CORONADO HEALTHCARE CENTER

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 employees (CNA A, LVN B and RNRS C) reviewed for infection control.<BR/>The facility failed to ensure CNA A, LVN B, and RNRS C practiced proper hand hygiene while serving and assisting residents during the lunch meal on 2/5/25.<BR/>This failure could place residents at risk of the spread of communicable diseases and infections and a diminished quality of life.<BR/>Findings included:<BR/>An observation of the lunch meal on 02/05/2025 between 12:00PM and 12:30PM revealed CNA A, LVN B and RNRS C assisted in the dining room.<BR/>CNA A was observed using ABHR while standing in the service line. CNA A placed her hands in her pockets immediately after the use of ABHR and they remained in her pockets until she received a resident tray from the kitchen. CNA A left the service line with the resident's tray. While on her way to deliver the tray, CNA A dropped a single-serving butter pat on the floor. CNA A was then observed to pick up the butter pat from the floor and place it back on the resident's tray. She delivered the tray to the resident and returned to the service line, without sanitizing her hands. CNA A was observed several times during the luncheon service, using ABHR and then placing her hands in her pockets or on her hips while waiting.<BR/>LVN B was observed using ABHR upon entry to the dining room, but then placed her hands on her hips, touching her clothing. LVN B's hands remained on her hips while she was waiting for a tray from the service line. LVN B received a tray from the kitchen and served it to a resident without re-sanitizing her hands.<BR/>RNRS C was observed leaning against the ice machine, with her right hand resting on top of the machine. The RNRS then received a tray from the kitchen and proceeded to help a resident who needed set-up and minimal feeding assistance with his meal.<BR/>An interview with RNRS C on 02/05/2025 at 1:47PM reflected she was aware of the lapse in hand hygiene and would take steps to do things better next time. RNRS C stated the negative outcome of not sanitizing her hands between resident trays was the possibility of cross-contamination or spreading of germs which might be infectious.<BR/>An interview with LVN B on 02/05/2025 at 1:51PM reflected she denied the lapse in hand-hygiene. LVN B stated the negative outcome of not sanitizing her hands between resident trays would be the potential transmission of infections. <BR/>Record review of the facility's employee roster reflected LVN B was the only employee with her first and last name, working at the facility, which indicated LVN B was the only LVN in the dining room during the lunch meal.<BR/>An interview with CNA A on 02/05/2025 at 2:00PM revealed she realized the lapse in hand hygiene as soon as she received the resident's tray from the kitchen. CNA A stated the negative outcome of not practicing proper hand hygiene would be the spread of germs or sicknesses.<BR/>An interview with the ADON on 02/05/2025 at 3:15PM revealed LVN B did not take responsibility for her actions at times, did not like to be questioned about her abilities. The ADON stated LVN B had been coached regarding customer service and employee relations. The ADON stated an in-service was going to be done on hand hygiene, starting immediately and would be passed on to the night supervisor for training of the night staff.<BR/>Record review of facility policy and procedures for hand hygiene dated 01/20/2023 revealed the following:<BR/>Policy Interpretation and Implementation:<BR/>1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.<BR/>3. Wash hands with soap; and water, when hands are visibly soiled and after contact with a resident with an infectious diagnosis.<BR/>4. Use an alcohol-based hand rub containing at least 60%-95% ethanol alcohol or isopropyl alcohol.<BR/>Procedure:<BR/>Using Alcohol-Based Hand Rubs:<BR/>1. Apply generous amount of product to palm of hand and rub hands together.<BR/>2. Cover all surfaces of hands and fingers until hands are dry<BR/>The facility did not have a policy regarding hand hygiene while serving resident meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of the residents needs and preferences for 2 of 16 residents (Resident # 3, #13) reviewed for accommodation of needs. <BR/>Resident #3 and #13's call light were not within reach . <BR/>This failure could place residents at risk of not having their needs met and a decline in their quality of care and life.<BR/>Findings included:<BR/>Record review of Resident #3's face sheet, dated 10/29/2024, revealed an [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, difficulty in walking, legal blindness, and hearing loss.<BR/>Record review of Resident #3's annual MDS dated [DATE], revealed a BIMS score of 3 out of 15 which indicated severe cognitive impairment. Resident #3 required maximal assistance with chair bed transfer and walking 50 feet.<BR/>Record review of Resident #3's care plan dated 08/29/2024 revealed, in part, Resident #3 had occasional bowel and bladder incontinence with an approach to have the call light in reach.<BR/>Record review of Resident #13's face sheet, dated 10/29/2024, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease, parkinsonism, muscle wasting and atrophy, and need for assistance with personal care.<BR/>Record review of Resident #13's quarterly MDS, dated [DATE], revealed a BIMS score of 08 out of 15 which indicated moderately impaired cognition. Resident #13 required extensive two-person staff assistance with bed mobility and dressing, and total two-person staff dependence with transferring.<BR/>Record review of Resident #13's care plan, dated 08/09/2024, revealed, in part, Resident #13 was at risk for injuries from falling with an approach to make sure the call light was within reach.<BR/>During an observation on 10/28/2024 at 10:00 AM, Resident #3 was sleeping in her recliner. The recliner was on the adjacent wall from her bed. The call light was next to her bed out of reach from the resident sitting in the recliner.<BR/>During an interview on 10/28/2024 at 10:05 AM, LVN C said that Resident #3 yells for help so they have her room located near the nurse's station so they can hear her when she needs them.<BR/>During an observation on 10/28/2024 at 1:58 PM Resident #13 was lying in her bed asleep. The call light was located on her dresser out of reach of the resident.<BR/>During an interview on 10/28/2024 at 1:50 PM, CNA A came into the Resident #13's room and said that the call light should be attached to the resident's blanket so she could call for help. CNA A said the Hospice nurses had given her a bath and must not have put the call light on her blanket. CNA A said that the resident usually pounds on the wall when she needs help. CNA A said that the call light should have been near the resident . <BR/>During on observation on 10/28/2024 at 1:53 PM, Resident #3 was sleeping in her recliner. The recliner was on the adjacent wall from her bed. The call light was next to her bed out of reach from the resident sitting in the recliner.<BR/>During an interview on 10/28/2024 at 5:30 PM, Resident #3's family member stated that Resident #3 was legally blind and was unable to hear well. Resident #3 said that if a call light was near Resident #3, she would use it to call for help.<BR/>During on observation on 10/29/2024 at 8:29 AM, Resident #3 was sleeping in her recliner. The recliner was on the adjacent wall from her bed. The call light was next to her bed out of reach from the resident sitting in the recliner.<BR/>During an observation on 10/29/24 at 8:39 AM, Resident #13 was lying in her bed sleeping. The call light was out of reach of the resident located on her side dresser. The State Surveyor observed CNA B to be walking down the hall. The State Surveyor pounded on the wall but observed CNA B to walk by without acknowledging the noise.<BR/>During an interview and observation on 10/29/2024 at 8:41 AM, CNA B stated she did not hear the pounding on the wall by the state surveyor. CNA B was observed putting the call light on Resident #13's blanket. CNA B said that she had observed Resident #13 using the call light and that it should have been on her blanket so she could call for help if needed. CNA B said that all staff were responsible for making sure call lights were near residents and a possible negative outcome for not having the call light in reach would be that the resident could fall out of bed.<BR/>During an interview on 10/30/2024 at 9:14 AM the ADM said that a possible negative outcome for not having a call light near a resident would be that a resident would not be able to call for help. The ADM stated that nurses were responsible for ensuring call light placement.<BR/>During an interview on 10/30/2024 at 10:45 AM, the DON said that a possible negative outcome for not having a call light near a resident would be a delay in care for that resident. <BR/>During an interview on 10/30/2024 at 11:05 AM, the Corporate RN said that a possible negative outcome for not having a call light near a resident would be a delay in care and it was unacceptable. The Corporate RN said that staff were responsible for ensuring call lights were near residents.<BR/>Record Review of Answering the Call light policy dated March 2021 revealed the following:<BR/> When a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interviews and record review, the facility failed to demonstrate their response and rationale regarding the resident's council's grievances after group meetings concerning issues of resident care and life in the facility for 1 of 1 resident council.<BR/>The facility failed to ensure feedback and concerns expressed in the resident council meetings were addressed by the facility staff for the past seven months. <BR/>This deficient practice could affect the residents who attended resident council meetings for the past seven months and place them at-risk to decrease quality of life and contribute to grievances not being resolved.<BR/>The findings were: <BR/>Record review of Resident Council Meetings from March 2024 to September 2024 revealed there was no complete feedback or response to the concerns made at the resident council meetings.<BR/>Record review of Resident Council Minutes dated 03/27/2024 revealed concerns about missing clothes and not enough snacks for all residents.<BR/>Record review of Resident Council Minutes dated 04/30/2024 revealed concerns about missing clothes.<BR/>Record review of Resident Council Minutes dated 05/29/2024 revealed concerns about missing clothes.<BR/>Record review of Resident Council Minutes dated 06/26/2024 revealed concerns about missing clothes.<BR/>Record review of Resident Council Minutes dated 07/03/2024 revealed concerns about missing clothes and drinks at night.<BR/>Record review of Resident Council Minutes dated 08/28/2024 revealed concerns about missing clothes.<BR/>Record review of Resident Council Minutes dated 09/25/2024 revealed concerns about missing clothes and not enough snacks.<BR/>During an interview on 10/28/2024 at 10:30 AM, an anonymous resident stated they do not get snacks daily and the only reason they were getting snacks was because the state was here. The resident also said that staff do not pass out snacks they sit at the counter.<BR/>During an interview on 10/28/2024 at 11:00 AM, an anonymous resident said that some residents take 3 or 4 snacks at a time so there was not enough for everyone.<BR/>During an interview on 10/28/2024 at 2:00 PM with residents in group, 10 of 13 residents revealed there had been concerns with missing clothes and they felt that the staff were not listening to their concerns. The, residents stated that nothing was getting done about the missing items. The residents stated that their clothing was being sent to the laundry and they would not get their clothing back or they would get clothes that did not belong to them. One resident during the group meeting stated that he wore large boxer underwear, and, on several occasions, he would get back small or medium underwear. During the meeting the group also stated that there were not enough snacks available for all residents. The group said that these concerns were brought up in the meetings but nothing changes. The resident's stated clothes were still coming up missing and not enough snacks were being offered for the entire resident population. One resident in the group was a diabetic and she stated that the snacks that were left out were full of sugar and she was not able to eat them due to her diabetes. Another resident stated that he had gone to bed hungry before because he did not have a good meal at dinner and the snacks that were left out were gone by the time, he got to the nurse's station where the snacks were located. <BR/>During an interview at 10/29/2024 at 10:35 AM, an anonymous resident said if you were in bed and can't get up, you don't get a snack because the staff will not pass the snacks out.<BR/>During an interview at 10/30/2024 at 8:35 AM, an anonymous resident said she had lost several clothing items and she felt staff were not listening to her concerns related to the missing items. The resident said she had to sleep in her sweats one night because she had three pair of pajamas that were still missing. The resident said she had informed the staff during resident council but had not received any feedback about her missing items.<BR/>During an interview with the AD on 10/30/2024 at 8:39 AM, the AD stated she took notes for the meeting. The AD said she did not feel that missing clothes were a big concern because the facility gets donations.; If a resident had anything missing, they can get items from the donations pile. The AD said the residents have valid concerns regarding the lack of snacks and was unsure if their concerns were being heard because some residents take more snacks than they should. The AD said she did not think there was a negative outcome for missing clothing or not enough snacks for residents because of the donations that were given to the facility and that nurses have a key to the kitchen if a resident wanted food.<BR/>During an observation on 10/30/2024 at 10:05 AM the State Surveyor observed the snack cart being unattended at the nurse's station.<BR/>During an interview on 10/30/2024 at 10:10 AM, LVN D stated that the snacks were left at the nurse's station for residents to get a snack and some residents take more than their share of snacks.<BR/>During an interview with the LS on 10/30/2024 at 10:18 AM, the LS said that she was also filling in as the dietary supervisor until the new one starts. The LS said the donated clothing was put in with the resident's lost and found laundry. The LS said that a possible negative outcome for mixing the lost and found laundry and the donations was that a resident may see their lost item on another resident and become angry thinking their items were stolen. The LS said that no one had discussed or implemented any changes in the way laundry was handled or stored. The LS said the snacks were left at the nurse's station and not passed out to residents; it was a first come first serve type situation. The LS said it was common for residents to hoard snacks causing other residents not to get one. The LS said that she believed that snacks should be passed out to each resident, so everyone had a chance to get a snack. The LS stated that she informed Administration that leaving the snack cart unattended at the nurse's station was causing issues with residents not receiving snacks because some residents were taking more than their share, but nothing had been done.<BR/>During an observation on 10/30/2024 at 10:18 AM the State Surveyor observed a stack of donated clothing and the lost and found clothing in same the area stacked together in the laundry room.<BR/>During an interview with the DON on 10/30/2024 at 10:45 AM, the DON said that possible negative outcome for not listening to the residents about their concerns with the laundry or snacks could be a dignity issue as they feel they were not being heard.<BR/>During an interview with the ADM on 10/30/2024 at 11:00 AM, the ADM said that he was responsible for the grievances and the AD tells him of any issues with the group meetings. The ADM said that a possible negative outcome for not listening to the residents about their concerns with laundry or snacks was they may feel that their concerns do not matter.<BR/>During an interview with the DON on 10/30/2024 at 1:15 PM revealed that she acknowledged that there had been issues with the not having enough snacks.<BR/>Record review of facility's policy on grievances dated 1/12/2023 revealed the following:<BR/>The resident has a right to organize and participate in resident groups in the facility. The facility must consider the views of a resident or family group and act promptly upon the grievance and recommendation of such groups concerning issues of resident care and life in the facility.

Based on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the facility's kitchen, reviewed for kitchen sanitation. <BR/>1. The facility failed to ensure refrigerated foods were properly labeled and dated.<BR/>2. The facility failed to ensure pantry foods were properly labeled and dated.<BR/>3. The facility failed to ensure expired foods were not in the pantry and refrigerator.<BR/>4. The facility failed to ensure food service workers wore gloves.<BR/>These failures could place residents at risk for food-borne illness.<BR/>Findings include:<BR/>Observation of the kitchen staff on 4/4/23 at 9:18 AM revealed the following:<BR/>Two dietary service workers were not wearing gloves while preparing resident food.<BR/>Observation of the refrigerator on 4/4/23 at 9:22 AM revealed the following:<BR/> -Five gallons of milk with best by date 4/1/23.<BR/> -75 4-ounce cartons of chocolate milk had no date.<BR/> -Two heads of lettuce had no date.<BR/> -4 large food service bags of cole slaw mix, had no date.<BR/> -1 food service box of fresh tomatoes had no date.<BR/> -3 gallons of maple syrup were open, with no date.<BR/> -1 gallon of fruit punch had no date.<BR/> -1 gallon of lemonade had no date.<BR/> -19 &frac12; dozen fresh eggs, had no date.<BR/> -4, 5-pound containers of cottage cheese with best by date 3/25/23.<BR/> -10 individual glasses of apple juice, covered, with no date.<BR/> -10 individual glasses of tomato juice, covered, with no date.<BR/> -5, 1-gallon food service containers of mayonnaise had no date.<BR/> -1 gallon of Worcestershire sauce, was opened with an expiration date of 2/21/23.<BR/>Observation of the walk-in pantry on 4/4/23 at 9:51 AM revealed the following:<BR/>-1 Food Service box of dry pasta, was opened to the air, with an expiration date of 9/21.<BR/>-6 boxes of wild rice pilaf, had no date.<BR/>-1 open bag of Fritos corn chips had no date and was closed with a paper clip.<BR/>-1 open bag of dry mashed potato flakes had no date and was closed with a paper clip.<BR/>-10 Food Service canisters of oatmeal, had no date.<BR/>-1 Food Service bag of bread pudding mix, had no date.<BR/>-2 Food Service loaves of white bread, had no date.<BR/>-15 Food Service bags of hot dog buns, had no date.<BR/>-4 Food Service bags of hamburger buns, had no date<BR/>-2 Food Service bags of turkey gravy mix, had no date.<BR/>-2 Food Service bags of peppered gravy mix, had no date.<BR/>-1 Food Service container of chicken base mix, had no date.<BR/>Observation of residents who were in the dining room at the time of the noon dining service revealed 2 residents were witnessed dipping their personal cups into the facility's ice maker, without using the ice scoop . There were no interventions by staff to keep residents from doing this.<BR/>In an interview with the facility Administrator on 4/4/23 at 10:28 AM after State Surveyor intervention, revealed the Administrator immediately reprimanded residents for using the ice machine on their own, posted a sign on the machine which indicated residents were not to use the machine without assistance and the ordering of an ice machine which dispenses ice versus having to use a scoop to put ice into a glass<BR/> .<BR/>In an interview on 4/4/23 at 11:01 AM, the Dietary Manager stated she started in the position about a month ago and she had been trying to train staff on food storage and the need to rotate things that were outdated. She stated residents could become sick if they were served foods that were expired or undated. The Dietary Manager stated residents could become sick if a food service worker did not properly sanitize their hands and don gloves before contact with resident foods . <BR/>Record review of the Food and Nutrition Services and Kitchen Sanitation to Prevent the Spread of Viral Illnesses policies and procedures, dated 3/3/20, revealed gloves are to be worn at all times, by kitchen staff and are to be changed:<BR/>1. <BR/>Between each food preparation task.<BR/>2. <BR/>After touching items, utensils or equipment not related to task.<BR/>3. <BR/>After touching hair, face, or another source of contamination.<BR/>4. <BR/>When leaving food preparation area for any reason.<BR/>5. <BR/>When damaged, soiled or when interrupted.<BR/>6. <BR/>Every hour for all tasks taking longer than one hour.<BR/>Record review of the Food Storage policy and procedures, dated 2018, revealed:<BR/>Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines.<BR/>Procedure:<BR/>1. <BR/>Dry storage rooms<BR/>d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated.<BR/>f. Where possible, leave items in the original cartons placed with the date visible.<BR/>g. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first.<BR/>2. <BR/> Refrigerators<BR/>d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.<BR/>e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement an effective discharge planning process for 1 of 15 residents (Resident #1) reviewed for care plans. <BR/>The facility failed to prepare Resident #1 to effectively transition to post-discharge care and the reduction of factors leading to preventable readmissions. <BR/>This failure placed the resident at risk of readmission and his needs not being met.<BR/>Findings included: <BR/>Record Review of Resident #'1's face sheet reflected a [AGE] year-old male admitted on [DATE] with a diagnosis of Chronic obstructive pulmonary disease, unspecified (Primary, Admission), Changes in skin texture, Enlarged and thickend finger nails, Labored breathing, unspecified, Generalized anxiety disorder, Hypertensive heart disease with heart failure, Unspecified systolic (congestive) heart failure, Reduced circulation of blood to another part of the body other than the brain or heart, unspecified, Other chronic pain, Nausea, Other muscle spasm, Allergic rhinitis, unspecified, Lower than normal blood potassium levels, Nicotine dependence, unspecified, uncomplicated, Anxiety disorder, unspecified, Other epilepsy, intractable, with status epilepticus, Stroke, unspecified, Narrowing and blockage of right carotid artery, Essential (primary) hypertension, Constipation, unspecified, Intense itching of the skin, unspecified, Muscle wasting and atrophy, not elsewhere classified, unspecified site, Urinary tract infection, site not specified, Unsteadiness on feet, Other abnormalities of gait and mobility, Other lack of coordination, Cognitive communication deficit, Pain, unspecified, Other reduced mobility, Need for assistance with personal care, Other excessive lipids in the blood. <BR/>Record Review of an MDS assessment for Resident #1 dated 9/16/23 reflected a BIMS score of 12, indicating moderate cognitive impairment<BR/>Record Review of Resident #1's Care Plan dated 8/1/2023 reflected that Resident #1 had a goal of I have no planned discharge plan at this time and will reside at the facility.<BR/>Record Review of Resident #1's Care Plan dated 9/16/223 reflected a significant change in health status on 6/16/23.<BR/>In an interview on 9/11/2023 at 11:40AM with the SW, SW stated that Resident #1 wanted to go to the apartments that are across the street and that he was on Hospice care and will continue to receive Hospice care when there. SW stated that Resident #1 is not being kicked out by the facility and he is asking to be discharged . <BR/>In an interview with the Advocate (ADVC) on 9/11/2023 at 1:00PM, ADVC stated that she had just gotten off the phone with the SW and was told that Resident #1 was being discharged that day. She stated that she was told if the apartment isn't ready that the SW told her Resident #1 would be taken to a motel. ADVC stated that Resident #1's Medicaid is pending at this time. <BR/>In an interview on 9/11/2023 at 1:18PM with the SW, the SW stated that Resident #1 was given a 30-day notice but did not know the date.<BR/>In an interview on 9/11/2023 at 1:23PM, Resident #1 stated that he was not aware that he was being discharged today. Resident #1 stated that he wanted to leave the facility and if he could leave today, he would. Resident #1 stated that he feels he can take care of himself. <BR/>In an interview on 9/11/2023 at 1:31PM with the DON, the DON stated that she didin't think that it was her call to say if Resident #1 was able to take care of himself or not. The DON stated that she felt better that he would stay in Hospice care and that they will not not hesitate to make an APS report if needed. <BR/>In an interview on 9/11/2023 at 1:34PM with the Admin, the Admin stated that Resident #1 was being discharged . The Admin stated that Resident #1 was given a 30-day notice to move out over 40 days ago due to non-payment. <BR/>In an interview on 9/11/2023 at 3:38PM with the DON, the DON stated that she was fairly certain that Resident #1's physician had been notified of his discharge and that she was ok with it. The DON stated that Resident #1 would have Hospice care and it is his right to leave. <BR/>In an interview on 9/12/2023 at 9:00AM with the Admin, the Admin was asked if a Discharge Plan was done with Resident #1 and the Admin stated that they had asked what Resident #1 wanted and needed and got with Hospice to make sure that they would follow him after he moved. When asked if there were any documentation of this Discharge Plan meeting the Admin stated that there was no documentation. <BR/>In an interview on 9/12/2023 at 9:03AM with the DON, the DON was asked if there was a Discharge Plan done with Resident #1, and the DON stated that she talked to Hospice to make sure that everything was going to be set up when he moved. When asked if there was documentation of this the DON stated that there wasn't any that she knew of. <BR/>In an interview on 9/12/2023 at 9:06AM with the SW, the SW was asked what the Post Discharge Plan policy was. The SW stated that they determine if the resident needed healthcare services once discharged , asked the family if they have support in place and made the necessary referrals. When asked if this was done for Resident #1, the SW stated that he and the DON had planned everything out together for Resident #1. When asked if there is a copy of the Post Discharge Plan, the SW stated that he hadn't seen one for Resident #1. When asked what the negative outcome would be of discharging Resident #1 today without a Post Discharge Plan, the SW stated that he could miss a medication or get sick, or he might have to move back into the facility. <BR/>In an interview on 9/12/2023 at 9:51AM with an HHSC Medicaid Specialist, HHSC Medicaid Specialist stated that Resident #1 did not have an application submitted at this time and he did not have Medicaid. <BR/>In an interview on 9/12/2023 at 1:47PM with the Admin, the Admin stated that they don't have the documentation that shows the IDT meeting happened and there was no discharge plan done. The Admin stated that there was no sit-down meeting with the IDT team and Resident #1 to develop a discharge plan. When asked why the facility was not following their own discharge policy, the Admin stated that it just wasn't done. <BR/>Record review of the facility discharge summary plan dated 2016 states when the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/IID, etc.), a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. The policy also stated The post-discharge plan will be developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and will include: where the resident planned to reside, arrangements that were made for follow-up care and services, a description of the resident's stated discharge goals, the degree of caregiver/support person availability, capacity and capability to perform required care, how the IDT will support the resident or representative in the transition to post-discharge care, what factors make the resident vulnerable to preventable readmission and how those factors would be addressed.

Based on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the facility's kitchen, reviewed for kitchen sanitation. <BR/>1. The facility failed to ensure refrigerated foods were properly labeled and dated.<BR/>2. The facility failed to ensure pantry foods were properly labeled and dated.<BR/>3. The facility failed to ensure expired foods were not in the pantry and refrigerator.<BR/>4. The facility failed to ensure food service workers wore gloves.<BR/>These failures could place residents at risk for food-borne illness.<BR/>Findings include:<BR/>Observation of the kitchen staff on 4/4/23 at 9:18 AM revealed the following:<BR/>Two dietary service workers were not wearing gloves while preparing resident food.<BR/>Observation of the refrigerator on 4/4/23 at 9:22 AM revealed the following:<BR/> -Five gallons of milk with best by date 4/1/23.<BR/> -75 4-ounce cartons of chocolate milk had no date.<BR/> -Two heads of lettuce had no date.<BR/> -4 large food service bags of cole slaw mix, had no date.<BR/> -1 food service box of fresh tomatoes had no date.<BR/> -3 gallons of maple syrup were open, with no date.<BR/> -1 gallon of fruit punch had no date.<BR/> -1 gallon of lemonade had no date.<BR/> -19 &frac12; dozen fresh eggs, had no date.<BR/> -4, 5-pound containers of cottage cheese with best by date 3/25/23.<BR/> -10 individual glasses of apple juice, covered, with no date.<BR/> -10 individual glasses of tomato juice, covered, with no date.<BR/> -5, 1-gallon food service containers of mayonnaise had no date.<BR/> -1 gallon of Worcestershire sauce, was opened with an expiration date of 2/21/23.<BR/>Observation of the walk-in pantry on 4/4/23 at 9:51 AM revealed the following:<BR/>-1 Food Service box of dry pasta, was opened to the air, with an expiration date of 9/21.<BR/>-6 boxes of wild rice pilaf, had no date.<BR/>-1 open bag of Fritos corn chips had no date and was closed with a paper clip.<BR/>-1 open bag of dry mashed potato flakes had no date and was closed with a paper clip.<BR/>-10 Food Service canisters of oatmeal, had no date.<BR/>-1 Food Service bag of bread pudding mix, had no date.<BR/>-2 Food Service loaves of white bread, had no date.<BR/>-15 Food Service bags of hot dog buns, had no date.<BR/>-4 Food Service bags of hamburger buns, had no date<BR/>-2 Food Service bags of turkey gravy mix, had no date.<BR/>-2 Food Service bags of peppered gravy mix, had no date.<BR/>-1 Food Service container of chicken base mix, had no date.<BR/>Observation of residents who were in the dining room at the time of the noon dining service revealed 2 residents were witnessed dipping their personal cups into the facility's ice maker, without using the ice scoop . There were no interventions by staff to keep residents from doing this.<BR/>In an interview with the facility Administrator on 4/4/23 at 10:28 AM after State Surveyor intervention, revealed the Administrator immediately reprimanded residents for using the ice machine on their own, posted a sign on the machine which indicated residents were not to use the machine without assistance and the ordering of an ice machine which dispenses ice versus having to use a scoop to put ice into a glass<BR/> .<BR/>In an interview on 4/4/23 at 11:01 AM, the Dietary Manager stated she started in the position about a month ago and she had been trying to train staff on food storage and the need to rotate things that were outdated. She stated residents could become sick if they were served foods that were expired or undated. The Dietary Manager stated residents could become sick if a food service worker did not properly sanitize their hands and don gloves before contact with resident foods . <BR/>Record review of the Food and Nutrition Services and Kitchen Sanitation to Prevent the Spread of Viral Illnesses policies and procedures, dated 3/3/20, revealed gloves are to be worn at all times, by kitchen staff and are to be changed:<BR/>1. <BR/>Between each food preparation task.<BR/>2. <BR/>After touching items, utensils or equipment not related to task.<BR/>3. <BR/>After touching hair, face, or another source of contamination.<BR/>4. <BR/>When leaving food preparation area for any reason.<BR/>5. <BR/>When damaged, soiled or when interrupted.<BR/>6. <BR/>Every hour for all tasks taking longer than one hour.<BR/>Record review of the Food Storage policy and procedures, dated 2018, revealed:<BR/>Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines.<BR/>Procedure:<BR/>1. <BR/>Dry storage rooms<BR/>d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated.<BR/>f. Where possible, leave items in the original cartons placed with the date visible.<BR/>g. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first.<BR/>2. <BR/> Refrigerators<BR/>d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.<BR/>e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 of 3 residents (Resident #86) reviewed for baseline care plans.<BR/>Resident #86 was admitted on [DATE] but his baseline care plan was not initiated until 08/07/22.<BR/>This failure could result in newly admitted residents not receiving person-centered care in a timely manner.<BR/>Findings include:<BR/>Record review of Resident #86's face sheet, dated 08/09/22, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, shortness of breath, direct infection of right hip in infectious and parasitic diseases classified elsewhere, retention of urine (inability to voluntarily empty the bladder), adult failure to thrive (insufficient weight gain or absence of adequate physical growth), gout (type of arthritis that causes inflammation of joints due to excess uric acid), rhabdomyolysis (breakdown of skeletal muscle due to direct or indirect muscle injury), acute kidney failure (abrupt reduction in kidney's ability to filter waste products that occurs within a few hours or a few days), benign prostatic hyperplasia without lower urinary tract symptoms (flow of urine is blocked due to the enlargement of prostate gland) , dehydration, alcohol dependence with withdrawal, nicotine dependence, hypertension and hypothyroidism (decreased production of thyroid hormones).<BR/>Record review of Resident #86's MDS, dated [DATE], revealed it was still in process.<BR/>Record review of Resident #86's care plan revealed a created date of 08/07/22.<BR/>During an observation and interview on 08/07/22 at 3:45 PM, Resident #86 was lying in bed in the COVID-19 positive unit. He was not wearing a gown or brief and covered only with a blanket. He did not respond to any questions but stated, where are my teeth? when his teeth were in his mouth. <BR/>During an interview on 08/09/22 at 11:45 AM, DON stated baseline care plans should have been completed within 48 hours of a resident's admission. DON stated she was responsible for resident's care plans, and she was gone from the facility when Resident #86 was admitted . When asked who was responsible for completing care plans when she was gone, she stated, probably no one. When asked what a negative resident outcome could have been if not having baseline care plans completed in a timely manner, DON stated a resident might not have gotten the care they needed.<BR/>Record review of a facility provided policy titled Care Plans - Baseline, dated December 2016, revealed, in part, Policy Statement .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 .Policy Interpretation and Implementation .1. To assure that resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission.

**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 unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 25 residents (Resident #8, Resident #9 and Resident #25) reviewed for ADL assistance. <BR/>The facility failed to:<BR/>Ensure Resident #8 and Resident #9 received baths/showers according to their preferred bathing schedule<BR/>Ensure Resident #25 received assistance with her ADLs according to her plan of care. <BR/>These failures could place residents that require assistance with ADLs at risk of depression, skin breakdown, and a decline in their quality of life.<BR/>Findings include:<BR/>Record review of Resident #8's face sheet, dated 07/21/22, revealed an [AGE] year-old male admitted on [DATE] with diagnoses that included, but were not limited to, type 2 diabetes mellitus, muscle weakness, other abnormalities of gait and mobility, unsteadiness on feet, candidiasis (fungal infection that causes irritation, discharge and intense itchiness) and need for assistance with personal care.<BR/>Record review of Resident #8's annual MDS, dated [DATE], revealed a BIMS score of 11 out of 15 which indicated his cognition was moderately impaired. He required one-person assistance with bed mobility, dressing and toilet use. He required a wheelchair for mobility.<BR/>Record review of Resident #8's care plan dated 6/8/2022, revealed ADL (assisted daily living) function/rehab potential, Bathing/hygiene amount of assist: Supervision x1 Staff; The following Tasks will be documented in POC CareAssist, The Resident will perform the following tasks at their highest practicable level. I prefer to take my Bath/Shower on Tuesday, Thursday, Saturday. My preferred time to Bath/Shower Shift 2. Once A Day on Tue, Thu, Sat; 06:00 PM- 06:00 AM.<BR/>Record review of Resident #8's Point of Care History dated 7/1/2022-8/8/2022, revealed 7/12/22 shower; 7/23/22 shower; 7/24/22 shower; 8/02/22 shower. <BR/>During an interview on 8/7/22 at 10:24 AM with Resident #8, he stated residents did not receive showers the way it was supposed to be. Resident # 8 stated he sometimes received one shower a week because the facility did not have enough staff.<BR/>Record review of Resident #9's face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included, but were not limited to, muscle weakness (generalized), unsteadiness on feet, other abnormalities of gait and mobility, and need for assistance with personal care. <BR/>Record review of Resident #9's annual MDS, dated [DATE], revealed a BIMS score of 8 out of 15 which indicated his cognition was moderately impaired. The resident did not have any behaviors and required a wheelchair for mobility.<BR/>Record review of Resident #9's care plan dated 6/1/2022, revealed The following Tasks will be documented in POC CareAssist, The Resident will perform the following tasks at their highest practicable level. I prefer to take my Bath/Shower on M-W-F. My preferred time to Bath/Shower Shift 2. Once A Day on Mon, Tues, Fri; 06:00 PM- 06:00 AM.<BR/>Record review of Resident #9's Point of Care History dated 7/1/2022-8/8/2022, revealed 7/1/22 (shower) done; 7/6/22 (shower) done; 7/8/22 (shower) done; 7/13/22 (shower) done.<BR/>During an interview on 8/8/22 at 10:34 AM, Resident # 9 stated he was frustrated with not getting a shower. Resident # 9 stated it took weeks to get a shower. Resident # 9 also stated he had brought it up to the staff and they tell him it was because they were short staffed. <BR/>Record review of Resident # 25's face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, urinary tract infection, candidiasis (fungal infection that causes irritation, discharge and intense itchiness), infection of obstetric surgical wound, limitation of activities due to disability, unsteadiness of feet, complete traumatic amputation at level between right hip and knee. <BR/>Record review of Resident #25's annual MDS, dated [DATE], revealed a BIMS score of 7 out of 15 which indicated her cognition was severely impaired. She required extensive assistance with bed mobility and transfer and total dependance for toilet use and bathing. The resident required a wheelchair for mobility. <BR/>Record review of Resident #25's care plan dated 1/13/2022, revealed ADL (assisted daily living) function/rehab potential, The Resident will achieve maximum functional mobility. Ambulation/Transfers amount of assist: Extensive x2 Staff; Bathing/hygiene amount of assist: Extensive x1 Staff, Dressing/Grooming amount of assist: Extensive x1 Staff. <BR/>During an observation and interview on 8/07/22 at 10:25 AM, Resident # 25 stated It's just there's a shortage of hands and I'm waiting to get back into bed, we're waiting for a lady to get back. Surveyor asked if she knew where the lady was, she said she did not know. She said she has been waiting 20 minutes or more to get back in bed.<BR/>During an observation and interview on 08/07/22 at 10:29 AM, CNA A went into Resident # 25's room and stated, I'm waiting on her [CNA was waiting on the other CNA to get back from break]. <BR/>During an interview on 08/07/22 at 10:31 AM, CNA A stated she was Running. We only have two (CNAs) and sometimes only one! It's a lot of work.<BR/>During an observation on 08/07/22 at 10:42 AM, Resident # 25 was still in the wheelchair waiting to get back into bed. <BR/>During an observation and interview on 08/07/22 at 11:14 AM, Resident # 25 was in the wheelchair waiting for staff to assist her to get back in bed. Surveyor asked her if she was still waiting and she said, Yes.<BR/>During an observation on 08/07/22 at 11:25 AM, CNA A and CNA G entered Resident # 25's room. Resident # 25 was heard saying I want to get in bed. One of the CNAs responded, Well it's lunch time now. Resident # 25 stated, I've been waiting all morning. <BR/>During an observation on 08/07/22 at 12:44 PM Resident # 25 was lying in bed asleep. <BR/>During an interview on 08/08/22 at 3:52 PM with LVN F, she stated that CNAs did the bathing. LVN F stated she had not received any complaints regarding bathing. LVN F stated the CNAs filled out shower sheets and documented them on the matrix. LVN F stated if residents did not get their baths, they could have gotten skin breakdown, fungal infections, and other skin issues. LVN F stated CNAs train the CNAs regarding baths and showers. <BR/>During an interview on 08/08/22 at 4:04 PM with CNA G, she stated ADLS were documented on the matrix and shower sheets got filled out after every shower/bath. CNA G stated nurse aides did the bathing. CNA G stated if residents did not get their baths, they have gotten skin issues. She also stated, There's been a few times residents did not receive their baths due to lack of time. CNA G stated the aides came in on days off to give them a bath or stay over shift. She stated sometimes residents had complaints of not getting baths. CNA G stated the residents had bath schedules according to resident's preferences. CNA G stated nurse aides train new nurse aides. <BR/>During an interview on 08/08/22 at 4:12 PM with CNA A, she stated she and other nurse aides oversaw showers. She stated the DON created a shower list and the CNAs split the residents. CNA A stated if residents did not get baths, they started smelling and were prone to skin breakdown. CNA A stated it has been a while since they have done in-services regarding bathing. CNA A stated CNAs train the new CNAs.<BR/>During an interview on 08/08/22 at 4:32 PM with the DON, she stated CNAs were in charge of showers. The DON stated if residents did not receive their bath, they could have gotten possible skin issues and infection. The DON stated the CNAs documented showers in the matrix and on the shower sheets located at the nurse's station. The DON stated an LVN or RN signed off on CNAs competencies. The DON stated her expectations were for residents to be showered on their shower day. The DON stated she or the ADON oversaw training of the CNAs. <BR/>Record review of Facility Policy, Bath, Shower/ Tub documented, Documentation<BR/>1. The date and time the shower/tub bath was performed.<BR/>5. If the resident refused the shower/tub bath, the reason (s) why and the intervention taken.<BR/>Record review of Facility Policy, Facility Assessment Tool documented, Purpose: To determine what resources are necessary to care for residents competently during regular 24/7/365 operations and during emergencies to ensure that each resident maintains or attains their highest practicable physical, mental, and psychosocial well-being.<BR/>Part 2: Services and Care We Offer Based on our Residents' Needs<BR/>Activities of daily living- Bathing, showers<BR/>Mobility and fall/ fall with injury prevention- transfers, ambulation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess residents for risk of entrapment from bed rails prior to installation and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 2 of 14 residents (Resident #30 and Resident #34) reviewed for bed rails.<BR/>Resident #30 and Resident #34 did not have bed rail consents or bed rail entrapment risk assessments when both of their beds contained bed rails. <BR/>These failures could place residents with side rails on their beds at an increased and unnecessary risk for unintended entrapment incidents, restraints, and injuries.<BR/>Findings include:<BR/>Record review of Resident #30's face sheet, dated 08/08/22, revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, nondisplaced intertrochanteric fracture of left femur (broken bone in left leg), vascular dementia without behavioral disturbance, type 2 diabetes mellitus with diabetic polyneuropathy (damage to multiple peripheral nerves), secondary hypertension (high blood pressure that's caused by another medical condition), primary osteoarthritis right ankle and foot (inflammation of one or more joints), unspecified symbolic dysfunctions (impaired ability in numerical concepts), unspecified lack of coordination, other abnormalities of gait and mobility, weakness, unsteadiness on feet, peripheral vascular disease (condition or disease affecting the blood vessels), Hallux valgus right foot (bony projection on the joint at the base of the big toe), other chronic pain, and syncope and collapse (temporary loss of consciousness). <BR/>Record review of Resident #30's quarterly MDS, dated [DATE], revealed a BIMS score of 3 out of 15 which indicated her cognition was severely impaired. She required extensive one-person assistance with bed mobility, transferring, dressing, toilet use and personal hygiene. Section P of the MDS titled Physical Restraints indicated bed rails were not used as a physical restraint.<BR/>Record review of Resident #30's care plan, dated 06/09/22, revealed, in part, I have assist bars on my bed .Assist bars on my bed to aid in repositioning and transferring and promote safety .I will use my assist bars to reposition and transfer myself.<BR/>Record review of Resident #30's electronic medical record revealed no consent for bed rails or an entrapment risk assessment. <BR/>During an observation on 08/07/22 at 2:39 PM, Resident #30 was not in her room. 1/8th bed rails were observed to both sides of her bed in the upright position. <BR/>During an observation and interview on 08/08/22 at 5:00 PM, Resident #30 was in her room in a wheelchair. 1/8th bed rails were observed to both sides of her bed in the upright position. She stated did not mind her bed rails and they did not make her feel entrapped. <BR/>Record review of Resident #34's face sheet, dated 08/08/22, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, muscle wasting and atrophy (loss of muscle leading to its shrinking and weakening), muscle weakness, sarcopenia (progressive and generalized skeletal muscle disorder involving the accelerated loss of muscle mass and function), pain, ventricular tachycardia (abnormal heartbeat), rheumatoid arthritis with rheumatoid factor of unspecified site (chronic inflammatory disease that affects the joints), acute kidney failure with tubular necrosis (kidney disorder involving damage to the tubule cells of the kidneys, which can lead to acute kidney failure), unsteadiness on feet, other abnormalities of gait and mobility, other lack of coordination, weakness, other reduced mobility, need for assistance with personal care, presence of automatic implantable cardiac defibrillator (small battery-powered device placed in the chest to detect and stop irregular heartbeats), and age-related cognitive decline.<BR/>Record review of Resident #34's quarterly MDS, dated [DATE], revealed a BIMS score of 8 out of 15 which indicated her cognition was moderately impaired. She required extensive two-person assistance with bed mobility, dressing, toilet use and personal hygiene, and total two-person dependence with transferring. Section P of the MDS titled Physical Restraints indicated bed rails were not used as a physical restraint.<BR/>Record review of Resident #34's care plan, dated 06/16/22, revealed, in part, I have assist bars on my bed to assist with transfers and repositioning . Assist bars will promote and maintain independence and promote safety . I will use my assist bars to assist me in repositioning and with transfers.<BR/>Record review of Resident #34's electronic medical record revealed no consent for bed rails or an entrapment risk assessment. <BR/>During an observation on 08/08/22 at 4:08 PM, Resident #34 was lying in her bed receiving wound care for her bilateral nephrostomy tubes (a thin plastic tube that is passed from the back, through the skin and then through the kidney, to the point where the urine collects). Observed Resident #34 roll to her right side where she used a right 1/8th side rail that was in the upright position to hold on to while LVN F was providing wound care. <BR/>During an interview on 08/09/22 at 5:15 PM, Resident #34 was sitting in a recliner, in her room. She stated that the bed rail on her bed did not make her feel entrapped and she did not mind having it on her bed. 1/8th side rail observed on the right side of her bed in the upright position.<BR/>During an interview on 08/09/22 at 5:10 PM, DON stated there were no bed rail consents or entrapment risk assessments for Resident #30 and Resident #34. She stated this was, on my to-do list and she had not been able to address it since she had been at the facility. When asked what a negative resident consequence could have been when not having a consent for bed rails or having an entrapment risk assessment, DON stated a resident could have not needed bed rails or could suffer strangulation.<BR/>Record review of a facility provided policy titled Proper Use of Side Rails, dated December 2016, revealed, in part, .General Guidelines .3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight .9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks .

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 employees (CNA A, LVN B and RNRS C) reviewed for infection control.<BR/>The facility failed to ensure CNA A, LVN B, and RNRS C practiced proper hand hygiene while serving and assisting residents during the lunch meal on 2/5/25.<BR/>This failure could place residents at risk of the spread of communicable diseases and infections and a diminished quality of life.<BR/>Findings included:<BR/>An observation of the lunch meal on 02/05/2025 between 12:00PM and 12:30PM revealed CNA A, LVN B and RNRS C assisted in the dining room.<BR/>CNA A was observed using ABHR while standing in the service line. CNA A placed her hands in her pockets immediately after the use of ABHR and they remained in her pockets until she received a resident tray from the kitchen. CNA A left the service line with the resident's tray. While on her way to deliver the tray, CNA A dropped a single-serving butter pat on the floor. CNA A was then observed to pick up the butter pat from the floor and place it back on the resident's tray. She delivered the tray to the resident and returned to the service line, without sanitizing her hands. CNA A was observed several times during the luncheon service, using ABHR and then placing her hands in her pockets or on her hips while waiting.<BR/>LVN B was observed using ABHR upon entry to the dining room, but then placed her hands on her hips, touching her clothing. LVN B's hands remained on her hips while she was waiting for a tray from the service line. LVN B received a tray from the kitchen and served it to a resident without re-sanitizing her hands.<BR/>RNRS C was observed leaning against the ice machine, with her right hand resting on top of the machine. The RNRS then received a tray from the kitchen and proceeded to help a resident who needed set-up and minimal feeding assistance with his meal.<BR/>An interview with RNRS C on 02/05/2025 at 1:47PM reflected she was aware of the lapse in hand hygiene and would take steps to do things better next time. RNRS C stated the negative outcome of not sanitizing her hands between resident trays was the possibility of cross-contamination or spreading of germs which might be infectious.<BR/>An interview with LVN B on 02/05/2025 at 1:51PM reflected she denied the lapse in hand-hygiene. LVN B stated the negative outcome of not sanitizing her hands between resident trays would be the potential transmission of infections. <BR/>Record review of the facility's employee roster reflected LVN B was the only employee with her first and last name, working at the facility, which indicated LVN B was the only LVN in the dining room during the lunch meal.<BR/>An interview with CNA A on 02/05/2025 at 2:00PM revealed she realized the lapse in hand hygiene as soon as she received the resident's tray from the kitchen. CNA A stated the negative outcome of not practicing proper hand hygiene would be the spread of germs or sicknesses.<BR/>An interview with the ADON on 02/05/2025 at 3:15PM revealed LVN B did not take responsibility for her actions at times, did not like to be questioned about her abilities. The ADON stated LVN B had been coached regarding customer service and employee relations. The ADON stated an in-service was going to be done on hand hygiene, starting immediately and would be passed on to the night supervisor for training of the night staff.<BR/>Record review of facility policy and procedures for hand hygiene dated 01/20/2023 revealed the following:<BR/>Policy Interpretation and Implementation:<BR/>1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.<BR/>3. Wash hands with soap; and water, when hands are visibly soiled and after contact with a resident with an infectious diagnosis.<BR/>4. Use an alcohol-based hand rub containing at least 60%-95% ethanol alcohol or isopropyl alcohol.<BR/>Procedure:<BR/>Using Alcohol-Based Hand Rubs:<BR/>1. Apply generous amount of product to palm of hand and rub hands together.<BR/>2. Cover all surfaces of hands and fingers until hands are dry<BR/>The facility did not have a policy regarding hand hygiene while serving resident meals.

Based on interview and record review, the facility failed to report the results of an investigation in accordance with State Law within 5 working days of the incident for 1 of 5 incidents (Resident #1) reviewed for reporting. <BR/>-The Administrator failed to report the results of an investigation within 5 days to the State Survey Agency. <BR/>This failure could affect residents if alleged violations are verified, and appropriate corrective actions are not taken.<BR/>Findings include:<BR/>Record review completed on 06/03/25 at 08:32 AM of the TULIP (Texas Unified Licensure Information Portal) system revealed that no Provider Investigation Report (Form 3613-A) had been filed in the system. The facility had filed the Facility Reported Incident and CII Self-Report Template on 5/11/2025.<BR/>During an interview on 06/03/25 at 11:14 AM, the Administrator reported that he did not remember doing a 5-day report, that they did an original report where they separated, assessed, and documented what they did for the two residents but he did not remember anything about a 5-day report. The Administrator stated, you are talking about the 3613 right. I think I just forgot to do it. I had a lot of things going on in the building and I just forgot to do it. The Administrator reported that not completing the 3613 or the 5-day results of an investigation could have the potential to affect other residents care because the process was not completed. <BR/>Record review of the Provider Investigation Report (form 3613-A) for the incident that occurred on 5/11/25 revealed that it was completed on 6/3/2025. The Provider Investigaiton Report revealed that a thorough investigation of the incident was completed. <BR/>Record review of the facility provided policy titled Reporting and Protection Program Policy revised 10/2023, revealed the following:<BR/>Reporting/Response:<BR/>B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 (RN F) of 13 staff reviewed for abuse policies.<BR/>The facility failed to make sure that a potential employee who would be working with residents directly was free of criminal charges. <BR/>This failure could place residents of the facility at risk of abuse or neglect at the hands of an employee with a documented history of these types of behaviors. <BR/>Findings Included:<BR/>Record review of RN F's employee file revealed a hire date of 7/4/2024 and an Employee Misconduct Registry (EMR) with a date of 7/9/2024. <BR/>During an interview on 10/30/24 at 11:21AM, HRD stated that RN F was supposed to start later in the month but started on July 4, 2024. The HRD stated the negative outcome for hiring staff without running their record first would be putting residents at risk for abuse. <BR/>Record review of the facilities ANE policy dated 10/2023 stated the following:<BR/> 1. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property.<BR/>2. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants.

Based on interviews, and record reviews, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 33 days in the months of April, May, June July and October, 2024. <BR/>The facility did not have an RN in the facility for 8 consecutive hours on the following dates:<BR/>April 4, 5, 6, 7, 10, 13, 14, 20, 21, 27, and 28th of 2024. <BR/>May 4, 5, 11, 12, 18, 19, 25, 2 6, and 27th of 2024. <BR/>June 1, 2, 8, .9. 15, 16., 22, .23, .29. and 30th of 2024. <BR/>July 13 and 14 of 2024. <BR/>The date of October 11, 2024 only had RN coverage for 5.63 hours. <BR/>This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for coordination of events such as emergency care. <BR/>Findings include: <BR/>During an interview on 10/29/24 at 10: 20 pm, the DON stated she did not have RN coverage for June. She stated it just fell through the cracks. When asked about RN coverage for April and May as listed on the facility PBJ report, she had no answer. She stated she had been actively looking for an RN. She stated an RN was not hired until July. The DON stated the consequences of not having an RN in the building would be There needs to be someone here to report incidents to. There was no one to report incidents to.<BR/>Record reviews of the facility's last 5 months of time sheets for RN coverage revealed that the facility did not have an RN in the facility on the following dates: <BR/>April 4,5, 6, 7, 10, 13, 14, 20, 21, 27, and 28 th of 2024<BR/>May 4, 5, 11, 12, 18, 19, 25, 26, and 27th of 2024<BR/>June 1, 2, 8, .9, 15. 16., 22., 23, .29. and 30th of 2024<BR/>July 13 and 14 th, 2024<BR/>The date of October 11, 2024, only had RN coverage for 5.63 hours. <BR/>Record review of the CMS PBJ Staffing Data Report dated 11/1/24 revealed the facility infraction dates listed the following dates as not having RN hours for: <BR/>April 4,5, 6, 7, 10, 13, 14, 20, 21, 27, and 28, 2024. <BR/>May 4, 5, 11, 12, 18, 19, 25, 26, and 27 ,2024 <BR/>June 1, 2, 8. 9. 15. 16., 22, .23., 29. and 30, 2024 <BR/>Record review of facility presented Time Clock Punch In Hours revealed there were no RN clock in hours prior to 7/4/24. <BR/>A policy for RN coverage was requested from the DON on 10/29/24 at 1:30 pm but never received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review; the facility failed to provide pharmaceutical services that included the accurate acquiring and receiving of all drugs and biologicals to meet the needs of each resident noted in 1 of 3 medication areas (medication room) reviewed for medication storage. <BR/>The facility medication room contained 3 prescription medications that were expired. <BR/>The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could result in a resident receiving the incorrect medication or a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes.<BR/>Findings include:<BR/>During an observation on 09-12-2023 at 09:31 AM of the facility's medication room with the DON and CRN present the following medications were noted to be expired that were present in the overflow bin for room [ROOM NUMBER]A:<BR/>Atorvastatin 1 bottle with expiration of 4-26-2023 and one bottle with expiration of 8-30-2023<BR/>Losartan 1 bottle with expiration of 6-21-2023 and one bottle with expiration of 8-30-2023<BR/>Gabapentin 1 bottle with expiration of 8-30-2023<BR/>During an interview on 9-12-2023 at 09:33 AM the DON and CRN they verified that the three prescription medication were expired, were part of the overflow stock, and that if the primary medication cart on the floor was out of medication, then the nurse would grab what they needed from this stock in the medication room. The DON reported that she did not feel the expired medication would be a problem because the staff are trained to check each medication for expiration prior to being administered. The DON stated, The chance an expired medication would be given would be slim. We check dates when we pass any meds. The CRN agreed. The DON reported that the expired medications were brought in when the resident in room [ROOM NUMBER]A was admitted recently and they expected him to be short term but he has since decided to stay and the medications he brought in were not discarded as they should have been.<BR/>During an interview on 09-13-2023 at 08:52 AM LVN A reported that if a resident is out of a prescription medication in the medication cart, they will check the medication room for the overflow section that is located on one wall and see if the resident has that medication that has been refilled. If the medication is available, they will check if for expiration and ensure that all other valid information is present such as resident name, dose, etc. then put the medication in use. <BR/>During an observation on 09-12-2023 at 09:27 AM of Medication Cart 1, the three medications currently in use listed above for room [ROOM NUMBER]A had an expiration date listed in the year 2024. <BR/>Record review of the facility provided policy titled Storage of Medications revised November 2020, revealed the following:<BR/>Policy Interpretation and Implementation:<BR/>4.Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the facility's kitchen, reviewed for kitchen sanitation. <BR/>1. The facility failed to ensure refrigerated foods were properly labeled and dated.<BR/>2. The facility failed to ensure pantry foods were properly labeled and dated.<BR/>3. The facility failed to ensure expired foods were not in the pantry and refrigerator.<BR/>4. The facility failed to ensure food service workers wore gloves.<BR/>These failures could place residents at risk for food-borne illness.<BR/>Findings include:<BR/>Observation of the kitchen staff on 4/4/23 at 9:18 AM revealed the following:<BR/>Two dietary service workers were not wearing gloves while preparing resident food.<BR/>Observation of the refrigerator on 4/4/23 at 9:22 AM revealed the following:<BR/> -Five gallons of milk with best by date 4/1/23.<BR/> -75 4-ounce cartons of chocolate milk had no date.<BR/> -Two heads of lettuce had no date.<BR/> -4 large food service bags of cole slaw mix, had no date.<BR/> -1 food service box of fresh tomatoes had no date.<BR/> -3 gallons of maple syrup were open, with no date.<BR/> -1 gallon of fruit punch had no date.<BR/> -1 gallon of lemonade had no date.<BR/> -19 &frac12; dozen fresh eggs, had no date.<BR/> -4, 5-pound containers of cottage cheese with best by date 3/25/23.<BR/> -10 individual glasses of apple juice, covered, with no date.<BR/> -10 individual glasses of tomato juice, covered, with no date.<BR/> -5, 1-gallon food service containers of mayonnaise had no date.<BR/> -1 gallon of Worcestershire sauce, was opened with an expiration date of 2/21/23.<BR/>Observation of the walk-in pantry on 4/4/23 at 9:51 AM revealed the following:<BR/>-1 Food Service box of dry pasta, was opened to the air, with an expiration date of 9/21.<BR/>-6 boxes of wild rice pilaf, had no date.<BR/>-1 open bag of Fritos corn chips had no date and was closed with a paper clip.<BR/>-1 open bag of dry mashed potato flakes had no date and was closed with a paper clip.<BR/>-10 Food Service canisters of oatmeal, had no date.<BR/>-1 Food Service bag of bread pudding mix, had no date.<BR/>-2 Food Service loaves of white bread, had no date.<BR/>-15 Food Service bags of hot dog buns, had no date.<BR/>-4 Food Service bags of hamburger buns, had no date<BR/>-2 Food Service bags of turkey gravy mix, had no date.<BR/>-2 Food Service bags of peppered gravy mix, had no date.<BR/>-1 Food Service container of chicken base mix, had no date.<BR/>Observation of residents who were in the dining room at the time of the noon dining service revealed 2 residents were witnessed dipping their personal cups into the facility's ice maker, without using the ice scoop . There were no interventions by staff to keep residents from doing this.<BR/>In an interview with the facility Administrator on 4/4/23 at 10:28 AM after State Surveyor intervention, revealed the Administrator immediately reprimanded residents for using the ice machine on their own, posted a sign on the machine which indicated residents were not to use the machine without assistance and the ordering of an ice machine which dispenses ice versus having to use a scoop to put ice into a glass<BR/> .<BR/>In an interview on 4/4/23 at 11:01 AM, the Dietary Manager stated she started in the position about a month ago and she had been trying to train staff on food storage and the need to rotate things that were outdated. She stated residents could become sick if they were served foods that were expired or undated. The Dietary Manager stated residents could become sick if a food service worker did not properly sanitize their hands and don gloves before contact with resident foods . <BR/>Record review of the Food and Nutrition Services and Kitchen Sanitation to Prevent the Spread of Viral Illnesses policies and procedures, dated 3/3/20, revealed gloves are to be worn at all times, by kitchen staff and are to be changed:<BR/>1. <BR/>Between each food preparation task.<BR/>2. <BR/>After touching items, utensils or equipment not related to task.<BR/>3. <BR/>After touching hair, face, or another source of contamination.<BR/>4. <BR/>When leaving food preparation area for any reason.<BR/>5. <BR/>When damaged, soiled or when interrupted.<BR/>6. <BR/>Every hour for all tasks taking longer than one hour.<BR/>Record review of the Food Storage policy and procedures, dated 2018, revealed:<BR/>Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines.<BR/>Procedure:<BR/>1. <BR/>Dry storage rooms<BR/>d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated.<BR/>f. Where possible, leave items in the original cartons placed with the date visible.<BR/>g. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first.<BR/>2. <BR/> Refrigerators<BR/>d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.<BR/>e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.

Based on interview and record review the facility failed to provide training to their staff for abuse, neglect, and exploitation for 4 (SLP, CNA B, CNA C, and LVN D) of 13 employees evaluated for the required trainings.<BR/>SLP was hired 7-11-2020 and no training had been provided on Abuse, Neglect, and Exploitation in the last 12 months. <BR/>CNA B was hired 7-11-2023 and no training was provided on Abuse, Neglect, and Exploitation at hire.<BR/>CNA C was hired 6-21-2023 and no training was provided on Abuse, Neglect, and Exploitation at hire.<BR/>LVN D was hired 12-23-2022 and no training was provided on Abuse, Neglect, and Exploitation at hire.<BR/>This failure could place residents at risk for harm from staff that have not been trained adequately to provide appropriate care and prevent injuries. This failure could result in deterioration in resident condition, injuries, and exacerbation of the disease process.<BR/>Findings included:<BR/>Record review completed 9-13-2023 at 02:01 PM of SLP's (Speech Language Pathologist) employee file revealed the following:<BR/>SLP was hired 7-11-2020 and no training was provided on Abuse, Neglect, and Exploitation in the last 12 months.<BR/>Record review completed 9-13-2023 at 10:47 AM of CNA B's employee file revealed the following: CNA B was hired on 7-11-2023 and no training was provided on Abuse, Neglect, and Exploitation at hire.<BR/>Record review completed 9-13-2023 at 10:59 AM of CNA C's employee file revealed the following: CNA C was hired on 6-21-2023 and no training was provided on Abuse, Neglect, and Exploitation at hire.<BR/>Record review completed 9-13-2023 at 11:08 AM of LVN D's employee file revealed the following: LVN D was hired on 12-23-2022 and no training was provided on Abuse, Neglect, and Exploitation at hire.<BR/>During an interview on 9-13-2023 at 01:38 PM the BOM/HR (Business Office Manager/Human Resource Manager) reported that she had just been placed as head of the HR department and that she was aware that new employee orientation had not been completed correctly. The BOM/HR reported that she was scheduled for a training next week that should correct all current problems with employee training. The BOM/HR verified that the 4 employees were not trained upon hire and reported that the nursing department was responsible for ensuring that the trainings were completed when hired. The BOM/HR reported that if staff did not receive the required trainings then we could have staff that are not prepared to take care of residents.<BR/>During an interview on 9-14-2023 at 10:12 AM the DON verified that she completed all required trainings related to nursing to include Abuse, Neglect, and Exploitation when an employee is hired. The DON reported that she felt that all employees listed above had completed the required training and that she just felt that their orientation form had been misplaced or was simply not filled out. The DON reported that if a staff member was not trained on what they need to know then they may not provide safe care.<BR/>Record review of the facility provide policy titled, New Hire and Annual Training Packet revealed the following:<BR/>Section-Abuse Prevention Program, revised 1-9-2023:<BR/>4, Our Center will implement and permanently maintain an effective training program for all staff .<BR/>Policy Interpretation and Implementation-<BR/>2. Requires staff training/orientation programs .