessment accurately reflects the resident's status .an accurate assessment requires collecting information from multiple sources.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 1 resident (#27) out of 2 residents reviewed for oxygen therapy in that:<BR/>Resident #27's oxygen setting was on 3L/min when she was prescribed 2L/min.<BR/>This deficient practice could affect residents who receive oxygen therapy and could result in respiratory distress.<BR/>The findings were:<BR/>Review of Resident #27's electronic face sheet dated 01/15/2023 revealed she was admitted to the facility on [DATE] with diagnoses of heart failure (a progressive heart disease that affects the pumping action of the heart muscles), myocardial infarction (damage to the heart muscle caused by a loss of blood supply due to blocks in the arteries), chronic obstructive pulmonary disease, (COPD) (persistent respiratory symptoms like progressive breathlessness and cough) atrial fibrillation (abnormal heart rhythm) and cardiac pacemaker (surgical insertion of a small device under the collarbone to control the electrical events of the heart).<BR/>Review of Resident #27's Annual MDS assessment with an ARD of 12/17/2022 revealed she scored a 15/15 on her BIMS which indicated she was cognitively intact. Resident #29 was not coded to be on oxygen therapy.<BR/>Review of Resident #27's comprehensive care plan with a revision date of 09/12/2022 revealed under Focus .has oxygen therapy r/t COPD .Interventions .Oxygen settings: The resident has O2 at 2L continuously.<BR/>Review of Resident #27's Active Orders As Of: 01/16/2023 revealed Continuous O2 at 2L per n/c to maintain O2 sat &gt;92% .with a start date of 09/29/2022.<BR/>Review of Resideent #27's MAR dated 01/01/2023 to 01/31/2023 reveaeled she had continuous O2 at 2L per n/c initialed off for each day to include 01/15/2023 and 01/16/2023.<BR/>Observation on 01/15/2023 at 10:56 a.m. of Resident #27 revealed she was sitting in her room in her wheel chair and had oxygen infusing at 3L/min via nasal cannula.<BR/>Observation on 01/16/2023 at 09:55 a.m. of Resident #27 revealed she was sitting in her room in her wheel chair and had oxygen infusing at 3L/min via nasal cannula.<BR/>Observation on 01/16/2023 at 1:00 p.m. of Resident #27 accompanied by LVN A revealed the resident's oxygen concentrator rate setting was 3L/min. LVN C stated the oxygen setting needed to be at 2L/min and that she had not checked it. LVN C stated the correct oxygen rate because too much or too little could cause respiratory distress. <BR/>Interview on 01/15/2023 at 11:00 a.m. with Resident #27, she stated she was on oxygen continuously since she was admitted to the facility. She stated that only the nurses adjusted the oxygen setting.<BR/>Interview on 01/18/2023 at 12:58 p.m. with the DON revealed that she knew about Resident #27's oxygen being set on 3L/min instead of 2L/min as ordered, and stated it is our responsibility to monitor that the rate is correct and we make rounds. She stated that a resident with COPD must have the right amount of O2 or could be harmed.<BR/>Review of the facility policy and procedure titled General Guidelines for Medication Administration dated 09-2018 revealed Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer .Medications are administered in accordance with written orders of the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 3 of 6 resident (Residents #64, #87 and, 92) reviewed for privacy, in that:<BR/>1. While providing wound care for Resident # 64, LVN E did not completely close the privacy curtain. <BR/>2. While providing colostomy care for Resident # 87, LVN D did not completely close the privacy curtain <BR/>3. While providing incontinent care for Resident # 92, CNA F and CNA G did not completely close the privacy curtain.<BR/>This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.<BR/>The findings include:<BR/>Record review of Resident #64's face sheet, dated 01/18/2023, revealed an admission date of 07/15/2022, and a readmission date of 10/14/2022, with diagnoses which included: Pressure ulcer of sacral region stage 4 (deep wound that may impact muscle, tendons, ligaments, and bone), Hypertension (high blood pressure), Hyperlipidemia (high level of fat in the blood), Congestive heart failure (heart doesn't pump blood as efficiently as it should).<BR/>Record review of Resident #64's 5 days MDS, dated [DATE], revealed the resident had a BIMS score of 5 indicating severe cognitive impairment. Resident #64 required extensive assistance to total care, had an indwelling catheter and was always incontinent of bowel. <BR/>Observation on 01/18/23 at 09:04 a.m. revealed during wound care the privacy curtain at the end of Resident #64's bed was left completely open by LVN E. Anybody opening the bedroom door would have had a full view of the resident. The wound being on Resident #64's buttocks, the resident's buttocks were fully exposed.<BR/>During an interview with LVN E on 01/18/2023 at 9:13 a.m., LVN E verbally confirmed the privacy curtain was not closed while she provided care for Resident #64 but it should have been to provide privacy and ensure dignity. <BR/>During an interview with the DON on 01/18/2023 at 10:30 a.m., the DON verbally confirmed privacy must be provided during nursing care and Resident #64's privacy curtains should have been closed completely. She confirmed the staff received training about Residents' rights and residents' privacy and they are doing return demonstration to ensure good retention of training<BR/>2. Record review of Resident #87's face sheet, dated 01/17/2023, revealed an admission date of 11/15/2022, and a readmission date of 12/06/2022, with diagnoses which included: Gastrostomy status (opening into the stomach from the abdomen made surgically for the introduction of food), Type 2 diabetes mellitus(high level of sugar in the blood), Dementia (progressive impairments in memory, thinking, and behavior), Parkinson's(long-term degenerative disorder of the central nervous system), Colostomy status(opening in the large intestine), Hypertension(high blood pressure)<BR/>Record review of Resident #87's 5 days MDS, dated [DATE], revealed the resident had a BIMS score of 3 indicating severe cognitive impairment. Resident #87 required extensive assistance to total care, had an indwelling catheter and a colostomy. <BR/>Observation on 01/17/23 at 01:50 p.m. revealed during colostomy care the privacy curtain at the end of Resident #87's bed was left completely open by LVN D. Anybody opening the bedroom door would have had a full view of the resident. <BR/>During an interview with LVN D on 01/17/2023 at 2:05 p.m., LVN D verbally confirmed the privacy curtain was not closed while she provided care for Resident #87 but it should have been to provide privacy and ensure dignity. <BR/>During an interview with the DON on 01/18/2023 at 10:30 a.m., the DON verbally confirmed privacy must be provided during nursing care and Resident #87's privacy curtains should have been closed completely. She confirmed the staff received training about Residents' rights and residents' privacy and they are doing return demonstration to insure good retention of training<BR/>3. Record review of Resident #92's face sheet, dated 01/17/2023, revealed an admission date of 08/23/2022, with diagnoses which included: Epileptic syndrome (seizure), Asthma (Chronic disease of the respiratory system), Down syndrome (A genetic disorder associated with physical growth delays, characteristic facial features and mild to moderate developmental and intellectual disability), Hyperlipidemia (Too much fat in the blood)<BR/>Record review of Resident #92's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating severe cognitive impairment. Resident #92 required extensive assistance, was occasionally incontinent of bladder and frequently incontinent of bowel. <BR/>Observation on 01/17/23 at 10:15 a.m. revealed during incontinent care the privacy curtain was too short to completely surround Resident #92's bed. The resident's roommate was in her bed and Resident #92's genitals were exposed during care. <BR/>During an interview with CNA F and CNA G on 01/17/2023 at 10:25 a.m., the CNAs verbally confirmed the privacy curtain was not completely closed while they provided care for Resident #92 but it should have been to provide privacy and ensure dignity. They confirmed the curtain was too short to completely close around the bed. <BR/>During an interview with the DON on 01/18/2023 at 10:30 a.m., the DON verbally confirmed privacy must be provided during nursing care and Resident #92's privacy curtains should have been closed completely. She confirmed the staff received training about Residents' rights and residents' privacy and they are doing return demonstration to insure good retention of training<BR/>Review of the facility's policy titled Residents Rights, undated, revealed, When providing resident care, always provide privacy [ .] pulling a curtain around the bed, pulling the drapes to windows, closing the door and draping the resident's body appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to review and revise the comprehensive care plan for 3 (#28, #37 and #90) of 16 residents reviewed for comprehensive care plans in that:<BR/>1. The facility failed to update Resident #28's comprehensive person-centered care plan to reflect the change to an NPO diet with enteral feedings (deliver nourishment through a tube directly into the gastrointestinal tract).<BR/>2. The facility failed to update Resident #37's comprehensive person-centered care plan to reflect the change to a fortified meal plan diet with pureed texture.<BR/>3. The facility failed to update Resident #90's comprehensive person-centered care plan to reflect she was ordered a LCS diet.<BR/>This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care.<BR/>The findings were:<BR/>1. Record review of Resident #28's face sheet dated 01/17/2023 revealed an initial admission date of 09/01/2015 with a recent admission of 08/02/2022 and diagnoses which included: benign neoplasm (noncancerous abnormal growth of tissue) of cerebral meninges (protective tissue surrounding the brain), protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and dysphasia (impairment of the ability to communicate).<BR/>Record review of Resident #28's Quarterly MDS, dated [DATE], revealed a BIMS score of 12, which indicated moderate cognitive impairment. Review of Section K-Swallowing/Nutritional Status .Nutritional Approaches revealed Resident #28 was on a feeding tube while a resident of the facility but was not coded for a mechanically altered diet.<BR/>Record review of Resident #28's Care Plan, undated, revealed a focus, [Resident] has a nutritional problem r/t protein calorie malnutrition, neurological issues, history of leukemia and other comorbidities (two or more diseases or medical conditions at the same time). Diet: FMP Regular diet with supplements and thin liquids. Revision 03/12/2022. Further review revealed another focus, The resident requires tube feeding r/t Dysphagia. Revision 10/03/2022. Focus area revealed from revision on 04/13/2021, [Resident] has a potential nutritional problem r/t eating disorder .current diet: FMP Regular diet with thin liquids. Enriched cereal topping at breakfast, yogurt daily, no gravy, add ice cream for lunch and dinner. An intervention for the focus was: Provide, serve Mech (mechanical) soft diet. Revision on 10/18/2022.<BR/>Record review of Resident #28's electronic clinical record, Order Summary Report with Active Orders as of 01/18/2023, revealed a dietary order, dated 08/02/2022, NPO diet Dysphagia texture. Further review revealed an enteral feed order, dated 01/03/2023, Enteral Feed Order three times a day for meal replacements Osmolite (high-protein tube-feeding formula) 1.5 Bolus (a discrete amount within a specific time) 8 fl oz 3 times daily for meal substitutions. <BR/>Record review of Resident #28's electronic clinical record progress notes revealed a Speech therapy note, dated 11/07/2022, Patient discharged from ST services. It is recommended patient remain NPO at this time. Patient given trial of puree with outward s/s of aspiration noted during intake with strategies in place.<BR/>2. Record review of Resident #37's face sheet dated 01/18/2023 revealed an admission date of 02/15/2021 and diagnoses which included: dementia (inability to remember, think or make decisions), anemia (lower-than-normal amount of healthy red blood cells), protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and dysphagia (difficulty swallowing).<BR/>Record review of Resident #37's Quarterly MDS, dated [DATE], revealed Resident #37 was not a candidate for a BIMS which indicated severe cognitive impairment. Review of Section K-Swallowing/Nutritional Status .Nutritional Approaches revealed Resident #37 was on a mechanically altered diet while a resident of the facility.<BR/>Record review of Resident #37's Care Plan, undated, revealed a focus, [Resident] has the potential nutritional problem r/t protein calorie malnutrition, having severe dementia, short attention span, ADL care refusal at times and other comorbidities. Diet: FMP Mechanical Soft diet with thin liquids. Date Initiated: 03/02/2022. Revision on: 03/02/2022<BR/>Record review of Resident #37's electronic clinical record, Order Summary Report with Active Orders as of 01/18/2023, revealed a dietary order, dated 10/28/2022, Fortified Meal Plan diet Pureed texture, Regular/Thin consistency, ALLERGY IODINE NO SEAFOOD: ice cream w/lunch and dinner. double super cereal with breakfast. Further review revealed a supplement order, dated 11/10/2022, Health Shake three times a day for Supplement.<BR/>In an interview with MDS Coordinator B on 01/18/2023 at 11:48 a.m., MDS Coordinator B confirmed the care plan had not been revised to reflect Resident #28's and Resident #37's diets. MDS Coordinator B stated the previous diets should have come off (care plan), it clearly was an oversight. When asked about potential harm of not updating a care plan, MDS Coordinator B stated that if a staff member used the care plan to follow what diet the resident should be receiving, the staff could provide an unsafe meal to their resident. <BR/>3. Review of Resident #90's electronic face sheet dated 04/19/2022 revealed she was admitted to the facility with diagnoses of diabetes mellitus (condition that results from insufficient production of insulin, causing high blood sugar), dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and anemia (deficiency of healthy red blood cells, causing fatigue and weakness).<BR/>Review of Resident #90's Quarterly MDS assessment with an ARD of 11/04/2022 revealed she was not a candidate for a BIMS which indicated she was severely cognitively impaired. Review of Section K-Swallowing/Nutritional Status .Nutritional Approaches revealed Resident #90 was on a mechanically altered diet but was not coded for a therapeutic diet.<BR/>Review of Resident #90's Active Orders As Of: 01/16/2023 revealed Diet: FMP, Pureed, Nectar Consistency, LCS. active as of 04/30/2022. <BR/>Review of Resident #90's comprehensive care plan with a revision date of 05/09/2022 revealed Focus .has the potential for a nutritional problem r/t protein calorie malnutrition .diet: FMP, pureed diet with nectar thin liquids.<BR/>Observation on 01/16/2023 at 12:00 p.m. of Resident #90 revealed she was in the dining room and was assisted with eating, her meal ticket read, FMP, Pureed, Nectar Consistency, LCS diet.<BR/>Interview on 01/18/2023 at 12:40 p.m. with MDS Coordinator B revealed that the comprehensive care plan did not reflect the LCS diet ordered for Resident #90 and that an incorrect diet could result in harm of a resident choking or receiving a diet that could make them ill.<BR/>Review of the facility policy and procedure titled Comprehensive Care Plan (undated) revealed c. The comprehensive care plan will be reviewed and revised, based on changing goals, preferences and needs of the resident in response to current interventions, by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Based on observation, interviews and record reviews, the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 medication cart checked (Hall 600) out of 4 medication carts checked for storage practices in that:<BR/>1 bottle of Dermarite Proheal Liquid Protein (A medical food developed for the dietary management of wounds and conditions requiring supplemental protein) had an opened date of 11/17/2022 written on it and 1 bottle of Nutricia Uti-Stat (a ready to drink medical food providing cranberry concentrate with added nutrients) had an opened date of 10/06/2022 written on it and both had passed the manufacturer discard dates after opening were located inside the 600 Hall medication cart<BR/>This deficient practice could affect residents who receive medications with manufacturers recommendations for discard after opening and could result in diminished effectiveness.<BR/>The findings were:<BR/>Observation on 01/16/2023 at 1:50 p.m. with LVN D, checked medication storage for the 600 Hall medication cart and one bottle of Dermarite Proheal Liquid Protein labeled with an opened date of 11/17/2022. The bottle had manufacturers recommendations listed on the back of the label: Discard 60 days after opening. One bottle of Nutricia Uti-Stat had an opened date of 10/6/2022 with manufacturers recommendations listed on the back of the label Discard 3 months after opening.<BR/>Interview on 1/16/2023 at 2:00 p.m. with LVN D revealed it is important to follow manufacturer's recommendations because the effectiveness of the medicated solution could decrease and not provide the desired effects. He stated that pharmacy checks the medication carts and the nurses, and he did not realize the solutions had recommended discard dates after being opened.<BR/>Interview on 01/18/2023 at 12:58 p.m. with the DON revealed she was informed the solutions were expired and she contacted the pharmacist that had just been at the facility two weeks prior to do medication cart audits about the expiration date requirements and the Pharmacist confirmed the solutions were out of date with the manufacturer's recommendations. She stated that harm of taking the protein solution after the discard date was it could cause a resident to have nausea and vomiting.<BR/>Review of the facility policy and procedure titled Storage of Medications (undated) revealed Ensure that medications are stored in a safe, secure and orderly manner .no discontinued, outdated or deteriorated medications are to be used for use in this facility. All such medications are destroyed according to facility policy.

Based on interviews and record reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 1 of 1 Activity Director, reviewed in that: <BR/>The facility failed to ensure the AD was qualified to serve as the director of the activities program. <BR/>This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.<BR/>The findings were: <BR/>Record review of staff roster, provided by the facility, undated, revealed the staff member was listed as Activities Director. Further review revealed the AD was hired on 07/09/2019. <BR/>Record review of a document provided by the AD revealed a certificate titled, Modular Education Program for Activity Professionals MEPAP 2nd Edition. Further review revealed the program provided 90 hours of instruction and 90 hours of practicum Advanced Technology Course (Part One of Two Parts) Activity Director Home Study Course, with a start date of 10/28/2017 and completion date of 03/01/2018. <BR/>Review of Modular Education Program for Activity Professionals, website, https://activityadvisor.org/, on 01/18/2023 revealed the MEPAP course is divided into two parts-MEPAP Part One and MEPAP Part Two. Further review revealed Activity Professional Certified (APC) requires only the MEPAP Part One.<BR/>Review of National Certification Council for Activity Professionals, website, https://nccap.org/, on 01/18/2023 revealed Certification Renewals: Renewal is required every 2 years. APC: 20 CE (Continuing Education) hours every 2 years.<BR/>Record review of a certificate of completion provided by the AD revealed the AD completed 8 continuing education hours for Activity Directors on October 2, 2020.<BR/>During an interview with the HR Manager on 01/18/2023 at 2:05 p.m., the HR Manager was asked for documentation of the AD's certification and any continuing education. The HR Manager stated she and did not have that information on file but called the AD to the office to provide the requested documentation.<BR/>During an interview with the AD on 01/18/2023 at 2:45 p.m., the AD revealed she became certified in 2018 and completed continuing education to renew in 2020. The AD stated when it was time to renew again in 2022 the facility had positive cases of COVID, and she was not allowed to attend training.<BR/>During an interview with the Administrator on 01/18/2023 at 3:10 p.m., the Administrator stated she did recall the AD informed her the facility where the continuing education was held had requested staff not attend if they worked in a facility currently caring for COVID positive residents. The Administrator further stated she had thought the AD had looked for some on-line renewal training at that time.<BR/>Record review of the AD's job description provided by the facility revealed a section, Required Education and Experience: Qualified therapeutic recreation specialist or activities professional who is licensed and registered by the State; Certified as a therapeutic recreation specialist or activities professional by a recognized accrediting body.

Based on observation, interviews and record reviews, the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 medication cart checked (Hall 600) out of 4 medication carts checked for storage practices in that:<BR/>1 bottle of Dermarite Proheal Liquid Protein (A medical food developed for the dietary management of wounds and conditions requiring supplemental protein) had an opened date of 11/17/2022 written on it and 1 bottle of Nutricia Uti-Stat (a ready to drink medical food providing cranberry concentrate with added nutrients) had an opened date of 10/06/2022 written on it and both had passed the manufacturer discard dates after opening were located inside the 600 Hall medication cart<BR/>This deficient practice could affect residents who receive medications with manufacturers recommendations for discard after opening and could result in diminished effectiveness.<BR/>The findings were:<BR/>Observation on 01/16/2023 at 1:50 p.m. with LVN D, checked medication storage for the 600 Hall medication cart and one bottle of Dermarite Proheal Liquid Protein labeled with an opened date of 11/17/2022. The bottle had manufacturers recommendations listed on the back of the label: Discard 60 days after opening. One bottle of Nutricia Uti-Stat had an opened date of 10/6/2022 with manufacturers recommendations listed on the back of the label Discard 3 months after opening.<BR/>Interview on 1/16/2023 at 2:00 p.m. with LVN D revealed it is important to follow manufacturer's recommendations because the effectiveness of the medicated solution could decrease and not provide the desired effects. He stated that pharmacy checks the medication carts and the nurses, and he did not realize the solutions had recommended discard dates after being opened.<BR/>Interview on 01/18/2023 at 12:58 p.m. with the DON revealed she was informed the solutions were expired and she contacted the pharmacist that had just been at the facility two weeks prior to do medication cart audits about the expiration date requirements and the Pharmacist confirmed the solutions were out of date with the manufacturer's recommendations. She stated that harm of taking the protein solution after the discard date was it could cause a resident to have nausea and vomiting.<BR/>Review of the facility policy and procedure titled Storage of Medications (undated) revealed Ensure that medications are stored in a safe, secure and orderly manner .no discontinued, outdated or deteriorated medications are to be used for use in this facility. All such medications are destroyed according to facility policy.

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS, in that: <BR/>The facility failed to submit staffing information to CMS for the 4th quarter of the fiscal year 2022.<BR/>The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.<BR/>The findings included:<BR/>Review of the facility's staff roster, undated indicated the following:<BR/>1 Administrator <BR/>5 RNs (included DON and 1 MDS Coordinator)<BR/>25 LVNs (included 2 ADONs, 1 MDS Coordinator and 1 Treatment Nurse)<BR/>42 CNA/CMAs (included 4 Caregivers)<BR/>3 Maintenance Personnel<BR/>12 Housekeeping/Laundry Personnel<BR/>14 Dietary Personnel<BR/>18 Therapy Personnel (included 2 Restorative Aides)<BR/>2 Social Work Personnel<BR/>2 Activity Directors<BR/>8 Security/Screener Personnel<BR/>6 Office Staff Personnel<BR/>Record review of the facility CMS form 672 (Resident Census and Conditions of Residents) dated 01/15/2023 provided by MDS Coordinator A indicated a total of 99 residents in the facility.<BR/>Record review of the PBJ Staffing Data Report, FY Quarter 4 2022 (July 1 - September 30), dated 01/11/2023, revealed the facility had failed to submit data for the quarter.<BR/>During an interview with the Administrator on 01/18/2023 at 3:20 pm, the Administrator revealed the Payroll Based Journal staffing hours are submitted by the corporate office. The Administrator further revealed the corporate office staff are able to pull directly from our time clocks and submit electronically. <BR/>During an interview with the Administrator on 01/18/2023 at 4:20 pm, the Administrator stated they did not have a policy regarding submitting the Payroll Based Journal. The Administrator stated the corporate office had informed her we report as required by CMS and provided a copy of the PBJ Policy Manual.<BR/>Record review of the CMS, Electronic Staffing Data Submission Payroll-Based Journal, Long-Term Care Facility Policy Manual, Version 2.6, June 2022, section 1.2 Submission Timeliness and Accuracy, revealed Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. Further review revealed Report Quarter 4 date range as July 1-September 30. Policy manual revealed, Deadline: Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 3 of 10 dietary aides (Dietary Aide H, Dietary Aide I, and Dietary Aide J) reviewed for competencies, in that: <BR/>The facility failed to ensure Dietary Aide H, Dietary Aide I and Dietary Aide J had a Food Handling Certificate prior to working in the facility kitchen. <BR/>This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. <BR/>The findings were: <BR/>Record review of the facility staff roster, undated, revealed Dietary Aide H was a full-time dietary aide with a hire date of 01/11/2023. <BR/>Record review of dietary staff credentials provided by the Food Service Supervisor revealed Dietary Aide H completed the Texas Food Handler Training Certificate Program on 01/17/2023, after surveyor requested dietary staff credentials on 01/15/2023.<BR/>Record review of the facility staff roster, undated, revealed Dietary Aide I was a full-time dietary aide with a hire date of 06/14/2021. <BR/>Record review of dietary staff credentials provided by the Food Service Supervisor revealed Dietary Aide I completed the Texas Food Handler Training Certificate Program on 01/16/2023, after surveyor requested dietary staff credentials on 01/15/2023.<BR/>Record review of the facility staff roster, undated, revealed Dietary Aide J was a part-time dietary aide with a hire date of 12/16/2022. <BR/>Record review of dietary staff credentials provided by the Food Service Supervisor revealed Dietary Aide J completed the Texas Food Handler Training Certificate Program on 01/16/2023, after surveyor requested dietary staff credentials on 01/15/2023.<BR/>During an interview with the Food Service Director on 01/18/2023 at 1:45 p.m., the Food Service Director confirmed she had not provided the certificates upon initial request but had them now. The FSS further stated Dietary Aide H and Dietary Aide J were new employees and that Dietary Aide I had recently transferred to dietary from the housekeeping department.<BR/>During an interview with the HR Manager on 01/18/2023 at 2:00 p.m., the HR Manager revealed Dietary Aide I had transferred from the housekeeping department to dietary on 12/16/2022.<BR/>During an interview with the Administrator on 01/18/2023 at 4:05 p.m., the Administrator stated Dietary Aide I had filled in during a brief time in the kitchen and decided she liked that department and put in for a request. The Administrator further stated dietary staff are required to have a Food Handler's Certificate prior to working in the kitchen and confirmed the certificates for Dietary Aide H, Dietary Aide I and Dietary Aide J were dated after surveyor request on 01/15/2023.<BR/>Record review of the facility's job description, Dietary Aide, undated, revealed, Required Education and Experience: Food Handler certification pursuant to requirements by the State.<BR/>Record review of the facility's policy, Dietary Staffing, undated, revealed, Ensure there is sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to maintain spaces of at least 80 square feet per resident for 13 (resident rooms #101, 102, 103, 104, 105, 106, 107, 401, 403, 404, 405, 406, and 407) of 34 Resident rooms inspected for resident room sufficient space for privacy and comfort, in that:<BR/>The facility failed to ensure resident rooms #101, 102, 103, 104, 105, 106, 107, 401, 403, 404, 405, 406, and 407 were maintained with at least 80 square feet of space per resident.<BR/>This failure could place residents at risk of restricting their resident rights for comfort and privacy.<BR/>The findings were:<BR/>Record review of the Bed Classification Form 3740 dated 01/15/2023 which was filled out by the Administrator indicated the capacity of the facility was 144 beds.<BR/>In an interview with the Administrator on 01/17/2023 at 3:00 p.m., the Administrator revealed she was not aware of any room waivers for the facility. The Administrator stated the bed classification was accurate and further stated even though some of the rooms were currently being used as private rooms her understanding was, they could be used as semi-private if needed.<BR/>In an interview with the Administrator on 01/18/2023 at 9:35 a.m., the Administrator stated her Maintenance Director would measure the rooms to ensure they meet regulations.<BR/>Review of the measurements provided by LSC, of the bedrooms which were measured and identified by the Maintenance Director indicated as follows:<BR/>Bedroom # (allocated for 2 Beds as per Form 3740)<BR/>101 - 78.32 square feet per bed <BR/>102 - 76.69 square feet per bed <BR/>103 - 78.325 square feet per bed<BR/>104 - 77.255 square feet per bed<BR/>105 - 77.05 square feet per bed<BR/>106 - 75.31 square feet per bed<BR/>107 - 78.31 square feet per bed<BR/>401 - 78.88 square feet per bed<BR/>403 - 71.62 square feet per bed<BR/>404 - 76.18 square feet per bed<BR/>405 - 77.17 square feet per bed<BR/>406 - 73.05 square feet per bed<BR/>and <BR/>room [ROOM NUMBER] (allocated for 3 beds as per Form 3740)<BR/>407 - 48.51 square feet per bed (LSC observation showed only 2 bed allocation based on 2 overbed lights and 2 nurse call fixtures)<BR/>In an interview with the Administrator on 01/18/2023 at 4:30 p.m., the Administrator stated she could not find any documentation for room waivers and would contact her corporate office for further assistance.

Based on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 7 of 21 staff (CNA N, CNA P, CNA Q, CNA R, CNA S, CNA T and LVN V) reviewed for training, in that:<BR/>The facility failed to ensure infection prevention and control training was provided to CNA N, CNA P, CNA Q, CNA R, CNA S, CNA T and LVN V.<BR/>This failure could place residents at risk of illness due to lack of staff training. <BR/>The findings were:<BR/>Review of Facility Staff Roster, undated, revealed: <BR/>CNA N - date of hire - 04/16/2020<BR/>CNA P - date of hire - 07/09/1996<BR/>CNA Q - date of hire - 01/24/2014<BR/>CNA R - date of hire - 08/02/1995<BR/>CNA S - date of hire - 01/27/1983<BR/>CNA T - date of hire - 03/30/2020<BR/>LVN V - date of hire - 01/07/2019<BR/>During a record review and interview with the HR Manager on 01/18/2023 at 2:15 p.m., the HR Manager reviewed the training spreadsheet and confirmed CNA N, CNA P, CNA Q, CNA R, CNA S, CNA T and LVN V had not received infection prevention and control training. The HR Manager stated training was a team effort however it is her responsibility to keep a spread sheet to track which training each employee has taken and when it was completed.<BR/>During an interview with the Administrator on 01/18/2023 at 4:10 p.m., the Administrator stated she would follow up on the training that was missing.<BR/>Record review of the facility's policy titled, Ongoing Staff Training, undated, revealed, Purpose: Provide on-going education for all staff to ensure proficiency and competency. Procedure: 8. Continuing education will include the following topics: .n. Infection control and prevention.

Based on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its resident for 4 of 21 employees (CNA N, CNA R, RN W and LVN X) reviewed for training, in that:<BR/>The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to CNA N, CNA R, RN W and LVN X.<BR/>This failure could affect residents and place them at risk of being uninformed due to lack of staff training. <BR/>The findings were:<BR/>Review of Facility Staff Roster, undated, revealed: <BR/>CNA N - date of hire - 04/16/2020<BR/>CNA R - date of hire - 08/02/1995<BR/>RN W - date of hire - 11/24/2015<BR/>LVN X - date of hire - 06/24/2020<BR/>During a record review and interview with the HR Manager on 01/18/2023 at 2:15 p.m., the HR Manager reviewed the training spreadsheet and confirmed CNA N, CNA R, RN W and LVN X had not received training in resident rights. The HR Manager stated training was a team effort however it is her responsibility to keep a spread sheet to track which training each employee has taken and when it was completed.<BR/>During an interview with the Administrator on 01/18/2023 at 4:10 p.m., the Administrator stated she was not aware resident rights was part of the mandatory training. She stated she will ensure it is added to the list of required training for staff.<BR/>Record review of the facility's policy titled, Ongoing Staff Training, undated, revealed, Purpose: Provide on-going education for all staff to ensure proficiency and competency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #5) reviewed for comprehensive care plans, in that:<BR/>Resident #5's call light was not within reach according to one of the resident's care plan interventions for falls.<BR/>This failure could place the resident at risk of inadequate care that may cause severe injury for the resident.<BR/>The findings included: <BR/>Record review of Resident #5's face sheet, dated 1/31/2025, revealed a [AGE] year old female was admitted on [DATE] with a readmission date of 7/25/2024 with diagnoses that included: anxiety disorder, dementia, and hypertension. <BR/>Record review of Resident #5's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 7 which was indicative of severe cognitive impairment. <BR/>Record review of Resident #5's Care Plan, dated 10/30/2024, revealed the resident was a fall risk and had a fall on 7/21/2024 that resulted in a left hip fracture with one of the interventions was for her call light to be within reach.<BR/>During observation and interview on 1/28/2025 at 12:33 PM revealed Resident #5 was sitting in a chair in her next to the bed. Resident #5's call light was not seen, wrapped around the bed rail and hidden behind her linens on the bed. Resident #5 said when she fell she tried to get out of the bed to go to the bathroom and lost her balance and fractured her left hip. <BR/>During an interview on 1/28/2025 at 12:37 PM, LVN C said Resident #5 would walk around the room independently, but she should have her call light within reach. <BR/>During an interview on 1/31/2025 at 4:50 PM, the DON said it was important for the call light to be in reach for a resident so they could ask for help when needed. The DON said it was important to follow the Care Plan interventions because it was person-centered and determined the best plan of care for the residents' needs to be followed.<BR/>Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered #8, Section M, undated, revealed, The person-centered care plan will: Aid in preventing or reducing decline in the resident's functional status and/or functioning levels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the recommendations from the PASARR level II determination and the PASARR evaluation report were included into a resident's assessment, care planning, and transitions of care for 1 (Resident #5) of 3 residents reviewed for PASARR services, in that: <BR/>Resident #5 did not receive specialized PASRR services as agreed upon during his Interdisciplinary Team meeting. <BR/>This failure could place residents with a positive PASRR evaluation at risk for the loss of opportunity to reach their highest level of functioning and could contribute to a decline in physical, mental, and psychosocial well-being.<BR/>The findings were:<BR/>Record review of Resident #5's face sheet, dated 02/15/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including Hypertensive Heart Disease Without Heart Failure, Other Developmental Disorders of Scholastic Skills, and Anxiety Disorder. <BR/>Record review of Resident #5's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. <BR/>Record review of Resident #5's care plan, revised 12/12/2023, revealed [Resident #5] is PASRR positive d/t [due to] OTHER DEVELOPMENTAL DISORDERS OF SCHOLASTIC SKILLS .<BR/>Further review revealed, 9/19/23 Quarterly [Interdisciplinary Team] meeting . Start: Behavioral Support and [physical therapy/occupational therapy/speech therapy] thru Habilitative services. <BR/>During an interview with the DOR on 02/14/2024 at 2:40 p.m., the DOR stated that Resident #5 had not received habilitative physical therapy, occupational therapy, or speech therapy since 01/04/2024 because the request for reimbursement had not yet been approved. <BR/>During an interview with the DON on 02/16/2024 at 2:30 p.m., the DON confirmed Resident #5 had not received habilitative physical therapy, occupational therapy, or speech therapy since 01/04/2024 and confirmed the resident may experience a functional decline as a result. <BR/>Record review of the facility policy, PASRR, undated, revealed, .the Facility collaborates with local resources when special services are necessary or required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to maintain spaces of at least 80 square feet per resident for 13 (resident rooms #101, 102, 103, 104, 105, 106, 107, 401, 403, 404, 405, 406, and 407) of 34 Resident rooms inspected for resident room sufficient space for privacy and comfort, in that:<BR/>The facility failed to ensure resident rooms #101, 102, 103, 104, 105, 106, 107, 401, 403, 404, 405, 406, and 407 were maintained with at least 80 square feet of space per resident.<BR/>This failure could place residents at risk of restricting their resident rights for comfort and privacy.<BR/>The findings were:<BR/>Record review of the Bed Classification Form 3740 dated 01/15/2023 which was filled out by the Administrator indicated the capacity of the facility was 144 beds.<BR/>In an interview with the Administrator on 01/17/2023 at 3:00 p.m., the Administrator revealed she was not aware of any room waivers for the facility. The Administrator stated the bed classification was accurate and further stated even though some of the rooms were currently being used as private rooms her understanding was, they could be used as semi-private if needed.<BR/>In an interview with the Administrator on 01/18/2023 at 9:35 a.m., the Administrator stated her Maintenance Director would measure the rooms to ensure they meet regulations.<BR/>Review of the measurements provided by LSC, of the bedrooms which were measured and identified by the Maintenance Director indicated as follows:<BR/>Bedroom # (allocated for 2 Beds as per Form 3740)<BR/>101 - 78.32 square feet per bed <BR/>102 - 76.69 square feet per bed <BR/>103 - 78.325 square feet per bed<BR/>104 - 77.255 square feet per bed<BR/>105 - 77.05 square feet per bed<BR/>106 - 75.31 square feet per bed<BR/>107 - 78.31 square feet per bed<BR/>401 - 78.88 square feet per bed<BR/>403 - 71.62 square feet per bed<BR/>404 - 76.18 square feet per bed<BR/>405 - 77.17 square feet per bed<BR/>406 - 73.05 square feet per bed<BR/>and <BR/>room [ROOM NUMBER] (allocated for 3 beds as per Form 3740)<BR/>407 - 48.51 square feet per bed (LSC observation showed only 2 bed allocation based on 2 overbed lights and 2 nurse call fixtures)<BR/>In an interview with the Administrator on 01/18/2023 at 4:30 p.m., the Administrator stated she could not find any documentation for room waivers and would contact her corporate office for further assistance.

Based on interview and record review, the facility failed to provide the required compliance and ethics training for 21 of 21 employees (the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X) reviewed for training requirements, in that:<BR/>The facility failed to ensure compliance and ethics training was provided to the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X.<BR/>This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. <BR/>The findings were:<BR/>Review of Facility Staff Roster, undated, revealed: <BR/>Administrator - date of hire - 01/31/2022<BR/>DON - date of hire - 07/06/2022<BR/>AD - date of hire - 07/09/2019<BR/>FSS - date of hire - 02/09/2014<BR/>PT - date of hire - 01/01/2020<BR/>OT - date of hire - 01/01/2020<BR/>ST - date of hire - 03/18/2020<BR/>ADON K - date of hire - 09/19/2019<BR/>ADON L - date of hire - 04/26/2022<BR/>SW M - date of hire - 03/01/2022<BR/>CNA N - date of hire - 04/16/2020<BR/>CNA O - date of hire - 01/11/2019<BR/>CNA P - date of hire - 07/09/1996<BR/>CNA Q - date of hire - 01/24/2014<BR/>CNA R - date of hire - 08/02/1995<BR/>CNA S - date of hire - 01/27/1983<BR/>CNA T - date of hire - 03/30/2020<BR/>LVN U - date of hire - 06/25/2021<BR/>LVN V - date of hire - 01/07/2019<BR/>RN W - date of hire - 11/24/2015<BR/>LVN X - date of hire - 06/24/2020<BR/>During a record review and interview with the HR Manager on 01/18/2023 at 2:15 p.m., the HR Manager reviewed the training spreadsheet and confirmed the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X had not received compliance and ethics training. The HR Manager stated training was a team effort however it is her responsibility to keep a spread sheet to track which training each employee has taken and when it was completed.<BR/>During an interview with the Administrator on 01/18/2023 at 4:10 p.m., the Administrator stated she was not aware ethics was part of the mandatory training. She stated she will ensure it is added to the list of required training for staff.<BR/>Record review of the facility's policy titled, Ongoing Staff Training, undated, revealed, Purpose: Provide on-going education for all staff to ensure proficiency and competency. Procedure: 8. Continuing education will include the following topics: .i. Ethical issues.

Based on interviews and record reviews, the facility failed to complete the baseline care plan for 1 of 32 residents (Resident #153) reviewed for baseline care plans in that:<BR/>The facility failed to complete (Resident # 153's) baseline care plan within the required time frame.<BR/>This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care.<BR/>The findings were:<BR/>Record review of Resident #153's face sheet dated 02/15/24 with recent admission date of 2/2/24 and diagnoses which included: displaced fracture of the left femur (a left broken thighbone), type 2 diabetes (a condition in which the body has difficulty controlling blood sugar) and atherosclerotic heart disease (an illness in which the heart's arteries are damaged).<BR/>Record review of Resident #153's MDS, completed on 2/10/24, revealed a BIMS score of 10, which indicated moderate cognitive impairment. <BR/>Record review of Resident #153's Baseline Care Plan, shows a completion date of 2/7/24 with a locked finalization date of 2/13/24.<BR/>In an interview with MDS Coordinator B on 02/15/24 at 1:45 p.m., confirmed that the baseline care plan for Resident # 153 was not done within the required time frame of 48 hours after admission. <BR/>In an interview with the ADON on 2/15/24 AT 2:00 p.m., stated that the time frame for completion of the baseline care plan for Resident # 153 was not met. She stated that the baseline care plans were usually completed by the charge nurses. She stated that the completion of the baseline care plan would help staff to understand what is going on with the resident's condition.<BR/>In an interview with the DON on 2/15/24 at 2:20pm confirmed that the baseline care plan for Resident # 153 did not meet the necessary time frames for completion.<BR/>Review of the facility policy and procedure titled, Care Plans-Baseline, (undated), revealed, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission.

Based on interview and record review, the facility failed to provide effective communications mandatory training for 21 of 21 employees (Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X) reviewed for training, in that:<BR/>The facility failed to ensure effective communication training was provided to the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X.<BR/>This failure could place residents at risk of miscommunication and social isolation due to lack of staff training. <BR/>The findings were:<BR/>Review of Facility Staff Roster, undated, revealed: <BR/>Administrator - date of hire - 01/31/2022<BR/>DON - date of hire - 07/06/2022<BR/>AD - date of hire - 07/09/2019<BR/>FSS - date of hire - 02/09/2014<BR/>PT - date of hire - 01/01/2020<BR/>OT - date of hire - 01/01/2020<BR/>ST - date of hire - 03/18/2020<BR/>ADON K - date of hire - 09/19/2019<BR/>ADON L - date of hire - 04/26/2022<BR/>SW M - date of hire - 03/01/2022<BR/>CNA N - date of hire - 04/16/2020<BR/>CNA O - date of hire - 01/11/2019<BR/>CNA P - date of hire - 07/09/1996<BR/>CNA Q - date of hire - 01/24/2014<BR/>CNA R - date of hire - 08/02/1995<BR/>CNA S - date of hire - 01/27/1983<BR/>CNA T - date of hire - 03/30/2020<BR/>LVN U - date of hire - 06/25/2021<BR/>LVN V - date of hire - 01/07/2019<BR/>RN W - date of hire - 11/24/2015<BR/>LVN X - date of hire - 06/24/2020<BR/>During a record review and interview with the HR Manager on 01/18/2023 at 2:15 p.m., the HR Manager reviewed the training spreadsheet and confirmed the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X had not received communication training. The HR Manager stated training was a team effort however it is her responsibility to keep a spread sheet to track which training each employee has taken and when it was completed.<BR/>During an interview with the Administrator on 01/18/2023 at 4:10 p.m., the Administrator stated she was not aware communication was part of the mandatory training. She stated she will ensure it is added to the list of required training for staff.<BR/>Record review of the facility's policy titled, Ongoing Staff Training, undated, revealed, Purpose: Provide on-going education for all staff to ensure proficiency and competency.

Based on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facilities reviewed for nursing services.<BR/>The facility did not have RN coverage for 24 days on 10/5/24, 10/12/24, 10/13/24, 10/20/24, 10/26/24, 10/27/24, 11/16/24, 11/17/24, 11/23/24, 11/24/24, 11/30/24, 12/1/24, 12/7/24, 12/8/24, 12/14/24, 12/15/24, 12/21/24, 12/22/24, 12/28/24, 12/29/24, 1/4/25, 1/5/25, 1/18/25, and 1/19/25.<BR/>This failure could place the residents at risk of not receiving needed care and services.<BR/>The findings were:<BR/>Review of the facility RN timesheets revealed there were no RN hours for Saturdays on 10/5/24, 10/12/24, 10/26/24, 11/16/24, 11/23/24, 11/30/24, 12/7/24, 12/14/24, 12/21/24, 12/28/24, 1/4/25, and 1/18/25.<BR/>Review of the facility RN timesheets revealed there were no RN hours for Sundays on 10/13/24, 10/20/24, 10/27/24, 11/17/24, 11/24/24, 12/1/24, 12/8/24, 12/15/24, 12/22/24, 12/29/24, 1/5/25, and 1/19/25.<BR/>In an interview on 1/31/25 at 9:58 a.m. the DON stated the facility did not currently have a designated weekend RN but ADON's do cover some shifts on the weekends but not all. The DON was unsure if there was an active job posting for an RN on the weekends.<BR/>In an interview on 1/31/25 at 5:23 p.m. the DON stated the facility was actively seeking an RN specifically for weekends and the job was posted online. The DON stated the facility did not have any nursing waivers and the possible consequences for not having a weekend RN would be not having the services of an RN onsite on the weekends.<BR/>In a telephone interview on 1/31/25 at 5:27 p.m. the Administrator stated she was not aware the facility was missing RN coverage for that many days. The Administrator further stated an ADON who was an RN was covering some of the weekend shifts.<BR/>Review of the facility policy on staffing coverage undated revealed . A Registered Nurse (RN) must be onsite 8 consecutive hours a day, 7 days a week .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (excessive dose and duplicative therapy) for 1 of 6 residents (Resident #6) reviewed for unnecessary medications, in that:<BR/>1. Resident #6 received Lorazepam 0.5 mg three times a day for general anxiety disorder. <BR/>2. Resident #6 received Buspirone 7.5 mg three times a day for general anxiety disorder <BR/>This failure could place residents at risk for adverse drug consequences and receiving unnecessary medications.<BR/>The findings were:<BR/>Record review of Resident #6's Face sheet, dated 2/15/24, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: [Generalized anxiety disorder] involves a persistent feeling of anxiety or dread, which can interfere with daily life, [ Major depressive disorder] mood disorder that causes a persistent feeling of sadness and loss of interest, and [Heart failure] occurs when the heart muscle doesn't pump blood as well as it should.<BR/>Record review of Resident #6's Quarterly MDS Assessment , dated 10/20/23, revealed the resident had a BIMS score of 4, which indicated severe cognitive impairment.<BR/>Record review of Resident # 6 's comprehensive physician orders, dated 2/14/24, revealed orders for: <BR/>- Lorazepam 0.5 mg three times a day orally for general anxiety disorder. There was no documentation indicating the need for duplication of therapy. Further review revealed Resident #6 had been on the medication since 1/29/24. <BR/>- Buspirone 7.5 mg three times a day orally for general anxiety disorder. There was no documentation indicating the need for duplication therapy. Further review revealed Resident # 6 had been on medication since 1/28/24. <BR/>Record review of Resident #6's comprehensive care plan, dated 2/14/24, revealed a care plan for Anxiety with interventions to administer medications as ordered. <BR/>Record review of Resident #6's Medicaion Adminstration Record for Febuary 2024 revealed the resident had received Lorazepam and Buspirone three times a day.<BR/>Record review of Resident #6's Pharmacy Consultant's Drug Regimen Reviews, from 01/01/24 to 02/01/24, revealed there was no recommendation for Lorazepam or Buspirone found indicating an issue.<BR/>During an interview with the DON on 02/15/2024 at 1:18 p.m., the DON stated she was unaware Resident #6 was on Lorazepam 0.5 mg three times a day and Buspirone 7.5 mg three times for anxiety. The DON stated these medications could be considered as duplication of therapy and could cause possible side effects when used concurrently. The DON stated the facility did not have a policy to address this issue.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, for 1 of 6 halls (400 hall) reviewed for physical environment, in that:<BR/>The facility failed to secure loose flooring on the 400 hall. <BR/>This failure could place residents who reside in the facility at-risk of falls and further injuries due to an unsafe environment.<BR/>The findings were: <BR/>Observation on 02/15/2024 at 08:35 a.m. revealed the flooring on the 400 hall was loose.<BR/>During an interview with the Maintenance Director on 2/16/2024 at 10:15 a.m., Maintenance Director confirmed there was loose flooring on the 400 hall. <BR/>Record review of the facility's policy titled, Homelike Environment, revised February 2014, revealed, Residents are provided with a safe, clean, comfortable, and homelike environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #5) reviewed for comprehensive care plans, in that:<BR/>Resident #5's call light was not within reach according to one of the resident's care plan interventions for falls.<BR/>This failure could place the resident at risk of inadequate care that may cause severe injury for the resident.<BR/>The findings included: <BR/>Record review of Resident #5's face sheet, dated 1/31/2025, revealed a [AGE] year old female was admitted on [DATE] with a readmission date of 7/25/2024 with diagnoses that included: anxiety disorder, dementia, and hypertension. <BR/>Record review of Resident #5's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 7 which was indicative of severe cognitive impairment. <BR/>Record review of Resident #5's Care Plan, dated 10/30/2024, revealed the resident was a fall risk and had a fall on 7/21/2024 that resulted in a left hip fracture with one of the interventions was for her call light to be within reach.<BR/>During observation and interview on 1/28/2025 at 12:33 PM revealed Resident #5 was sitting in a chair in her next to the bed. Resident #5's call light was not seen, wrapped around the bed rail and hidden behind her linens on the bed. Resident #5 said when she fell she tried to get out of the bed to go to the bathroom and lost her balance and fractured her left hip. <BR/>During an interview on 1/28/2025 at 12:37 PM, LVN C said Resident #5 would walk around the room independently, but she should have her call light within reach. <BR/>During an interview on 1/31/2025 at 4:50 PM, the DON said it was important for the call light to be in reach for a resident so they could ask for help when needed. The DON said it was important to follow the Care Plan interventions because it was person-centered and determined the best plan of care for the residents' needs to be followed.<BR/>Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered #8, Section M, undated, revealed, The person-centered care plan will: Aid in preventing or reducing decline in the resident's functional status and/or functioning levels.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, for 1 of 6 halls (400 hall) reviewed for physical environment, in that:<BR/>The facility failed to secure loose flooring on the 400 hall. <BR/>This failure could place residents who reside in the facility at-risk of falls and further injuries due to an unsafe environment.<BR/>The findings were: <BR/>Observation on 02/15/2024 at 08:35 a.m. revealed the flooring on the 400 hall was loose.<BR/>During an interview with the Maintenance Director on 2/16/2024 at 10:15 a.m., Maintenance Director confirmed there was loose flooring on the 400 hall. <BR/>Record review of the facility's policy titled, Homelike Environment, revised February 2014, revealed, Residents are provided with a safe, clean, comfortable, and homelike environment .

Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 21 of 21 employees (the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X) reviewed for training, in that:<BR/>The facility failed to ensure that quality assurance and performance improvement training was provided to the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X.<BR/>This failure could place residents at risk for injury or improper care due to a lack of training.<BR/>The findings were:<BR/>Review of Facility Staff Roster, undated, revealed: <BR/>Administrator - date of hire - 01/31/2022<BR/>DON - date of hire - 07/06/2022<BR/>AD - date of hire - 07/09/2019<BR/>FSS - date of hire - 02/09/2014<BR/>PT - date of hire - 01/01/2020<BR/>OT - date of hire - 01/01/2020<BR/>ST - date of hire - 03/18/2020<BR/>ADON K - date of hire - 09/19/2019<BR/>ADON L - date of hire - 04/26/2022<BR/>SW M - date of hire - 03/01/2022<BR/>CNA N - date of hire - 04/16/2020<BR/>CNA O - date of hire - 01/11/2019<BR/>CNA P - date of hire - 07/09/1996<BR/>CNA Q - date of hire - 01/24/2014<BR/>CNA R - date of hire - 08/02/1995<BR/>CNA S - date of hire - 01/27/1983<BR/>CNA T - date of hire - 03/30/2020<BR/>LVN U - date of hire - 06/25/2021<BR/>LVN V - date of hire - 01/07/2019<BR/>RN W - date of hire - 11/24/2015<BR/>LVN X - date of hire - 06/24/2020<BR/>During a record review and interview with the HR Manager on 01/18/2023 at 2:15 p.m., the HR Manager reviewed the training spreadsheet and confirmed the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X had not received training in the QAPI program. The HR Manager stated training was a team effort however it is her responsibility to keep a spread sheet to track which training each employee has taken and when it was completed.<BR/>During an interview with the Administrator on 01/18/2023 at 4:10 p.m., the Administrator stated she was not aware QAPI was part of the mandatory training. She stated she will ensure it is added to the list of required training for staff.<BR/>Record review of the facility's policy titled, Ongoing Staff Training, undated, revealed, Purpose: Provide on-going education for all staff to ensure proficiency and competency.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 3 of 10 dietary aides (Dietary Aide H, Dietary Aide I, and Dietary Aide J) reviewed for competencies, in that: <BR/>The facility failed to ensure Dietary Aide H, Dietary Aide I and Dietary Aide J had a Food Handling Certificate prior to working in the facility kitchen. <BR/>This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. <BR/>The findings were: <BR/>Record review of the facility staff roster, undated, revealed Dietary Aide H was a full-time dietary aide with a hire date of 01/11/2023. <BR/>Record review of dietary staff credentials provided by the Food Service Supervisor revealed Dietary Aide H completed the Texas Food Handler Training Certificate Program on 01/17/2023, after surveyor requested dietary staff credentials on 01/15/2023.<BR/>Record review of the facility staff roster, undated, revealed Dietary Aide I was a full-time dietary aide with a hire date of 06/14/2021. <BR/>Record review of dietary staff credentials provided by the Food Service Supervisor revealed Dietary Aide I completed the Texas Food Handler Training Certificate Program on 01/16/2023, after surveyor requested dietary staff credentials on 01/15/2023.<BR/>Record review of the facility staff roster, undated, revealed Dietary Aide J was a part-time dietary aide with a hire date of 12/16/2022. <BR/>Record review of dietary staff credentials provided by the Food Service Supervisor revealed Dietary Aide J completed the Texas Food Handler Training Certificate Program on 01/16/2023, after surveyor requested dietary staff credentials on 01/15/2023.<BR/>During an interview with the Food Service Director on 01/18/2023 at 1:45 p.m., the Food Service Director confirmed she had not provided the certificates upon initial request but had them now. The FSS further stated Dietary Aide H and Dietary Aide J were new employees and that Dietary Aide I had recently transferred to dietary from the housekeeping department.<BR/>During an interview with the HR Manager on 01/18/2023 at 2:00 p.m., the HR Manager revealed Dietary Aide I had transferred from the housekeeping department to dietary on 12/16/2022.<BR/>During an interview with the Administrator on 01/18/2023 at 4:05 p.m., the Administrator stated Dietary Aide I had filled in during a brief time in the kitchen and decided she liked that department and put in for a request. The Administrator further stated dietary staff are required to have a Food Handler's Certificate prior to working in the kitchen and confirmed the certificates for Dietary Aide H, Dietary Aide I and Dietary Aide J were dated after surveyor request on 01/15/2023.<BR/>Record review of the facility's job description, Dietary Aide, undated, revealed, Required Education and Experience: Food Handler certification pursuant to requirements by the State.<BR/>Record review of the facility's policy, Dietary Staffing, undated, revealed, Ensure there is sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, for 1 of 6 halls (400 hall) reviewed for physical environment, in that:<BR/>The facility failed to secure loose flooring on the 400 hall. <BR/>This failure could place residents who reside in the facility at-risk of falls and further injuries due to an unsafe environment.<BR/>The findings were: <BR/>Observation on 02/15/2024 at 08:35 a.m. revealed the flooring on the 400 hall was loose.<BR/>During an interview with the Maintenance Director on 2/16/2024 at 10:15 a.m., Maintenance Director confirmed there was loose flooring on the 400 hall. <BR/>Record review of the facility's policy titled, Homelike Environment, revised February 2014, revealed, Residents are provided with a safe, clean, comfortable, and homelike environment .

Based on observation, interviews and record reviews, the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 medication cart checked (Hall 600) out of 4 medication carts checked for storage practices in that:<BR/>1 bottle of Dermarite Proheal Liquid Protein (A medical food developed for the dietary management of wounds and conditions requiring supplemental protein) had an opened date of 11/17/2022 written on it and 1 bottle of Nutricia Uti-Stat (a ready to drink medical food providing cranberry concentrate with added nutrients) had an opened date of 10/06/2022 written on it and both had passed the manufacturer discard dates after opening were located inside the 600 Hall medication cart<BR/>This deficient practice could affect residents who receive medications with manufacturers recommendations for discard after opening and could result in diminished effectiveness.<BR/>The findings were:<BR/>Observation on 01/16/2023 at 1:50 p.m. with LVN D, checked medication storage for the 600 Hall medication cart and one bottle of Dermarite Proheal Liquid Protein labeled with an opened date of 11/17/2022. The bottle had manufacturers recommendations listed on the back of the label: Discard 60 days after opening. One bottle of Nutricia Uti-Stat had an opened date of 10/6/2022 with manufacturers recommendations listed on the back of the label Discard 3 months after opening.<BR/>Interview on 1/16/2023 at 2:00 p.m. with LVN D revealed it is important to follow manufacturer's recommendations because the effectiveness of the medicated solution could decrease and not provide the desired effects. He stated that pharmacy checks the medication carts and the nurses, and he did not realize the solutions had recommended discard dates after being opened.<BR/>Interview on 01/18/2023 at 12:58 p.m. with the DON revealed she was informed the solutions were expired and she contacted the pharmacist that had just been at the facility two weeks prior to do medication cart audits about the expiration date requirements and the Pharmacist confirmed the solutions were out of date with the manufacturer's recommendations. She stated that harm of taking the protein solution after the discard date was it could cause a resident to have nausea and vomiting.<BR/>Review of the facility policy and procedure titled Storage of Medications (undated) revealed Ensure that medications are stored in a safe, secure and orderly manner .no discontinued, outdated or deteriorated medications are to be used for use in this facility. All such medications are destroyed according to facility policy.

**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 1 of 6 residents (Resident #92) reviewed for infection control, in that:<BR/>While providing incontinent care for Resident #92 CNA F did not wash or sanitize her hands between change of gloves before touching the resident's clean brief and after cleaning the resident's buttocks' area. <BR/>These deficient practices could place residents at-risk for infection due to improper care practices. <BR/>The findings include:<BR/>Record review of Resident #92's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating severe cognitive impairment. Resident #92 required extensive assistance, was occasionally incontinent of bladder and frequently incontinent of bowel. <BR/>Observation on 01/17/23 at 10:15 a.m. revealed during incontinent care, after cleaning Resident #92's buttocks , CNA F changed her pair of gloves but did not sanitize her hands. The resident had had a bowel movement. CNA F, then, applied clean briefs to the resident and fastened them. <BR/>During an interview with CNA F on 01/17/2023 at 10:25 a.m., the CNA verbally confirmed not washing or sanitizing her hands. She confirmed receiving infection control in service multiple times in the last year. She forgot to wash her hands. <BR/>During an interview with the DON on 01/18/2023 at 10:30 a.m., the DON verbally confirmed the staff needed to sanitize their hands between change of gloves. The staff was trained multiple times a year on infection control and they did return demonstration with skill checks. The DON agreed it was a risk for infection for the resident. <BR/>Review of CNA F's Certified nurse aide proficiency audit, dated 07/06/2022 revealed CNA F received proficiency for perineal care and infection control. <BR/>Review of facility's policy, titled Hand Hygiene , undated, revealed Hands should be washed for 20 seconds using soap and water under the following conditions: [ .] i. after contact with blood, body fluids, excretions, secretions, mucous membrane or non intact skin, [ .] l. before putting on gloves, m. after removing gloves

Based on interviews and record reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 1 of 1 Activity Director, reviewed in that: <BR/>The facility failed to ensure the AD was qualified to serve as the director of the activities program. <BR/>This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.<BR/>The findings were: <BR/>Record review of staff roster, provided by the facility, undated, revealed the staff member was listed as Activities Director. Further review revealed the AD was hired on 07/09/2019. <BR/>Record review of a document provided by the AD revealed a certificate titled, Modular Education Program for Activity Professionals MEPAP 2nd Edition. Further review revealed the program provided 90 hours of instruction and 90 hours of practicum Advanced Technology Course (Part One of Two Parts) Activity Director Home Study Course, with a start date of 10/28/2017 and completion date of 03/01/2018. <BR/>Review of Modular Education Program for Activity Professionals, website, https://activityadvisor.org/, on 01/18/2023 revealed the MEPAP course is divided into two parts-MEPAP Part One and MEPAP Part Two. Further review revealed Activity Professional Certified (APC) requires only the MEPAP Part One.<BR/>Review of National Certification Council for Activity Professionals, website, https://nccap.org/, on 01/18/2023 revealed Certification Renewals: Renewal is required every 2 years. APC: 20 CE (Continuing Education) hours every 2 years.<BR/>Record review of a certificate of completion provided by the AD revealed the AD completed 8 continuing education hours for Activity Directors on October 2, 2020.<BR/>During an interview with the HR Manager on 01/18/2023 at 2:05 p.m., the HR Manager was asked for documentation of the AD's certification and any continuing education. The HR Manager stated she and did not have that information on file but called the AD to the office to provide the requested documentation.<BR/>During an interview with the AD on 01/18/2023 at 2:45 p.m., the AD revealed she became certified in 2018 and completed continuing education to renew in 2020. The AD stated when it was time to renew again in 2022 the facility had positive cases of COVID, and she was not allowed to attend training.<BR/>During an interview with the Administrator on 01/18/2023 at 3:10 p.m., the Administrator stated she did recall the AD informed her the facility where the continuing education was held had requested staff not attend if they worked in a facility currently caring for COVID positive residents. The Administrator further stated she had thought the AD had looked for some on-line renewal training at that time.<BR/>Record review of the AD's job description provided by the facility revealed a section, Required Education and Experience: Qualified therapeutic recreation specialist or activities professional who is licensed and registered by the State; Certified as a therapeutic recreation specialist or activities professional by a recognized accrediting body.

Based on interview and record review, the facility failed to provide effective behavioral health mandatory training for 21 of 21 employees (Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X) reviewed for training, in that: <BR/>The facility failed to ensure effective behavioral health training was provided to the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X.<BR/>This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. <BR/>The findings were:<BR/>Review of Facility Staff Roster, undated, revealed: <BR/>Administrator - date of hire - 01/31/2022<BR/>DON - date of hire - 07/06/2022<BR/>AD - date of hire - 07/09/2019<BR/>FSS - date of hire - 02/09/2014<BR/>PT - date of hire - 01/01/2020<BR/>OT - date of hire - 01/01/2020<BR/>ST - date of hire - 03/18/2020<BR/>ADON K - date of hire - 09/19/2019<BR/>ADON L - date of hire - 04/26/2022<BR/>SW M - date of hire - 03/01/2022<BR/>CNA N - date of hire - 04/16/2020<BR/>CNA O - date of hire - 01/11/2019<BR/>CNA P - date of hire - 07/09/1996<BR/>CNA Q - date of hire - 01/24/2014<BR/>CNA R - date of hire - 08/02/1995<BR/>CNA S - date of hire - 01/27/1983<BR/>CNA T - date of hire - 03/30/2020<BR/>LVN U - date of hire - 06/25/2021<BR/>LVN V - date of hire - 01/07/2019<BR/>RN W - date of hire - 11/24/2015<BR/>LVN X - date of hire - 06/24/2020<BR/>During a record review and interview with the HR Manager on 01/18/2023 at 2:15 p.m., the HR Manager reviewed the training spreadsheet and confirmed the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X had not received training in behavioral health. The HR Manager stated training was a team effort however it is her responsibility to keep a spread sheet to track which training each employee has taken and when it was completed.<BR/>During an interview with the Administrator on 01/18/2023 at 4:10 p.m., the Administrator stated she was not aware behavioral health was part of the mandatory training. She stated she will ensure it is added to the list of required training for staff.<BR/>Record review of the facility's policy titled, Ongoing Staff Training, undated, revealed, Purpose: Provide on-going education for all staff to ensure proficiency and competency. Procedure: 8. Continuing education will include the following topics: .b. Behavioral issues.

Based on observation, interviews and record reviews, the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 medication cart checked (Hall 600) out of 4 medication carts checked for storage practices in that:<BR/>1 bottle of Dermarite Proheal Liquid Protein (A medical food developed for the dietary management of wounds and conditions requiring supplemental protein) had an opened date of 11/17/2022 written on it and 1 bottle of Nutricia Uti-Stat (a ready to drink medical food providing cranberry concentrate with added nutrients) had an opened date of 10/06/2022 written on it and both had passed the manufacturer discard dates after opening were located inside the 600 Hall medication cart<BR/>This deficient practice could affect residents who receive medications with manufacturers recommendations for discard after opening and could result in diminished effectiveness.<BR/>The findings were:<BR/>Observation on 01/16/2023 at 1:50 p.m. with LVN D, checked medication storage for the 600 Hall medication cart and one bottle of Dermarite Proheal Liquid Protein labeled with an opened date of 11/17/2022. The bottle had manufacturers recommendations listed on the back of the label: Discard 60 days after opening. One bottle of Nutricia Uti-Stat had an opened date of 10/6/2022 with manufacturers recommendations listed on the back of the label Discard 3 months after opening.<BR/>Interview on 1/16/2023 at 2:00 p.m. with LVN D revealed it is important to follow manufacturer's recommendations because the effectiveness of the medicated solution could decrease and not provide the desired effects. He stated that pharmacy checks the medication carts and the nurses, and he did not realize the solutions had recommended discard dates after being opened.<BR/>Interview on 01/18/2023 at 12:58 p.m. with the DON revealed she was informed the solutions were expired and she contacted the pharmacist that had just been at the facility two weeks prior to do medication cart audits about the expiration date requirements and the Pharmacist confirmed the solutions were out of date with the manufacturer's recommendations. She stated that harm of taking the protein solution after the discard date was it could cause a resident to have nausea and vomiting.<BR/>Review of the facility policy and procedure titled Storage of Medications (undated) revealed Ensure that medications are stored in a safe, secure and orderly manner .no discontinued, outdated or deteriorated medications are to be used for use in this facility. All such medications are destroyed according to facility policy.

**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 1 of 6 residents (Resident #92) reviewed for infection control, in that:<BR/>While providing incontinent care for Resident #92 CNA F did not wash or sanitize her hands between change of gloves before touching the resident's clean brief and after cleaning the resident's buttocks' area. <BR/>These deficient practices could place residents at-risk for infection due to improper care practices. <BR/>The findings include:<BR/>Record review of Resident #92's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating severe cognitive impairment. Resident #92 required extensive assistance, was occasionally incontinent of bladder and frequently incontinent of bowel. <BR/>Observation on 01/17/23 at 10:15 a.m. revealed during incontinent care, after cleaning Resident #92's buttocks , CNA F changed her pair of gloves but did not sanitize her hands. The resident had had a bowel movement. CNA F, then, applied clean briefs to the resident and fastened them. <BR/>During an interview with CNA F on 01/17/2023 at 10:25 a.m., the CNA verbally confirmed not washing or sanitizing her hands. She confirmed receiving infection control in service multiple times in the last year. She forgot to wash her hands. <BR/>During an interview with the DON on 01/18/2023 at 10:30 a.m., the DON verbally confirmed the staff needed to sanitize their hands between change of gloves. The staff was trained multiple times a year on infection control and they did return demonstration with skill checks. The DON agreed it was a risk for infection for the resident. <BR/>Review of CNA F's Certified nurse aide proficiency audit, dated 07/06/2022 revealed CNA F received proficiency for perineal care and infection control. <BR/>Review of facility's policy, titled Hand Hygiene , undated, revealed Hands should be washed for 20 seconds using soap and water under the following conditions: [ .] i. after contact with blood, body fluids, excretions, secretions, mucous membrane or non intact skin, [ .] l. before putting on gloves, m. 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 that residents had the right to receive reasonable accommodation of resident needs and preferences that would not endanger the health or safety of the residents for 1 of 6 residents (Resident #5) reviewed for reasonable accommodations of needs and preferences, in that:<BR/>The facility failed to ensure Resident #5's call light was within reach.<BR/>This failure could place the residents at risk of failing to achieve or failing to maintain independent functioning, dignity, and well-being.<BR/>Findings included: <BR/>Record review of Resident #5's face sheet, dated 1/31/2025, revealed a [AGE] year old female was admitted on [DATE] with a readmission date of 7/25/2024 with diagnoses that included: anxiety disorder, dementia, and hypertension. <BR/>Record review of Resident #5's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 7 which was indicative of severe cognitive impairment. <BR/>Record review of Resident #5's Care Plan, dated 10/30/2024, revealed the resident was a fall risk and had a fall on 7/21/2024 that resulted in a left hip fracture with one of the interventions was for her call light to be within reach.<BR/>During observation and interview on 1/28/2025 at 12:33 PM revealed Resident #5 was sitting in a chair next to the bed. Resident #5's call light was not seen, wrapped around the bed rail and hidden behind her linens on the bed. Resident #5 said when she fell, she tried to get out of the bed to go to the bathroom and lost her balance and fractured her left hip. <BR/>During an interview on 1/28/2025 at 12:37 PM, LVN C said Resident #5 would walk around the room independently, but she should have her call light within reach. <BR/>During an interview on 1/31/2025 at 4:50 PM, the DON said it was important for the call light to be in reach for a resident so they could ask for help when needed. The DON said it was important because of the risk of more falls and more injuries they could potentially be fatal.<BR/>Record review of the facility policy, on 1/31/2025 not dated titled: Answering the Call Light stated in part: The facility maintains a functional call light system. This is the means of calling the staff, for the residents who are able to use the facility's existing call light system. The staff shall ensure that the call lights are within reach, at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #5) reviewed for comprehensive care plans, in that:<BR/>Resident #5's call light was not within reach according to one of the resident's care plan interventions for falls.<BR/>This failure could place the resident at risk of inadequate care that may cause severe injury for the resident.<BR/>The findings included: <BR/>Record review of Resident #5's face sheet, dated 1/31/2025, revealed a [AGE] year old female was admitted on [DATE] with a readmission date of 7/25/2024 with diagnoses that included: anxiety disorder, dementia, and hypertension. <BR/>Record review of Resident #5's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 7 which was indicative of severe cognitive impairment. <BR/>Record review of Resident #5's Care Plan, dated 10/30/2024, revealed the resident was a fall risk and had a fall on 7/21/2024 that resulted in a left hip fracture with one of the interventions was for her call light to be within reach.<BR/>During observation and interview on 1/28/2025 at 12:33 PM revealed Resident #5 was sitting in a chair in her next to the bed. Resident #5's call light was not seen, wrapped around the bed rail and hidden behind her linens on the bed. Resident #5 said when she fell she tried to get out of the bed to go to the bathroom and lost her balance and fractured her left hip. <BR/>During an interview on 1/28/2025 at 12:37 PM, LVN C said Resident #5 would walk around the room independently, but she should have her call light within reach. <BR/>During an interview on 1/31/2025 at 4:50 PM, the DON said it was important for the call light to be in reach for a resident so they could ask for help when needed. The DON said it was important to follow the Care Plan interventions because it was person-centered and determined the best plan of care for the residents' needs to be followed.<BR/>Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered #8, Section M, undated, revealed, The person-centered care plan will: Aid in preventing or reducing decline in the resident's functional status and/or functioning levels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident with a mental disorder was screened prior to admission for 1 of 3 of (#2) residents reviewed for PASRR: <BR/>The facility did not correctly identify Resident #2 on the PASRR Level 1 Screening Form as having Mental Illness and did not submit a request to correct their PASRR negative screening. <BR/>This failure could affect residents with mental illness that was not considered to be a Positive PASRR and could result in a decrease in services. <BR/>The Findings were:<BR/>Record review of Resident #2's Face sheet, dated 02/14/2024, revealed an [AGE] year-old, admitted on [DATE] and was diagnosed with schizoaffective [a condition where symptoms of both psychotic and mood disorders are present together during one episode], bipolar [causes extreme mood swings that include emotional highs (mania or hypomania) and lows] and [Type two Diabetes] health condition that affects how your body turns food into energy. <BR/>Record review of Resident #2's Quarterly MDS dated [DATE] section I Active Diagnoses, psychiatric/mood disorder revealed a diagnosis of schizoaffective disorder / bipolar disorder. <BR/>Record review of Resident # 2 quarterly MDS dated [DATE] revealed a BIMS score of 10, indicating cognition was moderately impaired.<BR/>Record review of Resident # 2's physician orders for February 2024, revealed an order for Depakote Sprinkles 125 mg daily for schizophrenia. <BR/>Record review of Resident # 2's care plan dated 5/11/22 revealed care plan Behavior problem Schizophrenia interventions Administer medication as ordered. <BR/>Record review of Resident #2's PASSR (Preadmission Screening & Resident Review) Level one, prior to this SNF, dated 7/1/2022, was positive for Mental Illness. <BR/>Interview on 02/14/2024 at 1:58 PM with the MDS Nurse revealed when asked if she knew that Resident #2 diagnosis of schizoaffective and bipolar disorder should trigger a positive PASRR screening, she responded that she was not aware that she probably inputted the wrong PL 1 information and would correct the mistake at this time. She noted that by this information not being reported accurately, residents risked possibly not receiving the services needed. <BR/>Interview on 02/14/2024 at 3:58 PM with the DON stated the MDS nurse was responsible for residents with positive PASRR. The DON stated if PASSR was not completed correctly, it could affect the resident by not receiving services. <BR/>Record review of the Policy PASRR (preadmission and screening resident review), undated, revealed, If the PASSR Level 1 screening indicates the individual may have an ID, DD or MI diagnosis, follow the state specific process for completion of the level II evaluation.