CROSS COUNTRY HEALTHCARE CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained for 1 of 1 medication rooms reviewed for medication labeling and storage.<BR/>The facility failed to maintain controlled substance record count sheet with accurate amount of lorazepam (a controlled substance) stored in medication room refrigerator. <BR/>These failures could place residents at risk of misappropriation of medications.<BR/>Findings Included: <BR/>Record review of Resident #3's electronic face sheet dated 01/23/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and most recently on 01/13/2025 with diagnoses to include: conversion disorder with seizures or convulsions (a mental health condition that causes seizures or convulsions) and anxiety. <BR/>Record review of Resident #3's quarterly MDS dated [DATE] revealed: BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS Section I - Active Diagnoses revealed resident had seizure disorder or epilepsy and anxiety disorder. <BR/>Record review of Resident #3's care plan dated 01/23/2025 revealed Resident #3 had seizures. Further review of care plan revealed interventions for seizures included to give medications as ordered, monitor/document effectiveness and side effects, use half side rails with seizure pads added to resident bed for safety, and to document seizure activity. <BR/>Record review of Resident #3's electronic physician orders dated 01/21/2025 revealed one time order for Ativan (lorazepam) 2mg/ml inject 2mg IM (intramuscularly) one time only for anxiety. Further review revealed an electronic physician order dated 01/14/2025 lorazepam injection 1mg IM every 5 minutes prn anxiety.<BR/>Record review of Resident #3's nursing progress notes which indicated that resident received 4 doses of Ativan (lorazepam) IM on 1/21/2025. Further review of nursing progress notes indicated Resident #3 received 1 dose of Ativan (lorazepam) IM on 1/22/2025 at 5:08 p.m. <BR/>Record review of Resident #3's narcotic count sheet titled controlled substance record indicated 4 doses of lorazepam were administered on 1/21/2025. There was no evidence that 1 dose of lorazepam had been administered on 1/22/2025. <BR/>During an observation and interview on 01/23/2025 at 11:48 a.m., the medication room refrigerator had a sealed bag of lorazepam vials for Resident #3 inside of the controlled substance box that had 25 vials inside of the box. LVN A was present and agreed that there were 25 vials of lorazepam in sealed bag for Resident #3. LVN A stated medications were counted every shift to make sure that the counts were correct. She stated she had not counted the medication in the refrigerator because she was not responsible for 200-300 medication cart which had the count sheets for Ativan (lorazepam) in the binder. <BR/>During an interview on 01/22/2025 at 12:10 p.m., MA C stated she was responsible for the 200-300 hall medication cart. She observed the controlled substance count sheet and agreed that it stated 26 vials of lorazepam should be in the refrigerator for Resident #3. She stated she should have counted the refrigerator medications when she took control of the 200-300 medication cart at shift change. She stated she did not count the refrigerator medications this morning during shift change. She did not answer why she did not count the medications in the refrigerator when asked.<BR/>During an interview on 01/23/2025 at 12:14 p.m., the DON stated medication aides and nurses were responsible for making sure controlled substance count sheets were accurate with medication on hand during shift change. He stated that both he and the ADON monitored the medication aides and nurses performed counts and had just counted the medication room fridge on 01/22/2025 before 4:00 p.m. and the count was correct. He stated he expected for nurses and medication aides to sign out medication on the controlled substance count sheets as they were given. He stated medication aides and nurses were to contact him if the count did not match what was written on the controlled substance count sheet and he would do an investigation to see why count sheets were off. He stated he would let corporate and state agency know of issue when his investigation could not find reason for why counts sheets were incorrect. He stated he would investigate why Ativan (lorazepam) did not match controlled count sheet.<BR/>During a follow up interview on 01/23/2025 at 1:00 p.m., the DON stated his investigation led to the finding that LVN B had given lorazepam on 01/22/2025 around 5:00 p.m. He stated had LVN B signed the medication off of the controlled substance count sheet, the counts would match how much medication was on hand in the refrigerator. He stated the nurses and medication aides had been educated in the past about making sure count sheets were accurate and counted every shift change. He stated he felt more education was needed.<BR/>During an interview on 01/23/2025 at 1:02 p.m., LVN B stated Resident #3 was having a seizure on 01/22/2025 around 5:00 p.m. and his hospice nurse was present in the facility. She stated she remembered the time because a new admission had arrived at the facility around the same time. She stated she had gotten medication vial from refrigerator in the medication room and had administered the Ativan (lorazepam) to Resident #3. She stated she did not sign it out on the controlled substance count sheet because she was distracted. She stated it was important to sign out medication use on controlled substance count sheet to keep account of the medication and prevent someone from taking it. <BR/>During an observation on 01/23/2025 at 2:38 p.m., Resident #3 was in his room lying in bed that was in low position. He had side rails that were padded on his bed. His eyes were closed and no distress observed. His respirations were even and unlabored. Resident #3's call light was within reach of him.<BR/>During an observation and interview on 01/24/2025 at 5:50 p.m., LVN D counted controlled substances in medication room refrigerator with MA C. LVN D removed keys from beside of the refrigerator and opened the locked box inside of the refrigerator to count the medications. She stated whoever was responsible for 200-300 medication cart should count the controlled substances in the refrigerator. She stated she had not been responsible for 200-300 medication cart on 1/22/2025 and was unsure why the controlled substances were not correct on the count sheet on 01/23/2025.<BR/>During an interview on 01/24/2025 at 6:04 p.m., RN E stated she was responsible for 200-300 medication cart on the night of 01/22/2025. She stated she should have counted the controlled substances in the medication room refrigerator. She stated she had been education in the past to count the box for controlled substances in the refrigerator when she was responsible for the 200-300 medication cart. She did not give a reason why she did not count the controlled substances the night of 01/22/2025. She stated controlled substances were counted to prevent loss of medication from people taking medication out of the controlled substance box.<BR/>During a telephone interview on 01/24/2025 at 8:41 a.m., the MD stated he expected for controlled medications to be counted every shift and for staff to follow facility's policy. He stated he expected for nurses and medication aides to follow facility policy when storing controlled substances. He stated the DON was responsible for monitoring that nurses and medication aides followed the policy. The MD stated he does not review the narcotic count sheets during his resident review of how often medication was administered. He stated he obtains medication administration frequency from the DON and does not know where the DON obtains that information.<BR/>During an interview on 01/24/2025 at 10:30 a.m., the ADON stated the facility utilized controlled substance count sheets to correctly manage the controlled substances and dosages. She stated the controlled substance count sheets do help keep track of medication and reduce risk for misappropriation. She stated her expectation would be that the controlled substance count sheets be promptly updated when a medication dose had been given. She stated both her and the DON do weekly audits to make sure the controlled substances matched what was documented on the controlled substance count sheets. <BR/>During a telephone interview on 01/24/2025 at 11:44 a.m., the pharmacy consultant stated she rounded in the facility once a month. She stated she would do random spot checks of controlled substance count sheets to see if nurses and medication aides were signing medication in and out. She stated her expectation would be that the medication on hand match the controlled substance count sheet. She stated the negative effect of controlled substances not being accurate could be misappropriation of medications. She stated nurses and medication aides should document medication on controlled substance count sheet as soon as the medication was given. <BR/>During a follow up interview on 01/24/2025 at 10:54 a.m., the DON stated staff laziness may have led to the failure of staff not counting the controlled substances in refrigerator because they had been educated to do so prior to 01/22/2025. He stated not counting controlled substance during shift change could lead to misappropriation of medications and if not found then licensure reporting to appropriate agency.<BR/>During an interview on 01/24/2025 at 1:09 p.m., the ADMN stated she expected for controlled substance count sheets to accurately reflect the amount of medication in storage. She stated controlled substance count sheets were done to help prevent medication misappropriation. She stated she expected for staff to go by facility policy when storing medications. She stated the ADON and the DON monitored that staff were controlled substances during shift change.<BR/>Review of drugs.com accessed on 01/24/2025 at https://www.drugs.com/schedule-4-drugs.html revealed: Ativan (lorazepam) was listed under The following drugs are listed as Schedule 4 (IV) Drugs by the Controlled Substances Act (CSA)<BR/>Review of the facility policy titled Controlled Substances dated July 2024 revealed: Dispensing and Reconciling Controlled Substances 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection / follow-up. 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records. 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services .15. The consultant pharmacist or designee routinely monitors controlled substance storage records. 16. The director of nursing services maintains and disseminates to appropriate individuals a list of staff who have access to medication storage areas and controlled substance containers.

Based on observation, interview, and record review the facility failed to ensure separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 1 medication rooms reviewed for medication labeling and storage.<BR/>The facility failed to maintain controlled substance record count sheet with accurate amount of lorazepam (a controlled substance) stored in medication room refrigerator. <BR/>These failures could place residents at risk of misappropriation of medications.<BR/>Findings Included: <BR/>During an observation on 01/23/2025 at 11:48 a.m., the medication room refrigerator had a locked box inside of the refrigerator that was not secured and could be removed easily from the refrigerator. Keys to the locked box, inside of the refrigerator, were stored on a hook that was secured to the left of the outside of the refrigerator. Anyone with access to the medication room had access to the locked box key. <BR/>During an observation and interview on 01/24/2025 at 5:50 p.m., LVN D counted controlled substances in medication room refrigerator with MA C. LVN D removed keys from beside of the refrigerator and opened the locked box inside of the refrigerator to count the medications. <BR/>During a telephone interview on 01/24/2025 at 8:41 a.m., the MD stated he expected for nurses and medication aides to follow facility policy when storing controlled substances. He stated the DON was responsible for monitoring that nurses and medication aides followed the policy. <BR/>During an interview on 01/24/2025 at 10:30 a.m., the ADON stated the locked box in refrigerator, for controlled substances, should be secured to the refrigerator. She stated she did not know why the box had not been secured to the refrigerator. She stated the keys to the locked box in refrigerator for controlled substances should not be kept to the left outside of the refrigerator and should be stored on the nurse or medication aide keys that were responsible for the medication cart that kept the controlled substance count sheets in binder. She stated she did not know why keys had been stored next to the refrigerator but that storing the key that way could cause potential misuse of the controlled medications. She stated both her and the DON monitor that medication were stored appropriately. <BR/>During a telephone interview on 01/24/2025 at 11:44 a.m., the pharmacy consultant stated she expected for staff not to store key to the locked box in the medication room next to the unlocked refrigerator. She stated the facility had moved the medication room recently from the back of the facility to the front and that may have led to controlled substances to not be stored appropriately. She stated the controlled substance box should be secured to the refrigerator and did not know why it was not. <BR/>During a follow up interview on 01/24/2025 at 10:54 a.m., the DON stated the controlled substance box should be secured to the refrigerator and the keys to the box should not be stored outside of the refrigerator for all staff that had access to the medication room to have access to the controlled substances in the locked box. He stated recently the controlled substance box had been replaced due to the old one had rusted and he felt that led to the failure of new controlled substance box not being affixed. He stated staff laziness may have led to the failure of the key to the controlled substance box being stored next to the refrigerator in medication room. He stated not storing medication correctly could lead to misappropriation of medications <BR/>During an interview on 01/24/2025 at 1:09 p.m., the ADMN stated she expected for staff to go by facility policy when storing medications. She stated the ADON and the DON monitored that staff were storing medications appropriately.<BR/>Review of the facility policy titled Controlled Substances dated July 2024 revealed: Storing Controlled Substances. 1. Controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. 2. All keys to controlled substance containers are on a single key ring that is different from any other keys. 3. The charge nurse on duty maintains the keys to controlled substance containers. The director of nursing services maintains a set of back-up keys for all medication storage areas including keys to controlled substance containers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 1 (Resident #3) of 6 residents reviewed for resident records.<BR/>The facility failed to ensure Medication Administration Records were accurate in the electronic medical record for Resident #3.<BR/>This failure could place residents at risk of having errors in care and treatment.<BR/>The Findings included: <BR/>Record review of Resident #3's electronic face sheet dated 01/23/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and most recently on 01/13/2025 with diagnoses to include: conversion disorder with seizures or convulsions (a mental health condition that causes seizures or convulsions) and anxiety. <BR/>Record review of Resident #3's quarterly MDS dated [DATE] revealed: BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS Section I - Active Diagnoses revealed resident had seizure disorder or epilepsy and anxiety disorder. <BR/>Record review of Resident #3's care plan dated 01/23/2025 revealed Resident #3 had seizures. Further review of care plan revealed interventions for seizures included to give medications as ordered, monitor/document effectiveness and side effects, use half side rails with seizure pads added to resident bed for safety, and to document seizure activity. <BR/>Record review of Resident #3's electronic physician orders dated 01/21/2025 revealed one time order for Ativan (lorazepam) 2mg/ml inject 2mg IM (intramuscularly) one time only for anxiety. Further review revealed an electronic physician order dated 01/14/2025 lorazepam injection 1mg IM every 5 minutes prn anxiety.<BR/>Record review of Resident #3's nursing progress notes which indicated that resident received 4 doses of Ativan (lorazepam) IM on 1/21/2025. Further review of nursing progress notes indicated Resident #3 received 1 dose of Ativan (lorazepam) IM on 1/22/2025 at 5:08 p.m.<BR/>Record review of Resident #3's MAR dated January 2025 revealed no evidence that Ativan (lorazepam) had been administered on 1/22/2025. <BR/>During an interview on 01/23/2025 at 1:02 p.m., LVN B stated she had administered lorazepam IM to Resident #3 on 01/22/2025. She stated she had written a progress note about resident on that date but must have forgotten to document medication administration on the MAR. She stated Resident #3's hospice nurse was present when lorazepam IM was administered, and medication was for an active seizure that Resident #3 had. She stated she felt being distracted prevented her from documenting medication administration in the MAR. She stated she knew to document medication administration in the resident's medical record and not performing could cause other nurses not to know she had administered the medication.<BR/>During a telephone interview on 01/24/2025 at 8:41 a.m., the MD stated he expected for medication administration records to be correct for residents. He stated he expected for nursing staff to follow the facility's policy on medication administration and for the ADON and DON to monitor that nursing staff was following that policy. He stated he did not review MARs for his knowledge of the residents in the facility and would get information that he needed from the DON.<BR/>During an interview on 01/24/2025 at 9:30 a.m., the ADMN stated the facility should follow the medication administration policy for clinical documentation of medications being administered. She stated the facility did not have a clinical documentation policy and used the medication administration policy.<BR/>During an interview on 01/24/2025 at 10:30 a.m., the ADON stated she expected for nurses and medication aides to document medication administration on the MARs to help prevent medication errors. She stated documentation should be completed when medication was administered and no later than the end of nurses' and medication aide's shift. She stated the resident's clinical record should reflect what was going on with the residents including the medications that residents had taken to help prevent adverse effects. She stated both herself and the DON monitored that nurses and medication aides documented medications in the medical record. She stated emergent situation may have caused the nurse to forget to document the medication administration. <BR/>During an interview on 01/24/2025 at 10:54 a.m., the DON stated he expected for the resident's MARs to reflect what medication had been given to those residents. He stated it was the responsibility of the nurse or medication aide to document medication administered on the MAR. He stated both he and the ADON monitored weekly that nurses and medication aides were documenting correctly by random chart reviews. He stated not documenting medications on the MAR would not affect what he reported to the MD because he used the controlled substance count sheets to see how frequently controlled substances were given. The DON stated it was easier to identify the time and frequency of medication administration on the controlled substance count sheets opposed to the MARs. He stated when Ativan (lorazepam) medication was documented on the MAR, it would trigger for the nurse to document the effectiveness of the medication. He stated not documenting Ativan (lorazepam) administration on the MAR could interfere with monitoring the effectiveness of medication. <BR/>During a telephone interview on 01/24/2025 at 12:17 p.m., the pharmacy consultant stated she rounded in the facility once a month. She stated she did look at resident's MARs but did not monitor the MARs when in the building. She stated she relied on physician orders to see what medications were prescribed for her medication reviews. She stated she made recommendations based on physician orders. She stated she would expect for the MAR to reflect what medication had been given to residents. She stated not documenting on the MAR could interfere with other nurses and medication aides knowing what had been given to monitor the effectiveness of the medication. She stated not documented could also interfere with nurses to know to monitor for side effects including lethargy (difficult to be aroused / sleepy). <BR/>During an interview on 01/24/2025 at 1:09 p.m., the ADMN stated she expected for nursing staff to follow policy when documenting medication administration. She stated the ADON and DON monitored that nursing staff followed the policy. She stated she expected for documentation to be completed by the end of the nurses' or medication aides' shift. She stated the MAR should reflect what had been given to the resident. She stated not documenting medication administration could cause adverse reaction to occur or could delay the responses to effectiveness of the medications. <BR/>Review of facility policy titled Medication Administration dated 07/08/2024 revealed: 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions .22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; d. the injection site (if applicable); e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 Resident (Resident #34) of 4 residents reviewed for accident and hazards: <BR/>The facility failed to ensure Resident #34's bed was on its lowest position while the resident was in his bed.<BR/>This failure could place residents at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues as a result of accident hazards.<BR/>Findings included: <BR/>Record review of Resident #34's admission record dated 01/24/24 indicated he was admitted to the facility on [DATE] with diagnoses of dementia and muscle weakness. He was [AGE] years of age.<BR/>Record review of Resident #34's care plan dated 01/23/24 indicated in part: Focus: Resident is High risk for falls r/t dementia. GOAL: The resident will be free of falls through the review date. Interventions: Keep bed in low position with fall mat beside bed. Bed at lowest position and fall mat in place.<BR/>Record review of Resident #34's MDS dated [DATE] indicated in part: BIMS = 00 indicating resident had severe impairment. Functional abilities and goals - Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) = 01 indicating Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity or, the assistance of 2 or more helpers is <BR/>required for the resident to complete the activity. <BR/>Record review of Resident #34's incident report dated 01/11/2024 indicated in part: Location: Resident's room. Nursing description: Heard resident calling for help. Nurse walked in room and found resident on the floor. Resident on the floor bed not in lowest position fall mat on the floor, resident in between bed and floor mat. Resident with right hip on floor, right arm behind his back, left leg and arm straight, With two assists, resident assisted back to bed. Denies pain in either shoulder. Full ROM with both shoulders. Full ROM to right hip. c/o low amount of pain during ROM. No pain to right hip when right hip joint is still. No pain to left leg. Full ROM to left leg. Dr. notified of fall and pain with right hip movement. <BR/>Resident description: Resident unable to give description. <BR/>Immediate action taken. Spoke with one CNAs and one TNA who put the resident to bed. Both stated bed would not go to lowest position. Nurse requested when equipment isn't working write it down in maintenance log. Bed put in maintenance log. LPN put bed in lowest position, did take longer than normal for bed to go to the floor. <BR/>Record review of the facility self-report 476720 PIR dated 01/12/24 indicated in part: Resident #34 was found on the floor next to his bed and complained of right hip pain. X-ray was done and revealed a non-displaced right hip fracture. Review of hospital document date 01/11/24 indicated in part: Return to NH. Dx 1. Incomplete right inter-trochanter fracture non-surgical 2. AKA. This is a non-surgical fracture. Note: (An intertrochanteric fracture is a specific type of hip fracture, intertrochanteric means between the trochanters, which are bony protrusions on the femur or thighbone). Review of final radiology report document date 01/12/24 indicated in part: Impression subtle lucency through the right intertrochanteric region which may be secondary to a nondisplaced fracture. <BR/>During an observation and interview on 01/23/24 at 12:24 PM Resident #34 was in the main dining room sitting up on his wheelchair awake and alert eating his lunch. Resident was asked if he recalled falling out of bed and he said he had never fallen out of bed before and had no complaints.<BR/>During an interview and observation on 01/24/24 at 12:46 PM CNA A said she was working the floor on 01/11/2024 the day Resident #34 fell. CNA A said the bed was not fully down because the bed remote was not working correctly and she felt at fault because the resident had fallen and fractured his hip. The aide went to the resident's room and demonstrated at what height the bed was which was approximately 22 inches off the floor. CNA A said RN C performed the assessment and then they placed the resident back onto the bed and later the x-ray people came and took x-rays of the resident. <BR/>During an interview on 01/24/24 at 03:00 PM RN C said on 01/11/24 she was at the nurses station and heard Resident #34 calling out for help. RN C said she walked into the room and noted the bed was not in its lowest position. RN C said the resident was on the floor on his right hip and was not on the mat, the resident was in between the bed and the mat on the floor. RN C said she assessed him and everything seemed okay at that time. RN C said CNA A said the bed would not go all the way down to the floor as it was not working properly. RN C said she asked the aide why she had not reported it to maintenance and the aide did not say anything and just started walking towards the maintenance log to book to document it. RN C said the bed worked just fine when she pressed the down button on the remote as the bed went all the way to the floor that same day. RN C said she called the doctor and family member to report the fall. RN C said it took a little while for doctor to get back and he ordered an x-ray which was done later in the day and it was positive non-displaced fracture. <BR/>During an interview on 01/24/24 at 03:24 PM CNA A said Resident #34's bed was actually working that day, 01/11/24, and she just had not lower it all the way down. CNA A said she had gotten nervous and did not recall how the incident actually all occurred.<BR/>During a telephone interview on 01/25/24 at 11:32 AM Resident #34's doctor said the resident's osteopenia (a condition in which bone mineral density is low) diagnosis could have contributed to the fracture even if the bed was in a low position. The doctor said he was aware of the fall and that corrective measures had been put into place. <BR/>Record review of the maintenance log dated 01/11/24 indicated in part: Date 1/11. Room/Location Resident #34 bed in 14A. What needs to be repaired Resident #34's bed won't go in low position. Date\Time of repair Nothing wrong with bed works 2:30pm. <BR/>During an interview on 01/25/24 at 12:46 PM the Maintenance Supervisor was asked about the maintenance log report where it indicated about Resident #34's bed no going to low position on 01/11/24. He said he had checked the bed and remote and that it was working fine when he checked it and did not need any repairs. <BR/>During an interview on 01/25/24 at 03:12 PM the Administrator was made aware of how Resident #34's bed not being on lowest position due to staff not lowering it all the way down could have contributed to the resident sustaining a fracture. The Administrator said it was her expectations for staff to report any issue with beds not working properly right away to prevent falls. <BR/>Record Review of the facility's policy titled, Fall prevention program dated 07/20/21 indicated in part: All residents will be assessed for the risk of falls at the time of admissions on a quarterly basis and upon significant change in condition thereafter. Based on the results of this assessments, specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. A fall can be defined as when a resident is found on the floor, a resident slide to the floor unassisted, a resident rolls off the bed/chair onto the floor including bedside mat. The following is a list of commonly used interventions that may be considered to minimize falls and injury - Resident room is maintained clutter free, bed maintained in low position with bedside mat.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promptly notify the resident's physician when there was radiology results outside of clinical reference range for 1 of 5 residents (Resident #17) reviewed for physician notification of radiology results.<BR/>The facility failed to promptly notify Resident #17's physician by phone per facility protocol on 02/12/25 when x-ray results falling outside of clinical reference ranges reflected Resident #17 had a right femur fracture<BR/>This failure could place residents at risk of a delay in medical treatment and could result in not receiving appropriate care and interventions.<BR/>The findings included:<BR/>Record review of Resident #17's face sheet dated 04/03/2025 revealed an [AGE] year-old female admitted on [DATE] with diagnoses which included: Schizoaffective disorder (mental health condition), major depressive disorder (mental health condition), hypothyroidism (an underactive thyroid), unspecified dementia (cognitive decline), hypertension (high blood pressure), osteoporosis (weakened bones), iron deficiency anemia (body does not have enough iron for healthy red blood cell production), gastro-esophageal reflux disease without esophagitis (reflux without inflammation or damage to the esophageal lining).<BR/>Record review of Resident #17's quarterly MDS dated [DATE] revealed a BIMS score of 00 which indicated a severe cognitive impairment and required extensive assistance and/or two plus persons physical assist for ADL care.<BR/>Record review of Resident #17's care plan report dated 02/09/2025 revealed focus areas that included moderate risk for falls related to confusion, gait/balance problems, psychoactive drug use as well as impaired cognitive function/dementia or impaired thought processes related to dementia. <BR/>Record review of Resident #17's care plan report dated 03/11/2025 revealed added focus areas of has had an actual fall and lists dates of falls as 02/26/24, 04/01/24, 04/19/24, 06/24/24, 11/01/24 (all with no injury), 02/04/25 (with abrasion to right knee), and 02/10/25 (fall with late onset right hip fracture resulting in hospital stay).<BR/>Record review of Resident #17's progress notes revealed: <BR/>02/10/25 at 01:08 AM, RN A noted Resident #17 was found lying in the floor, she was assisted back to bed after being assessed with noted hip bruising. The MD (on call), DON, and family were notified. <BR/>02/11/25 at 03:38 AM, LVN B noted Resident #17 was up in her wheelchair, eyes open, respirations even and unlabored, denied any pain or discomfort, and refused help to get back in bed.<BR/>02/11/25 at 01:18 PM, RN C noted in a Weekly Skin Observations Summary [in part]: Skin Condition Site(s) / Description(s): Face - forehead (bruise), Right trochanter (hip) - bruise, Other (specify) - right side (bruise) Skin condition(s) requires no treatment/dressing. Monitoring ongoing. Treatment/Care Plan Status: Skin condition(s) were not resolved. Continue current treatment plan. Education/Training Provided was described as: staff informed to round on resident every 2 hours and monitor the sides with bruising and to assess her to prevent anymore falls. Turning and repositioning outcome: The resident allowed clinician to reposition them for pressure redistribution and comfort. The resident was also left clean and dry. Referrals and/or additional notes if applicable: the nurse was notified of the resident, x-ray to be ordered.<BR/>02/11/25 at 03:34 PM, LVN D noted a portable x-ray bilateral (both sides) hip 3 views and cervical 2-3 view, due to post fall pain.<BR/>02/12/25 at 00:59 AM(12:59AM), RN A noted the x-ray results were received, and faxed to the MD for review. <BR/>Xray report reflected: Impression: 2. Mildly displaced fracture of the right femoral neck(upper long bone of leg). <BR/>02/12/25 at 09:24 AM, RN C noted in a Weekly Wound Observation Summary Note [in part]: The resident allowed clinician to reposition them for pressure redistribution and comfort. No new referrals / consultations were needed currently.<BR/>02/12/25 at 10:27 AM, the ADON noted they called and spoke with receptionist at MD's office related to fracture report and increased pain to right hip. The MD ordered to send the resident to the ER to eval and treat. <BR/>02/12/25 at 04:55 PM, the ADON noted they called and spoke with the ER. The resident admitted for a fracture from ortho.<BR/>Record review of Resident #17's Hospital Notes dated 02/12/25 - 02/16/25 revealed: Resident #17 underwent a right hip arthroplasty(joint replacement) to repair the fracture.<BR/>In an observation of Resident #17 on 04/02/25 at 8:20 AM, revealed the resident was lying in bed stated, I'm good, then closed her eyes and turned over towards the wall. Hydration at bedside, the call light was within reach, the fall mat was on the floor by the bed, and the bed was in a low position.<BR/>In an interview on 04/03/25 at 11:10 AM, the DON stated he was unsure what took place or what was going on at the time but that when it was brought to his attention the morning of 2/12/25, that the physician was not called with the x-ray results report that night. He stated he and the ADON completed an in-service over the phone with RN A, that reporting abnormal x-rays and labs to the MD, DON, and RR with all critical/abnormal findings must be done by phone. He further stated that for no reason should abnormal results be faxed. At that time the DON provided the policy for Fall Prevention Program and Medication Orders. The DON stated those were the only policies he had for falls and orders/reporting to physicians.<BR/>In an interview on 04/03/25 at 01:26 PM, LVN E stated the process for reporting an abnormal x-ray or lab report was to call the ordering physician immediately. She stated when a resident fell, the nurse did a head toe assessment making sure the resident was ok, a neuro check was done at that time and then every 30 min for 4 hours and then every hour for 4 hours. After the assessment, if at night, call the DON, family, and MD to inform of the incident and receive any orders the MD adds. She stated if the MD ordered an x-ray, the nurse placed the order in the computer, called the mobile x-ray provider to complete the order, then once the report was back call the MD with the results especially if they were positive for a fracture, or if a lab level was abnormal. She further stated that was the expectation. She also stated an adverse outcome, if a positive x-ray was reported and not immediately reported, could be the resident suffered in pain for a prolonged period of time and didn't get the care needed, also if staff did not know of the fracture, staff would do ADL's and activities with the resident like normal. <BR/>In a telephone interview on 04/03/25 at 4:28 PM, the MD for the facility stated the expectation when a resident fell was, he was immediately contacted via call or text, and informed if there was an injury or no injury. He stated the adverse outcome in the situation was the delay in care from the time the x-ray was done, the day after the fall, to the time he was notified of the fracture the next day 02/12/2025. He further stated when he was notified of the fall it was reported as no injury therefore an x-ray was not ordered at that time.<BR/>An attempt for phone interview on 04/03/25, at 4:40 PM and 5:15 PM to contact RN A and was unsuccessful. Unable to reach her with two attempts and voicemails were left.<BR/>In an interview on 04/04/25 at 8:10 AM, the ADON stated she called the MD's office on 02/12/25 as soon as she was made aware with the report of Resident #17's hip fracture. She stated the expectation of the nurses when an abnormal lab or x-ray came across the fax was to call the MD and speak to them directly. She further stated an adverse outcome was a delay in care.<BR/>In a record review of the facility policy labeled Fall Prevention Program last reviewed date 06/10/2024 reflected [in part]:<BR/>#5 If a fall occurs, the following will be done:<BR/>k. If the resident with dementia sustains a fall, in addition to the nursing assessment, the facility will also prioritize diagnostics such as STAT x-ray/transfer to the ER for appropriate investigation and intervention.<BR/>In an interview on 4/4/25 at 9:45 AM , the ADMN stated there was no further documentation or evidence to provide.

Based on observation and interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure that non-potable water was properly labeled and stored in the kitchen.<BR/>The facility failed to ensure that cleaning supplies were stored separately from food in the kitchen.<BR/>These failures could affect residents who received meals prepared meals in the kitchen at risk for food borne illness and cross-contamination.<BR/>The findings included:<BR/>Observation on 01/23/24 beginning at 11:15 AM in the kitchen revealed:<BR/>- <BR/>6 boxes, each containing 3 1-gallon plastic jugs of water with expiration date of 9/2/23 <BR/>- <BR/>8 boxes, each containing 3 1-gallon plastic jugs of water with expiration date of 9/2/23 (sign on top of two of the boxes stating non-potable water do not drink; these boxes were stored on a shelf with 10 boxes, each containing 3 1-gallon plastic jugs of water that were not expired, making it very difficult to distinguish between the expired and non-expired boxes)<BR/>- <BR/>2, 50-pound boxes of potatoes stored on a shelf next to a gray plastic tub containing stained wash rags and a gray plastic tub containing mop heads<BR/>In an interview on 01/23/24 at 11:35 AM the Dietary Manager stated that she was aware of the expired water that was being stored in the dry storage room. She stated it was kept there because the dietary staff used it to wash dishes when the water heater went out or the facility water had to be turned off for any reason. She stated that the reason the expired water and the non-expired water were stored together was a lack of storage space. Dietary Manager stated she had placed a sign on some of the water to make sure the staff was aware that it was not for drinking and was expired. When asked why all the expired boxes of water were not labeled with a sign and stored on a single shelf, she was unable to give an answer. She stated there was very little storage space in the kitchen and they (dietary staff) had to use whatever space they could to store everything (food, supplies). When asked if there was any external storage space, she stated that corporate had told her the facility would get a storage building but there had not been a timeline given for when.<BR/>In an interview on 01/24/24 at 11:30 AM [NAME] B stated that the expired water should be stored in a different area than the food because it was not for drinking. She stated that the way the water storage was set up was not good and it was confusing. [NAME] B stated that anybody could walk into the kitchen and grab a jug of the expired water and not know because it was not clearly marked expired or not for resident use. She stated that the sign that stated do not drink looked like it was for only two boxes, not eight, and that was confusing because the expired water and the good water were stored together. [NAME] B stated there were times the jugs of water were used for the residents drinking water in addition to dishwashing, and she felt not having the boxes clearly marked and separated could be a problem. She stated that storage was a problem for the kitchen, and they needed more storage space.<BR/>In an interview on 01/24/24 at 11:47 AM the Dietary Manager stated that the reason the wash rags and mop heads were stored on a shelf with food was due to lack of storage. She stated that the cleaning supplies were kept in the restroom in the kitchen but there was not enough storage space in there for the mop heads and rags. She stated that she believed by keeping the rags and mop heads in the plastic tubs they were separated enough from the food. She stated that the rags and mop heads were clean even though they were stained. The Dietary Manager acknowledged that storing the cleaning supplies with food items was a potential cross contamination issue and the rags and mop heads should be stored elsewhere.<BR/>In an interview on 01/25/24 at 1:57 PM the Administrator stated that she had spoken with the Dietary Manager about the findings from the kitchen inspection on 1/23/24 and 1/24/24 and was aware of the issues. The Administrator stated the cleaning supplies should never be stored with food. She stated she was unaware of exactly how the water was stored but after it was explained to her, she agreed that having the expired water stored the way it was would be confusing and was not appropriate. She stated the facility did not have adequate storage space in the kitchen and that was the cause of the failure. She stated was in the process of getting the facility a 20-foot by 20-foot storage building to help with some of the storage issues the kitchen had. The Administrator stated the facility's parent corporation was supposed to do renovations in the kitchen to improve the storage but there had been no date set for them to start. <BR/>Record review of facility policy titled Food Receiving and Storage dated October 2022 revealed, in part:<BR/>Foods shall be received and stored in a manner that complies with safe food handling practices. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 Resident (Resident #34) of 4 residents reviewed for accident and hazards: <BR/>The facility failed to ensure Resident #34's bed was on its lowest position while the resident was in his bed.<BR/>This failure could place residents at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues as a result of accident hazards.<BR/>Findings included: <BR/>Record review of Resident #34's admission record dated 01/24/24 indicated he was admitted to the facility on [DATE] with diagnoses of dementia and muscle weakness. He was [AGE] years of age.<BR/>Record review of Resident #34's care plan dated 01/23/24 indicated in part: Focus: Resident is High risk for falls r/t dementia. GOAL: The resident will be free of falls through the review date. Interventions: Keep bed in low position with fall mat beside bed. Bed at lowest position and fall mat in place.<BR/>Record review of Resident #34's MDS dated [DATE] indicated in part: BIMS = 00 indicating resident had severe impairment. Functional abilities and goals - Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) = 01 indicating Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity or, the assistance of 2 or more helpers is <BR/>required for the resident to complete the activity. <BR/>Record review of Resident #34's incident report dated 01/11/2024 indicated in part: Location: Resident's room. Nursing description: Heard resident calling for help. Nurse walked in room and found resident on the floor. Resident on the floor bed not in lowest position fall mat on the floor, resident in between bed and floor mat. Resident with right hip on floor, right arm behind his back, left leg and arm straight, With two assists, resident assisted back to bed. Denies pain in either shoulder. Full ROM with both shoulders. Full ROM to right hip. c/o low amount of pain during ROM. No pain to right hip when right hip joint is still. No pain to left leg. Full ROM to left leg. Dr. notified of fall and pain with right hip movement. <BR/>Resident description: Resident unable to give description. <BR/>Immediate action taken. Spoke with one CNAs and one TNA who put the resident to bed. Both stated bed would not go to lowest position. Nurse requested when equipment isn't working write it down in maintenance log. Bed put in maintenance log. LPN put bed in lowest position, did take longer than normal for bed to go to the floor. <BR/>Record review of the facility self-report 476720 PIR dated 01/12/24 indicated in part: Resident #34 was found on the floor next to his bed and complained of right hip pain. X-ray was done and revealed a non-displaced right hip fracture. Review of hospital document date 01/11/24 indicated in part: Return to NH. Dx 1. Incomplete right inter-trochanter fracture non-surgical 2. AKA. This is a non-surgical fracture. Note: (An intertrochanteric fracture is a specific type of hip fracture, intertrochanteric means between the trochanters, which are bony protrusions on the femur or thighbone). Review of final radiology report document date 01/12/24 indicated in part: Impression subtle lucency through the right intertrochanteric region which may be secondary to a nondisplaced fracture. <BR/>During an observation and interview on 01/23/24 at 12:24 PM Resident #34 was in the main dining room sitting up on his wheelchair awake and alert eating his lunch. Resident was asked if he recalled falling out of bed and he said he had never fallen out of bed before and had no complaints.<BR/>During an interview and observation on 01/24/24 at 12:46 PM CNA A said she was working the floor on 01/11/2024 the day Resident #34 fell. CNA A said the bed was not fully down because the bed remote was not working correctly and she felt at fault because the resident had fallen and fractured his hip. The aide went to the resident's room and demonstrated at what height the bed was which was approximately 22 inches off the floor. CNA A said RN C performed the assessment and then they placed the resident back onto the bed and later the x-ray people came and took x-rays of the resident. <BR/>During an interview on 01/24/24 at 03:00 PM RN C said on 01/11/24 she was at the nurses station and heard Resident #34 calling out for help. RN C said she walked into the room and noted the bed was not in its lowest position. RN C said the resident was on the floor on his right hip and was not on the mat, the resident was in between the bed and the mat on the floor. RN C said she assessed him and everything seemed okay at that time. RN C said CNA A said the bed would not go all the way down to the floor as it was not working properly. RN C said she asked the aide why she had not reported it to maintenance and the aide did not say anything and just started walking towards the maintenance log to book to document it. RN C said the bed worked just fine when she pressed the down button on the remote as the bed went all the way to the floor that same day. RN C said she called the doctor and family member to report the fall. RN C said it took a little while for doctor to get back and he ordered an x-ray which was done later in the day and it was positive non-displaced fracture. <BR/>During an interview on 01/24/24 at 03:24 PM CNA A said Resident #34's bed was actually working that day, 01/11/24, and she just had not lower it all the way down. CNA A said she had gotten nervous and did not recall how the incident actually all occurred.<BR/>During a telephone interview on 01/25/24 at 11:32 AM Resident #34's doctor said the resident's osteopenia (a condition in which bone mineral density is low) diagnosis could have contributed to the fracture even if the bed was in a low position. The doctor said he was aware of the fall and that corrective measures had been put into place. <BR/>Record review of the maintenance log dated 01/11/24 indicated in part: Date 1/11. Room/Location Resident #34 bed in 14A. What needs to be repaired Resident #34's bed won't go in low position. Date\Time of repair Nothing wrong with bed works 2:30pm. <BR/>During an interview on 01/25/24 at 12:46 PM the Maintenance Supervisor was asked about the maintenance log report where it indicated about Resident #34's bed no going to low position on 01/11/24. He said he had checked the bed and remote and that it was working fine when he checked it and did not need any repairs. <BR/>During an interview on 01/25/24 at 03:12 PM the Administrator was made aware of how Resident #34's bed not being on lowest position due to staff not lowering it all the way down could have contributed to the resident sustaining a fracture. The Administrator said it was her expectations for staff to report any issue with beds not working properly right away to prevent falls. <BR/>Record Review of the facility's policy titled, Fall prevention program dated 07/20/21 indicated in part: All residents will be assessed for the risk of falls at the time of admissions on a quarterly basis and upon significant change in condition thereafter. Based on the results of this assessments, specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. A fall can be defined as when a resident is found on the floor, a resident slide to the floor unassisted, a resident rolls off the bed/chair onto the floor including bedside mat. The following is a list of commonly used interventions that may be considered to minimize falls and injury - Resident room is maintained clutter free, bed maintained in low position with bedside mat.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained for 1 of 1 medication rooms reviewed for medication labeling and storage.<BR/>The facility failed to maintain controlled substance record count sheet with accurate amount of lorazepam (a controlled substance) stored in medication room refrigerator. <BR/>These failures could place residents at risk of misappropriation of medications.<BR/>Findings Included: <BR/>Record review of Resident #3's electronic face sheet dated 01/23/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and most recently on 01/13/2025 with diagnoses to include: conversion disorder with seizures or convulsions (a mental health condition that causes seizures or convulsions) and anxiety. <BR/>Record review of Resident #3's quarterly MDS dated [DATE] revealed: BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS Section I - Active Diagnoses revealed resident had seizure disorder or epilepsy and anxiety disorder. <BR/>Record review of Resident #3's care plan dated 01/23/2025 revealed Resident #3 had seizures. Further review of care plan revealed interventions for seizures included to give medications as ordered, monitor/document effectiveness and side effects, use half side rails with seizure pads added to resident bed for safety, and to document seizure activity. <BR/>Record review of Resident #3's electronic physician orders dated 01/21/2025 revealed one time order for Ativan (lorazepam) 2mg/ml inject 2mg IM (intramuscularly) one time only for anxiety. Further review revealed an electronic physician order dated 01/14/2025 lorazepam injection 1mg IM every 5 minutes prn anxiety.<BR/>Record review of Resident #3's nursing progress notes which indicated that resident received 4 doses of Ativan (lorazepam) IM on 1/21/2025. Further review of nursing progress notes indicated Resident #3 received 1 dose of Ativan (lorazepam) IM on 1/22/2025 at 5:08 p.m. <BR/>Record review of Resident #3's narcotic count sheet titled controlled substance record indicated 4 doses of lorazepam were administered on 1/21/2025. There was no evidence that 1 dose of lorazepam had been administered on 1/22/2025. <BR/>During an observation and interview on 01/23/2025 at 11:48 a.m., the medication room refrigerator had a sealed bag of lorazepam vials for Resident #3 inside of the controlled substance box that had 25 vials inside of the box. LVN A was present and agreed that there were 25 vials of lorazepam in sealed bag for Resident #3. LVN A stated medications were counted every shift to make sure that the counts were correct. She stated she had not counted the medication in the refrigerator because she was not responsible for 200-300 medication cart which had the count sheets for Ativan (lorazepam) in the binder. <BR/>During an interview on 01/22/2025 at 12:10 p.m., MA C stated she was responsible for the 200-300 hall medication cart. She observed the controlled substance count sheet and agreed that it stated 26 vials of lorazepam should be in the refrigerator for Resident #3. She stated she should have counted the refrigerator medications when she took control of the 200-300 medication cart at shift change. She stated she did not count the refrigerator medications this morning during shift change. She did not answer why she did not count the medications in the refrigerator when asked.<BR/>During an interview on 01/23/2025 at 12:14 p.m., the DON stated medication aides and nurses were responsible for making sure controlled substance count sheets were accurate with medication on hand during shift change. He stated that both he and the ADON monitored the medication aides and nurses performed counts and had just counted the medication room fridge on 01/22/2025 before 4:00 p.m. and the count was correct. He stated he expected for nurses and medication aides to sign out medication on the controlled substance count sheets as they were given. He stated medication aides and nurses were to contact him if the count did not match what was written on the controlled substance count sheet and he would do an investigation to see why count sheets were off. He stated he would let corporate and state agency know of issue when his investigation could not find reason for why counts sheets were incorrect. He stated he would investigate why Ativan (lorazepam) did not match controlled count sheet.<BR/>During a follow up interview on 01/23/2025 at 1:00 p.m., the DON stated his investigation led to the finding that LVN B had given lorazepam on 01/22/2025 around 5:00 p.m. He stated had LVN B signed the medication off of the controlled substance count sheet, the counts would match how much medication was on hand in the refrigerator. He stated the nurses and medication aides had been educated in the past about making sure count sheets were accurate and counted every shift change. He stated he felt more education was needed.<BR/>During an interview on 01/23/2025 at 1:02 p.m., LVN B stated Resident #3 was having a seizure on 01/22/2025 around 5:00 p.m. and his hospice nurse was present in the facility. She stated she remembered the time because a new admission had arrived at the facility around the same time. She stated she had gotten medication vial from refrigerator in the medication room and had administered the Ativan (lorazepam) to Resident #3. She stated she did not sign it out on the controlled substance count sheet because she was distracted. She stated it was important to sign out medication use on controlled substance count sheet to keep account of the medication and prevent someone from taking it. <BR/>During an observation on 01/23/2025 at 2:38 p.m., Resident #3 was in his room lying in bed that was in low position. He had side rails that were padded on his bed. His eyes were closed and no distress observed. His respirations were even and unlabored. Resident #3's call light was within reach of him.<BR/>During an observation and interview on 01/24/2025 at 5:50 p.m., LVN D counted controlled substances in medication room refrigerator with MA C. LVN D removed keys from beside of the refrigerator and opened the locked box inside of the refrigerator to count the medications. She stated whoever was responsible for 200-300 medication cart should count the controlled substances in the refrigerator. She stated she had not been responsible for 200-300 medication cart on 1/22/2025 and was unsure why the controlled substances were not correct on the count sheet on 01/23/2025.<BR/>During an interview on 01/24/2025 at 6:04 p.m., RN E stated she was responsible for 200-300 medication cart on the night of 01/22/2025. She stated she should have counted the controlled substances in the medication room refrigerator. She stated she had been education in the past to count the box for controlled substances in the refrigerator when she was responsible for the 200-300 medication cart. She did not give a reason why she did not count the controlled substances the night of 01/22/2025. She stated controlled substances were counted to prevent loss of medication from people taking medication out of the controlled substance box.<BR/>During a telephone interview on 01/24/2025 at 8:41 a.m., the MD stated he expected for controlled medications to be counted every shift and for staff to follow facility's policy. He stated he expected for nurses and medication aides to follow facility policy when storing controlled substances. He stated the DON was responsible for monitoring that nurses and medication aides followed the policy. The MD stated he does not review the narcotic count sheets during his resident review of how often medication was administered. He stated he obtains medication administration frequency from the DON and does not know where the DON obtains that information.<BR/>During an interview on 01/24/2025 at 10:30 a.m., the ADON stated the facility utilized controlled substance count sheets to correctly manage the controlled substances and dosages. She stated the controlled substance count sheets do help keep track of medication and reduce risk for misappropriation. She stated her expectation would be that the controlled substance count sheets be promptly updated when a medication dose had been given. She stated both her and the DON do weekly audits to make sure the controlled substances matched what was documented on the controlled substance count sheets. <BR/>During a telephone interview on 01/24/2025 at 11:44 a.m., the pharmacy consultant stated she rounded in the facility once a month. She stated she would do random spot checks of controlled substance count sheets to see if nurses and medication aides were signing medication in and out. She stated her expectation would be that the medication on hand match the controlled substance count sheet. She stated the negative effect of controlled substances not being accurate could be misappropriation of medications. She stated nurses and medication aides should document medication on controlled substance count sheet as soon as the medication was given. <BR/>During a follow up interview on 01/24/2025 at 10:54 a.m., the DON stated staff laziness may have led to the failure of staff not counting the controlled substances in refrigerator because they had been educated to do so prior to 01/22/2025. He stated not counting controlled substance during shift change could lead to misappropriation of medications and if not found then licensure reporting to appropriate agency.<BR/>During an interview on 01/24/2025 at 1:09 p.m., the ADMN stated she expected for controlled substance count sheets to accurately reflect the amount of medication in storage. She stated controlled substance count sheets were done to help prevent medication misappropriation. She stated she expected for staff to go by facility policy when storing medications. She stated the ADON and the DON monitored that staff were controlled substances during shift change.<BR/>Review of drugs.com accessed on 01/24/2025 at https://www.drugs.com/schedule-4-drugs.html revealed: Ativan (lorazepam) was listed under The following drugs are listed as Schedule 4 (IV) Drugs by the Controlled Substances Act (CSA)<BR/>Review of the facility policy titled Controlled Substances dated July 2024 revealed: Dispensing and Reconciling Controlled Substances 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection / follow-up. 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records. 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services .15. The consultant pharmacist or designee routinely monitors controlled substance storage records. 16. The director of nursing services maintains and disseminates to appropriate individuals a list of staff who have access to medication storage areas and controlled substance containers.

Based on observation, interview, and record review the facility failed to ensure separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 1 medication rooms reviewed for medication labeling and storage.<BR/>The facility failed to maintain controlled substance record count sheet with accurate amount of lorazepam (a controlled substance) stored in medication room refrigerator. <BR/>These failures could place residents at risk of misappropriation of medications.<BR/>Findings Included: <BR/>During an observation on 01/23/2025 at 11:48 a.m., the medication room refrigerator had a locked box inside of the refrigerator that was not secured and could be removed easily from the refrigerator. Keys to the locked box, inside of the refrigerator, were stored on a hook that was secured to the left of the outside of the refrigerator. Anyone with access to the medication room had access to the locked box key. <BR/>During an observation and interview on 01/24/2025 at 5:50 p.m., LVN D counted controlled substances in medication room refrigerator with MA C. LVN D removed keys from beside of the refrigerator and opened the locked box inside of the refrigerator to count the medications. <BR/>During a telephone interview on 01/24/2025 at 8:41 a.m., the MD stated he expected for nurses and medication aides to follow facility policy when storing controlled substances. He stated the DON was responsible for monitoring that nurses and medication aides followed the policy. <BR/>During an interview on 01/24/2025 at 10:30 a.m., the ADON stated the locked box in refrigerator, for controlled substances, should be secured to the refrigerator. She stated she did not know why the box had not been secured to the refrigerator. She stated the keys to the locked box in refrigerator for controlled substances should not be kept to the left outside of the refrigerator and should be stored on the nurse or medication aide keys that were responsible for the medication cart that kept the controlled substance count sheets in binder. She stated she did not know why keys had been stored next to the refrigerator but that storing the key that way could cause potential misuse of the controlled medications. She stated both her and the DON monitor that medication were stored appropriately. <BR/>During a telephone interview on 01/24/2025 at 11:44 a.m., the pharmacy consultant stated she expected for staff not to store key to the locked box in the medication room next to the unlocked refrigerator. She stated the facility had moved the medication room recently from the back of the facility to the front and that may have led to controlled substances to not be stored appropriately. She stated the controlled substance box should be secured to the refrigerator and did not know why it was not. <BR/>During a follow up interview on 01/24/2025 at 10:54 a.m., the DON stated the controlled substance box should be secured to the refrigerator and the keys to the box should not be stored outside of the refrigerator for all staff that had access to the medication room to have access to the controlled substances in the locked box. He stated recently the controlled substance box had been replaced due to the old one had rusted and he felt that led to the failure of new controlled substance box not being affixed. He stated staff laziness may have led to the failure of the key to the controlled substance box being stored next to the refrigerator in medication room. He stated not storing medication correctly could lead to misappropriation of medications <BR/>During an interview on 01/24/2025 at 1:09 p.m., the ADMN stated she expected for staff to go by facility policy when storing medications. She stated the ADON and the DON monitored that staff were storing medications appropriately.<BR/>Review of the facility policy titled Controlled Substances dated July 2024 revealed: Storing Controlled Substances. 1. Controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. 2. All keys to controlled substance containers are on a single key ring that is different from any other keys. 3. The charge nurse on duty maintains the keys to controlled substance containers. The director of nursing services maintains a set of back-up keys for all medication storage areas including keys to controlled substance containers.

Based on observation and interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure that non-potable water was properly labeled and stored in the kitchen.<BR/>The facility failed to ensure that cleaning supplies were stored separately from food in the kitchen.<BR/>These failures could affect residents who received meals prepared meals in the kitchen at risk for food borne illness and cross-contamination.<BR/>The findings included:<BR/>Observation on 01/23/24 beginning at 11:15 AM in the kitchen revealed:<BR/>- <BR/>6 boxes, each containing 3 1-gallon plastic jugs of water with expiration date of 9/2/23 <BR/>- <BR/>8 boxes, each containing 3 1-gallon plastic jugs of water with expiration date of 9/2/23 (sign on top of two of the boxes stating non-potable water do not drink; these boxes were stored on a shelf with 10 boxes, each containing 3 1-gallon plastic jugs of water that were not expired, making it very difficult to distinguish between the expired and non-expired boxes)<BR/>- <BR/>2, 50-pound boxes of potatoes stored on a shelf next to a gray plastic tub containing stained wash rags and a gray plastic tub containing mop heads<BR/>In an interview on 01/23/24 at 11:35 AM the Dietary Manager stated that she was aware of the expired water that was being stored in the dry storage room. She stated it was kept there because the dietary staff used it to wash dishes when the water heater went out or the facility water had to be turned off for any reason. She stated that the reason the expired water and the non-expired water were stored together was a lack of storage space. Dietary Manager stated she had placed a sign on some of the water to make sure the staff was aware that it was not for drinking and was expired. When asked why all the expired boxes of water were not labeled with a sign and stored on a single shelf, she was unable to give an answer. She stated there was very little storage space in the kitchen and they (dietary staff) had to use whatever space they could to store everything (food, supplies). When asked if there was any external storage space, she stated that corporate had told her the facility would get a storage building but there had not been a timeline given for when.<BR/>In an interview on 01/24/24 at 11:30 AM [NAME] B stated that the expired water should be stored in a different area than the food because it was not for drinking. She stated that the way the water storage was set up was not good and it was confusing. [NAME] B stated that anybody could walk into the kitchen and grab a jug of the expired water and not know because it was not clearly marked expired or not for resident use. She stated that the sign that stated do not drink looked like it was for only two boxes, not eight, and that was confusing because the expired water and the good water were stored together. [NAME] B stated there were times the jugs of water were used for the residents drinking water in addition to dishwashing, and she felt not having the boxes clearly marked and separated could be a problem. She stated that storage was a problem for the kitchen, and they needed more storage space.<BR/>In an interview on 01/24/24 at 11:47 AM the Dietary Manager stated that the reason the wash rags and mop heads were stored on a shelf with food was due to lack of storage. She stated that the cleaning supplies were kept in the restroom in the kitchen but there was not enough storage space in there for the mop heads and rags. She stated that she believed by keeping the rags and mop heads in the plastic tubs they were separated enough from the food. She stated that the rags and mop heads were clean even though they were stained. The Dietary Manager acknowledged that storing the cleaning supplies with food items was a potential cross contamination issue and the rags and mop heads should be stored elsewhere.<BR/>In an interview on 01/25/24 at 1:57 PM the Administrator stated that she had spoken with the Dietary Manager about the findings from the kitchen inspection on 1/23/24 and 1/24/24 and was aware of the issues. The Administrator stated the cleaning supplies should never be stored with food. She stated she was unaware of exactly how the water was stored but after it was explained to her, she agreed that having the expired water stored the way it was would be confusing and was not appropriate. She stated the facility did not have adequate storage space in the kitchen and that was the cause of the failure. She stated was in the process of getting the facility a 20-foot by 20-foot storage building to help with some of the storage issues the kitchen had. The Administrator stated the facility's parent corporation was supposed to do renovations in the kitchen to improve the storage but there had been no date set for them to start. <BR/>Record review of facility policy titled Food Receiving and Storage dated October 2022 revealed, in part:<BR/>Foods shall be received and stored in a manner that complies with safe food handling practices. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly.

Based on observation and interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure that non-potable water was properly labeled and stored in the kitchen.<BR/>The facility failed to ensure that cleaning supplies were stored separately from food in the kitchen.<BR/>These failures could affect residents who received meals prepared meals in the kitchen at risk for food borne illness and cross-contamination.<BR/>The findings included:<BR/>Observation on 01/23/24 beginning at 11:15 AM in the kitchen revealed:<BR/>- <BR/>6 boxes, each containing 3 1-gallon plastic jugs of water with expiration date of 9/2/23 <BR/>- <BR/>8 boxes, each containing 3 1-gallon plastic jugs of water with expiration date of 9/2/23 (sign on top of two of the boxes stating non-potable water do not drink; these boxes were stored on a shelf with 10 boxes, each containing 3 1-gallon plastic jugs of water that were not expired, making it very difficult to distinguish between the expired and non-expired boxes)<BR/>- <BR/>2, 50-pound boxes of potatoes stored on a shelf next to a gray plastic tub containing stained wash rags and a gray plastic tub containing mop heads<BR/>In an interview on 01/23/24 at 11:35 AM the Dietary Manager stated that she was aware of the expired water that was being stored in the dry storage room. She stated it was kept there because the dietary staff used it to wash dishes when the water heater went out or the facility water had to be turned off for any reason. She stated that the reason the expired water and the non-expired water were stored together was a lack of storage space. Dietary Manager stated she had placed a sign on some of the water to make sure the staff was aware that it was not for drinking and was expired. When asked why all the expired boxes of water were not labeled with a sign and stored on a single shelf, she was unable to give an answer. She stated there was very little storage space in the kitchen and they (dietary staff) had to use whatever space they could to store everything (food, supplies). When asked if there was any external storage space, she stated that corporate had told her the facility would get a storage building but there had not been a timeline given for when.<BR/>In an interview on 01/24/24 at 11:30 AM [NAME] B stated that the expired water should be stored in a different area than the food because it was not for drinking. She stated that the way the water storage was set up was not good and it was confusing. [NAME] B stated that anybody could walk into the kitchen and grab a jug of the expired water and not know because it was not clearly marked expired or not for resident use. She stated that the sign that stated do not drink looked like it was for only two boxes, not eight, and that was confusing because the expired water and the good water were stored together. [NAME] B stated there were times the jugs of water were used for the residents drinking water in addition to dishwashing, and she felt not having the boxes clearly marked and separated could be a problem. She stated that storage was a problem for the kitchen, and they needed more storage space.<BR/>In an interview on 01/24/24 at 11:47 AM the Dietary Manager stated that the reason the wash rags and mop heads were stored on a shelf with food was due to lack of storage. She stated that the cleaning supplies were kept in the restroom in the kitchen but there was not enough storage space in there for the mop heads and rags. She stated that she believed by keeping the rags and mop heads in the plastic tubs they were separated enough from the food. She stated that the rags and mop heads were clean even though they were stained. The Dietary Manager acknowledged that storing the cleaning supplies with food items was a potential cross contamination issue and the rags and mop heads should be stored elsewhere.<BR/>In an interview on 01/25/24 at 1:57 PM the Administrator stated that she had spoken with the Dietary Manager about the findings from the kitchen inspection on 1/23/24 and 1/24/24 and was aware of the issues. The Administrator stated the cleaning supplies should never be stored with food. She stated she was unaware of exactly how the water was stored but after it was explained to her, she agreed that having the expired water stored the way it was would be confusing and was not appropriate. She stated the facility did not have adequate storage space in the kitchen and that was the cause of the failure. She stated was in the process of getting the facility a 20-foot by 20-foot storage building to help with some of the storage issues the kitchen had. The Administrator stated the facility's parent corporation was supposed to do renovations in the kitchen to improve the storage but there had been no date set for them to start. <BR/>Record review of facility policy titled Food Receiving and Storage dated October 2022 revealed, in part:<BR/>Foods shall be received and stored in a manner that complies with safe food handling practices. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a Baseline Care Plan within 48 hours of a resident's admission for 3 of 3 Resident's (#39, #43, and #48's) reviewed for baseline care plan completion.<BR/>The facility failed to complete baseline care plans for Resident #39, Resident #43, Resident #48 within the required 48-hour timeframe. <BR/>This failure could place residents who were newly admitted at risk of not receiving necessary care and services or having important care needs identified.<BR/>Findings included: <BR/>Resident #39 <BR/>Review of Resident #39's electronic face sheet revealed an [AGE] year-old male admitted on [DATE] with diagnoses including: Restlessness and agitation, acute respiratory disease, Cellulitis, muscle spasm, dementia with behavioral disturbance<BR/>Record review of Resident #39's Minimum Data Set (MDS) dated [DATE] revealed: A Brief Interview for Mental Status (BIMS) Summary Score was, 03 (severe impairment).<BR/>Record review on 11/22/2022 of Resident #39's electronic care plan revealed no evidence of baseline care plan. <BR/>Resident #43 <BR/>Review of Resident #43's electronic face sheet revealed a 28 -year-old male admitted on [DATE] with diagnoses including: Huntington's disease (condition that stops parts of brain working properly over time), mild cognitive impairment, muscle spasms, and unsteadiness on feet with lack of coordination.<BR/>Record review of Resident # 43's Minimum Data Set (MDS) dated [DATE] revealed: A Brief Interview for Mental Status (BIMS) of a 09 (moderate impairment). <BR/>Record review on 11/22/2022 of Resident #43's electronic care plan revealed no evidence of baseline care plan.<BR/>Resident #48 <BR/>Record review of Resident #48's Electronic Face Sheet revealed an [AGE] year-old male with an initial admit date of 03/26/2021 with latest return 08/18/2022 with diagnosis including Dementia, altered mental status, Cognitive communication deficit, unsteadiness on feet and unsteady on feet. <BR/>Record review of Resident #48's Minimum Data Set (MDS) dated [DATE] revealed: A Brief Interview for Mental Status (BIMS) of a 03 (severe impairment).<BR/>Record review on 11/22/2022 of Resident #48's electronic care plan revealed no evidence of baseline care plan.<BR/>During an interview on 11/22/2022 at 1:45 PM, the CCM stated baseline care plans should be completed within 24 hours of admission and comprehensive care plans should be completed within 21 days of admission. CCM was not able to locate baseline care plans for Resident #39, #43 and #48 in the electronic medical chart. CCM stated that the DON was in charge of completing baseline care plans and he was in charge of completing comprehensive care plans. <BR/>During an interview on 11/22/2022 at 2:00 PM, the DON stated she does the baseline care plans for residents. DON stated the baseline care plans were located in the resident's electronic medical charts. She continued to state Resident #39, #43 and #48's baseline care plans should have been done and updated accordingly but those residents were most likely not completed. She stated the failure was time management on her part, with the expectations of getting them completed within 48 hours of resident's admission.<BR/>During an interview on 09/22/21 at 1:50 PM, the ADMIN stated the failure of Baseline Care plans not being completed was the DON has had to work the floor, and her expectations was for the facility to get staff that will work harder so the DON can do her job. <BR/>Review of the facility's policy titled: The Care Plans-Baseline dated December 2016 indicated 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.<BR/>1. <BR/>To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (4838) hours of the resident's admission.<BR/>2. <BR/>The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to:<BR/>a. <BR/>Initial goals based on admission orders;<BR/>b. <BR/>Physician orders;<BR/>c. <BR/>Dietary orders;<BR/>d. <BR/>Therapy services;<BR/>e. <BR/>Social services; and <BR/>f. <BR/>PASARR recommendation, if applicable <BR/>3. <BR/>The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan.<BR/>4. <BR/>The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: <BR/>a. <BR/>The initial goals of the resident;<BR/>b. <BR/>A summary of the resident's medications and dietary instructions;<BR/>c. <BR/>Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and <BR/>d. <BR/>Any updated information based on the details of the comprehensive care plan, as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #52 and Resident #7) of 20 residents reviewed for comprehensive person-centered care plans. <BR/>1. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address antipsychotic and antidepressant medication use for Resident #52 and to accurately address the diet texture for Resident #52 who had an order for a mechanical soft diet but was stated to be on a puree diet on the comprehensive care plan. <BR/>2. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address the diet or swallowing difficulty for Resident #7.<BR/>These failures could affect the residents by placing them at risk for not receiving care and services to meet their needs.<BR/>Findings included:<BR/>Resident #52<BR/>Record review of Resident #52's electronic face sheet accessed 11/20/2022 revealed resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis to include brain stroke, difficulty swallowing, dementia, schizophrenia, and anxiety. <BR/>Record review of Resident #52's Quarterly MDS dated [DATE] revealed: Section C: Cognitive Patterns: BIMS score interview not conducted. Section I: Active Diagnosis: Anxiety and Schizophrenia. Section K: Swallowing/Nutrition Status: Swallowing Disorder: Loss of liquids/solids from mouth when eating or drinking, Nutritional Approach: Mechanically altered diet. Section N Medications received: Antipsychotic and Antidepressant.<BR/>Review of Resident's #52's electronic care plan initiated 05/26/2022 revealed no evidence of a focus, objective, or interventions related to the use of antipsychotic and antidepressant medication. Further review of the electronic care plan revealed: Category: Nutritional Status Pureed Diet. Goal: No choking incidents. Approach: Offer correct diet, allow time to chew and swallow, and make sure position is correct.<BR/>Record review of Resident #52's electronic physicians orders accessed 11/20/2022 revealed the following orders: <BR/>04/05/2022- Remeron 15 mg tablet 0.5 tablet oral at bedtime for depression,<BR/>10/20/2022-Risperdal 0.5 mg 1 tablet at bedtime for schizophrenia,<BR/>10/14/2022- Risperdal 3 mg 1 tablet at bedtime for schizophrenia, and <BR/>12/15/2021- Diet: Regular Texture: Mechanical Soft Fluid Consistency: Thin. <BR/>Resident #7<BR/>Review of Resident #7's electronic face sheet accessed 11/20/2022 revealed resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis to include difficulty swallowing.<BR/>Review of Resident #7's Quarterly MDS dated [DATE] revealed: Section C: Cognitive Patterns: BIMS score of 03 indicating severe cognitive impairment. Section I: Active Diagnosis: Dysphagia. Section K: Swallowing/Nutrition Status: Swallowing Disorder: None of the above. Nutritional Approaches: None of the above.<BR/>Review of Resident's #7's electronic care plan last revised 09/23/2022 revealed no evidence of a focus, objective, or interventions related to diet or swallowing difficulty.<BR/>Review of Resident #7's electronic physicians orders accessed 11/2/2022 revealed: Diet: Regular Texture: Puree Fluid Consistency: Thin dated 03/09/2021. <BR/>During an interview on 11/22/2022 at 2:00 PM, the CCM stated he was only responsible for comprehensive care plans. He stated he did not update the comprehensive care plan with new or acute information. He stated he reviewed the comprehensive care plan when he did care plan conferences and updated them. He stated that anything related to resident care should have been on the comprehensive care plan which included code status, diet, behaviors, medications, and any specialty services such as Hospice, PASSAR, or Dialysis.<BR/>During an interview on 11/22/22 03:00 PM, the DON stated the CCM was responsible for all other care plans including updating and adding new or acute problems. She stated she was ultimately responsible for ensuring that care plans were updated. She stated the failure occurred due to miscommunication on who was responsible for updating acute issues on the comprehensive care plan. She stated not having accurate care plans could lead to residents not receiving the care that they need.<BR/>Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised December 2020 revealed: t . 8. The comprehensive person-centered care plan will: a. Include measurable objectives and time frame; b. Describe the services that are to be furnished to attain or maintain the residents highest practical physical, mental, and psychosocial well-being; .g. Incorporate identified problem areas; h. incorporates risk factors associated with identified problems; i. Build on the resident strengths; j. Reflect the residence expressed wishes regarding care and treatment goals; k. Reflect treatment goals, the timetables, and objectives in measurable outcomes; .9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the careful .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents Commission changed. 14. The interdisciplinary team must review, update the residence diagnosis within the clinical software system: a. When your diagnosis is resolved, b. When the diagnosis is established; and c. Reviewed at least quarterly in conjunction with the required MSDS assessment schedule. 15. The interdisciplinary team must review and update the care plan: a. When there has been a significant change in the residence position; b. When the dust desired outcome is not met .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents drug regimen were free from unnecessary drugs for 1 of 5 (Resident #41) reviewed for unnecessary drugs.<BR/>The facility failed to address pharmacist consultant recommendations for duplicate therapy in the months of December of 21, March of 22, September of 22 for Resident #41 inhaler medications of Symbicort and Advair.<BR/>The facility failed to discontinue Advair in October of 22 after physician agreed with pharmacist consultant recommendation of duplicate therapy for Resident #41.<BR/>These findings placed residents at risk of receiving unnecessary medications<BR/>Findings included:<BR/>Record review of Resident #41's Facesheet dated 11/21/22 revealed a [AGE] year-old male with an active diagnosis list that included COPD, Acute upper respiratory infection and Other seasonal allergic rhinitis.<BR/>Record review of Resident #41's Quarterly MDS dated [DATE] revealed Resident had a BIMS of 3, meaning severe cognitive impairment, and an active diagnosis list that included COPD.<BR/>Record review of Resident #41's Careplan last revised 09/16/22 revealed: Problem: I have SOB, wheeze related to emphysema/COPD. I have history of acute upper respiratory infections. Goal: Resident will not exhibit signs of respiratory distress (restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, tachycardia, cyanosis, decreased breath sounds). Interventions: Provide medications: Advair, albuterol. Explain medication regime, actions, and side effects. <BR/>Record review of Resident #41 Physician Order dated 11/22/22 revealed: Advair Diskus (fluticasone propion-salmeterol) blister with device; 250-50 mcg/dose; AMt: 1 puff; inhalation. Twice A Day. Start Date: 12/26/2019 open ended, meaning no stop date. <BR/>Record review of Pharmacist Consultant Recommendations reviewed from December 2021 through November 2022, revealed the following:<BR/>Normal MRR date 12/15/21 recommendation. Duplicate therapy refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication that the individual is taking. This resident is receiving Advair and Symbicort which have similar effects and may be considered duplicative therapy please consider doing one of these. Notation in margin stated, sent to MD. <BR/>Normal MRR date 3/28/22 Recommendation: Duplicate therapy refers to multiple medications of the same pharmacological class/category or any medication therapy that subsequently duplicates a particular effect of another medication that the individual is taking. This resident is receiving Advair and Symbicort which have similar effects and may be considered duplicative therapy please consider doing one of these recommendations. Status Pending. <BR/>Note to attending physician prescriber dated 3/28/22 by the consultant pharmacist with no documentation a physician agreeing or disagreeing with the recommendation. <BR/>Note to attending physician prescriber MRR date 9/16/22 Duplicate therapy refers to multiple medications of the same pharmacological class/category or any medication therapy that substantially duplicates a particular effect of another medication that the individual is taking this resident is receiving Advair and Symbicort which have similar effects and may be considered duplicate therapy please consider doing one of these. Physician Agree with the note to Discontinue Advair dated 10/03/22.<BR/>During an interview on 11/22/22 at 03:43 PM with DON and ADON, DON said she did pharmacy recommendations until mid-September then ADON took over. ADON said they get the recommendations from pharmacist, fax recommendations to MD, then give a week then call MD if no response. ADON said as soon as they got a decision for the pharmacist recommendations, then they would get the orders changed. DON said she was, 1 woman and had a PIP (Performance Improvement Plan) because I know that I had issues with getting those done. DON said herself and ADON, work the floor a lot and it just wasn't getting done. ADON said she took over the pharmacist consultant recommendations mid-September or first of [DATE] but didn't realize they did not do the follow through for the inhalers for Resident #41.<BR/>Record review of Performance Improvement Plan dated 9/15/22 revealed: Topic identified: Pharmacy recommendation. Identified problem: Not followed up on timely. Plan of Action: Pharmacy letter to physician will be forwarded to physician within 24 hours of receipt. Physician recommendations will be followed up to ensure responsible response received within 7 days and documented in residence MAR. Nursing recommendations will be reviewed and documented follow up within 7 days of receipt recommendations and follow up will be maintained in a binder for review. Person responsible DON/ADON. Resolution: ADON delegated to start pharmacy recommendations as of 10/01/22.<BR/>Record review of Advair accessed on 12/01/22 at https://www.advair.com/ revealed: ADVAIR DISKUS 250/50 helps significantly improve lung function* so you can breathe better and is clinically proven to help reduce the number of COPD exacerbations in people who have had an exacerbation . ADVAIR contains an ICS and a [NAME]. When an ICS and [NAME] are used together, there is not a significant increased risk in hospitalizations and death from asthma problems . Do not take ADVAIR with other medicines that contain a [NAME] for any reason.<BR/>Record review of Symbicort accessed 12/01/22 at https://www.mysymbicort.com/ revealed: SYMBICORT combines an ICS, budesonide and a [NAME] medicine, formoterol. [NAME] medicines, such as formoterol, when used alone can increase the risk of hospitalizations and death from asthma problems. When an ICS and [NAME] are used together, this risk is not significantly increased . While taking SYMBICORT, do not use another medicine containing a [NAME] for any reason . Using too much of a [NAME] medicine may cause chest pain, fast and irregular heartbeat, tremor, increased blood pressure, headache or nervousness . COPD: SYMBICORT 160/4.5 mcg is used long-term to improve symptoms of chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema, for better breathing and fewer flare-ups.

Based on observation and interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure that non-potable water was properly labeled and stored in the kitchen.<BR/>The facility failed to ensure that cleaning supplies were stored separately from food in the kitchen.<BR/>These failures could affect residents who received meals prepared meals in the kitchen at risk for food borne illness and cross-contamination.<BR/>The findings included:<BR/>Observation on 01/23/24 beginning at 11:15 AM in the kitchen revealed:<BR/>- <BR/>6 boxes, each containing 3 1-gallon plastic jugs of water with expiration date of 9/2/23 <BR/>- <BR/>8 boxes, each containing 3 1-gallon plastic jugs of water with expiration date of 9/2/23 (sign on top of two of the boxes stating non-potable water do not drink; these boxes were stored on a shelf with 10 boxes, each containing 3 1-gallon plastic jugs of water that were not expired, making it very difficult to distinguish between the expired and non-expired boxes)<BR/>- <BR/>2, 50-pound boxes of potatoes stored on a shelf next to a gray plastic tub containing stained wash rags and a gray plastic tub containing mop heads<BR/>In an interview on 01/23/24 at 11:35 AM the Dietary Manager stated that she was aware of the expired water that was being stored in the dry storage room. She stated it was kept there because the dietary staff used it to wash dishes when the water heater went out or the facility water had to be turned off for any reason. She stated that the reason the expired water and the non-expired water were stored together was a lack of storage space. Dietary Manager stated she had placed a sign on some of the water to make sure the staff was aware that it was not for drinking and was expired. When asked why all the expired boxes of water were not labeled with a sign and stored on a single shelf, she was unable to give an answer. She stated there was very little storage space in the kitchen and they (dietary staff) had to use whatever space they could to store everything (food, supplies). When asked if there was any external storage space, she stated that corporate had told her the facility would get a storage building but there had not been a timeline given for when.<BR/>In an interview on 01/24/24 at 11:30 AM [NAME] B stated that the expired water should be stored in a different area than the food because it was not for drinking. She stated that the way the water storage was set up was not good and it was confusing. [NAME] B stated that anybody could walk into the kitchen and grab a jug of the expired water and not know because it was not clearly marked expired or not for resident use. She stated that the sign that stated do not drink looked like it was for only two boxes, not eight, and that was confusing because the expired water and the good water were stored together. [NAME] B stated there were times the jugs of water were used for the residents drinking water in addition to dishwashing, and she felt not having the boxes clearly marked and separated could be a problem. She stated that storage was a problem for the kitchen, and they needed more storage space.<BR/>In an interview on 01/24/24 at 11:47 AM the Dietary Manager stated that the reason the wash rags and mop heads were stored on a shelf with food was due to lack of storage. She stated that the cleaning supplies were kept in the restroom in the kitchen but there was not enough storage space in there for the mop heads and rags. She stated that she believed by keeping the rags and mop heads in the plastic tubs they were separated enough from the food. She stated that the rags and mop heads were clean even though they were stained. The Dietary Manager acknowledged that storing the cleaning supplies with food items was a potential cross contamination issue and the rags and mop heads should be stored elsewhere.<BR/>In an interview on 01/25/24 at 1:57 PM the Administrator stated that she had spoken with the Dietary Manager about the findings from the kitchen inspection on 1/23/24 and 1/24/24 and was aware of the issues. The Administrator stated the cleaning supplies should never be stored with food. She stated she was unaware of exactly how the water was stored but after it was explained to her, she agreed that having the expired water stored the way it was would be confusing and was not appropriate. She stated the facility did not have adequate storage space in the kitchen and that was the cause of the failure. She stated was in the process of getting the facility a 20-foot by 20-foot storage building to help with some of the storage issues the kitchen had. The Administrator stated the facility's parent corporation was supposed to do renovations in the kitchen to improve the storage but there had been no date set for them to start. <BR/>Record review of facility policy titled Food Receiving and Storage dated October 2022 revealed, in part:<BR/>Foods shall be received and stored in a manner that complies with safe food handling practices. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections reviewed for 3 of 7 staff (TNA-C, TNA-D, LVN-B) reviewed for infection control. <BR/>1. The facility failed to perform fit tests for staff (LVN-B) to ensure their N95 face coverings were worn appropriately while providing care for or near residents during a COVID-19 outbreak per facility response plan<BR/>2. The facility failed to ensure staff were wearing masks in the common area (TNA-A, TNA-B) per their facility response plan.<BR/>These failures could place residents, and staff at risk of the spread of infections, including COVID-19.<BR/>Findings included: <BR/>During an observation and interview on 01/03/2023 at 9:30 AM, there was tape in front of resident rooms. LVN-B stated the tape distinguised between hot zone and warm zone of COVID. She stated the hallway was considered warm and the COVID positive resident rooms were considered hot.<BR/>During an interview on 01/03/2023 at 09:50 AM, the Admin stated the MCU was considered the warm zone (quarantined, exposed hall) with resident positive rooms considered to be hot zones (COVID-19 positive). The Admin also stated outside of COVID-19 positive rooms (common areas), the staff were to wear surgical masks at all times.<BR/>During an observation and interview on 01/03/2023 at 11:05 AM, two residents were in the hallway warm zone of the MCU. TNA-C and TNA-D were without a surgical mask and within 3 feet of residents. They both stated they were supposed to be wearing masks in the common areas of the warm unit. <BR/>During an observation and interview 01/03/2023 at 1:21PM, LVN-B was observed wearing a surgical mask under and N-95 mask prior to entering a COVID positive residents room. LVN-B stated no one on the MCU had been fit tested for the proper seal of their mask nor had been educated on how to perform seal check of wearing her N95.<BR/>During an interview 01/03/2023 at 1:22 PM, DON stated she was the facility's Infection Preventionist. She stated the negative impact of staff not being fit tested was that COVID-19 positive residents could spread the virus to staff members, visitors and other residents if masks (N95's) were not sealed correctly. She stated the failures would be the spread of COVID-19 to others. She stated her expectations were for more education to be done and for staff to follow through with what they are taught.<BR/>During an interview 01/03/2023 at 4:39 PM, the Admin stated she was not aware of a fit testing of N-95 masks being performed at the facility for staff. She also stated fit testing was only to be done in hospitals. She stated the facility policy did not include fit testing n95 masks for staff. She stated the residents would be impacted if staff did not have a good seal of an N-95 mask. She stated that the COVID-19 virus could also impact other residents, visitors, staff members and family to contract. <BR/>Admin stated the facility doesn not have fit testing equipment for N-95 masks. She stated her expectations were for staff to follow the Infection Control policy and for PPE to be available at all times. Admin also stated all staff were to wear surgical masks in all common areas including the hallways of the MCU. <BR/>Record review of facility's COVID Tracking log date 01/03/2022 revealed: 2 positive staff, and 5 positive residents.<BR/>Record review facility's Infection Prevention and Control Program dated 11/28/2022 reflected in part: Texas Health and Human Services, COVID-19 Response for Nursing Facilities most current version, should be referred to and followed by centers located in the state of Texas. <BR/>Record review of the facility's Covid Response dated 09/26/2022 under Implement Source Control Measures, reflected in part: Source Control refers to use of respirators or well-fitting facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control options for health care professionals include; .A well-fitted facemask <BR/>Record review of the facility's COVID-19 Response for Nursing Facilities, Version 4.3, dated 06/27/2022, pg 52 concerning fit testing, reflected in part: N95 respirator fit testing -NFs must make every effort to ensure HCP who need to use tight-fitting respirators are fit-tested to identify the right respirator for the HCP and remember that OSHA requirements for adequate fit-testing are fundamental to any respiratory protection program . Under serious outbreak conditions, there may be limited availability of respirators or fit-test kits. However, PPE production and supplies have increased throughout the pandemic and there is now an adequate supply of respirators and test kits, according to the CDC and FDA. NFs must make every effort to perform fit-testing as respirator supplies allow.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment in 9 of 112 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) and Memory Care Unit hallway.<BR/>Resident room [ROOM NUMBER] A/B had chipped and scraped walls, rotting/missing baseboards, dirty, grimy, sticky floors, dirty and stained toilet. <BR/>Resident room [ROOM NUMBER]B had only a recliner with no bed. <BR/>Resident room [ROOM NUMBER] A/B had broken baseboards, unpainted spackling. <BR/>Resident room [ROOM NUMBER] had a broken window seal, different shades of paint that did not match, and unpainted spackling.<BR/>Resident room [ROOM NUMBER] A/B had broken baseboards, nail holes and exposed nails, exposed drywall, broken window seal, missing window insulation foam, unclean floors, walls, toilet grout and caulking.<BR/>Resident room [ROOM NUMBER] had no tile at the entryway.<BR/>Resident room [ROOM NUMBER] had the flooring scraped wood vinyl laminate as the appearance of the door scrapping the wood grain detail off, paint missing from the door. <BR/>Resident Room # 72 had a piece of missing tile in entryway.<BR/>Resident room [ROOM NUMBER] had screws on baseboard, doorjamb had minimal repair with a gap in the frame with missing wood. Door trim had exposed screw.<BR/>The Memory Care Unit had numerous scuff marks along the floors with dirty/grimy railings and walls.<BR/>These failures could place residents who reside in the facility in an unsafe and uncomfortable environment.<BR/>Findings included:<BR/>During observation on 11/20/22 at 12:19 PM, Resident room [ROOM NUMBER] A/B had chipped and scraped walls, exposing drywall beside bed. There were also rotting baseboards exposing raw wood inside and outside of restroom, with dirty, grimy, and sticky floors. The restroom had dead roaches scattered on the floor. The closet floor presented with dirt and black grime. <BR/>During observation 11/20/2022 at 2:19 PM at Resident room [ROOM NUMBER] had no bed with only a recliner with pillows and blankets placed on top. <BR/>During observation on 11/21/22 at 10:19 AM, Resident room [ROOM NUMBER] had no tile at entryway of resident's room. <BR/>During observation on 11/21/22 at 10:25 AM, Resident room [ROOM NUMBER] had the flooring scraped and the vinyl laminate had the appearance of the door scraping the wood grain detail off. The Resident Room door also had a large portion of paint missing from the door. <BR/>During observation on 11/21/22 at 10:25 AM, Resident room [ROOM NUMBER]'s entry way had a piece of missing tile on floor.<BR/>During observation on 11/21/22 at 10:28 AM, Resident room [ROOM NUMBER] had entrance doorjamb had minimal repair with a gap in the frame, had missing wood and the door trim had exposed screw that could scrape skin of residents. There were also screws on the baseboard.<BR/>During an interview on 11/21/22 at 9:21AM, LVN-G stated the facility has had new maintenance and she wasis unaware of finishing what in the logbook had been finished.<BR/>During an interview on 11/21/22 10:16 AM with LVN-G, she stated housekeeping comes daily, but she had never seen them clean the walls nor the doors for the drips or grime. <BR/>During an interview on 11/22/2022 at 9:34 AM, CNA-D, he stated the scrapes, broken door jambs, dirty walls, and railing, were not considered homelike to him.<BR/>During an interview on 11/22/22 at 11:10 AM with HK, he stated they were contracted out and are shorthanded with only 2-3 staff members. He stated his staff are to sweep mop hallways, touch up common areas, then proceed to dining rooms and resident rooms. His staff also should wipe walls and rails as they go, daily sweep and mop resident rooms that included under resident beds. They should have been cleaning restrooms and the toilets daily. He stated on this day of the interview he had one other staff besides himself, and they were doing the best they can. HK stated Resident Room # 43's restroom was not acceptable and unhomelike. The failure is not staying on top of cleaning when needed, his expectations were for the residents to live in a comfortable clean, sanitary, and homelike environment. <BR/>During an interview on 11/22/22 at 11:45 AM, RMD stated there had been no improvements of windows and walls for Room #'s 16, 20, and 21 since previous survey. The failures had been the previous maintenance that had been with the facility, it is his expectations for this to be corrected immediately. <BR/>During an interview on 11/22/2022 at 2:15 PM with the DON, she stated, Resident #43's <BR/>bed was taken out of his room because there was not room for both the bed and recliner for him to maneuver. She also stated the blankets and pillows on the floor was an increased risk of Infection for Resident #43. The failure is not having anything to place the resident's belongings on. Her expectations were for staff and herself to pay closer attention as to where residents belongings are placed. <BR/>During an interview with ADMIN on 11/22/22 at 2:30 PM, she stated the facility did have issues and would give it a D if graded. The cleanliness of the facility was unacceptable due to problems keeping staff in housekeeping. She stated the cleanliness of the rooms need more attention to detail that unfortunately the residents' level of happiness had been exceeded farther in this facility than where they grew up and whatever they have now she considered a step up. The ADMIN also stated the failures fell on the facility as a whole but ultimately it was all on her, with the unclean and un-updated rooms. She also stated being unclean and un-homelike was unacceptable. Her expectations were, each room should be cleaned every day, even if it was a spill. The floors should still be cleaned with being short staffed and getting good people to do their jobs would make for a better homelike environment. <BR/>Review of Maintenance Service policy, revised December 2009, revealed the following theThe maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times, maintaining building in compliance with current federal, state and local laws, regulations, and guidelines, maintaining the building in good repair and free from hazards, provide routine scheduled maintenance service to all areas and maintain records of work order requests . <BR/>Review of facility policy titled Resident Rights with revision date February 2021 revealed:<BR/>Policy statement: employees shall treat all residents with kindness, respect, and dignity.<BR/>Policy interpretation and implementation:<BR/>1. <BR/>Federal and state laws guaranteed certain basic rights to all residents of this facility. These rights include the residents right to:<BR/>a. <BR/>Dignified existence<BR/>b. <BR/>Be treated with respect, kindness, and dignity <BR/>Record review of the facility policy statement and procedures for Homelike Environment, revised February 2021 show that Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their person belongings to the extent possible. <BR/>#2 The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These Characteristics include:<BR/>a. <BR/>Clean, sanitary and orderly environment;<BR/>b. <BR/>Comfortable, adequate lighting;<BR/>c. <BR/>Inviting colors and d&eacute;cor; <BR/>d. <BR/>Personalized furniture and room arrangements;<BR/>e. <BR/>Clean bed and bath linens that are in good condition;<BR/>f. <BR/>Pleasant neutral scents;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain a clean, sanitary, comfortable, and homelike environment in 1 of 2 shower rooms, and 2 of 18 resident restrooms as evidenced by:<BR/>- <BR/>1 of 2 shower rooms did not have a mirror.<BR/>- <BR/>Two resident restrooms did not have a mirror.<BR/>This failure could place the residents who use these restrooms and shower room at risk for a diminished quality of life and a homelike environment.<BR/>Findings include:<BR/>Observation on 01/24/24 at 04:31 PM of two resident rooms, 20 and 61, revealed it did not have mirrors in the restroom. The other rooms did have a mirror.<BR/>Observation on 01/24/24 at 04:40 PM of the shower room in the locked unit revealed it did not have a mirror . The other shower room does have a mirror.<BR/>Interview with DON on 01/25/24 at 12:21 pm. the DON stated he was unaware of the missing mirrors in the resident's rooms and will have this fixed. The DON Sstated the facility is about to have major updates done and will have this rectified. <BR/>Interview with the Maintenance Supervisor on 01/25/24 at 01:45 PM stated he was is aware of the missing mirrors in the resident's room but is not sure since when they had been missing. He stated the facility had tried to replace the mirrors at one point but the mirror that were bought were too big to fit the space. The Maintenance Supervisor was not aware of the shower room in the locked unit not having a mirror. <BR/>Interview with resident who occupied room [ROOM NUMBER] on 01/25/24 at 02:35 PM stated she has not had a mirror in her bathroom since she was admitted to the facility on [DATE]. Resident stated she would like to have a mirror in her bathroom so she can put herself together in the morning. <BR/>Record review of facilities policy titled Homelike Environment revised February 2021 indicated in part: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections reviewed for 3 of 7 staff (TNA-C, TNA-D, LVN-B) reviewed for infection control. <BR/>1. The facility failed to perform fit tests for staff (LVN-B) to ensure their N95 face coverings were worn appropriately while providing care for or near residents during a COVID-19 outbreak per facility response plan<BR/>2. The facility failed to ensure staff were wearing masks in the common area (TNA-A, TNA-B) per their facility response plan.<BR/>These failures could place residents, and staff at risk of the spread of infections, including COVID-19.<BR/>Findings included: <BR/>During an observation and interview on 01/03/2023 at 9:30 AM, there was tape in front of resident rooms. LVN-B stated the tape distinguised between hot zone and warm zone of COVID. She stated the hallway was considered warm and the COVID positive resident rooms were considered hot.<BR/>During an interview on 01/03/2023 at 09:50 AM, the Admin stated the MCU was considered the warm zone (quarantined, exposed hall) with resident positive rooms considered to be hot zones (COVID-19 positive). The Admin also stated outside of COVID-19 positive rooms (common areas), the staff were to wear surgical masks at all times.<BR/>During an observation and interview on 01/03/2023 at 11:05 AM, two residents were in the hallway warm zone of the MCU. TNA-C and TNA-D were without a surgical mask and within 3 feet of residents. They both stated they were supposed to be wearing masks in the common areas of the warm unit. <BR/>During an observation and interview 01/03/2023 at 1:21PM, LVN-B was observed wearing a surgical mask under and N-95 mask prior to entering a COVID positive residents room. LVN-B stated no one on the MCU had been fit tested for the proper seal of their mask nor had been educated on how to perform seal check of wearing her N95.<BR/>During an interview 01/03/2023 at 1:22 PM, DON stated she was the facility's Infection Preventionist. She stated the negative impact of staff not being fit tested was that COVID-19 positive residents could spread the virus to staff members, visitors and other residents if masks (N95's) were not sealed correctly. She stated the failures would be the spread of COVID-19 to others. She stated her expectations were for more education to be done and for staff to follow through with what they are taught.<BR/>During an interview 01/03/2023 at 4:39 PM, the Admin stated she was not aware of a fit testing of N-95 masks being performed at the facility for staff. She also stated fit testing was only to be done in hospitals. She stated the facility policy did not include fit testing n95 masks for staff. She stated the residents would be impacted if staff did not have a good seal of an N-95 mask. She stated that the COVID-19 virus could also impact other residents, visitors, staff members and family to contract. <BR/>Admin stated the facility doesn not have fit testing equipment for N-95 masks. She stated her expectations were for staff to follow the Infection Control policy and for PPE to be available at all times. Admin also stated all staff were to wear surgical masks in all common areas including the hallways of the MCU. <BR/>Record review of facility's COVID Tracking log date 01/03/2022 revealed: 2 positive staff, and 5 positive residents.<BR/>Record review facility's Infection Prevention and Control Program dated 11/28/2022 reflected in part: Texas Health and Human Services, COVID-19 Response for Nursing Facilities most current version, should be referred to and followed by centers located in the state of Texas. <BR/>Record review of the facility's Covid Response dated 09/26/2022 under Implement Source Control Measures, reflected in part: Source Control refers to use of respirators or well-fitting facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control options for health care professionals include; .A well-fitted facemask <BR/>Record review of the facility's COVID-19 Response for Nursing Facilities, Version 4.3, dated 06/27/2022, pg 52 concerning fit testing, reflected in part: N95 respirator fit testing -NFs must make every effort to ensure HCP who need to use tight-fitting respirators are fit-tested to identify the right respirator for the HCP and remember that OSHA requirements for adequate fit-testing are fundamental to any respiratory protection program . Under serious outbreak conditions, there may be limited availability of respirators or fit-test kits. However, PPE production and supplies have increased throughout the pandemic and there is now an adequate supply of respirators and test kits, according to the CDC and FDA. NFs must make every effort to perform fit-testing as respirator supplies allow.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain a clean, sanitary, comfortable, and homelike environment in 1 of 2 shower rooms, and 2 of 18 resident restrooms as evidenced by:<BR/>- <BR/>1 of 2 shower rooms did not have a mirror.<BR/>- <BR/>Two resident restrooms did not have a mirror.<BR/>This failure could place the residents who use these restrooms and shower room at risk for a diminished quality of life and a homelike environment.<BR/>Findings include:<BR/>Observation on 01/24/24 at 04:31 PM of two resident rooms, 20 and 61, revealed it did not have mirrors in the restroom. The other rooms did have a mirror.<BR/>Observation on 01/24/24 at 04:40 PM of the shower room in the locked unit revealed it did not have a mirror . The other shower room does have a mirror.<BR/>Interview with DON on 01/25/24 at 12:21 pm. the DON stated he was unaware of the missing mirrors in the resident's rooms and will have this fixed. The DON Sstated the facility is about to have major updates done and will have this rectified. <BR/>Interview with the Maintenance Supervisor on 01/25/24 at 01:45 PM stated he was is aware of the missing mirrors in the resident's room but is not sure since when they had been missing. He stated the facility had tried to replace the mirrors at one point but the mirror that were bought were too big to fit the space. The Maintenance Supervisor was not aware of the shower room in the locked unit not having a mirror. <BR/>Interview with resident who occupied room [ROOM NUMBER] on 01/25/24 at 02:35 PM stated she has not had a mirror in her bathroom since she was admitted to the facility on [DATE]. Resident stated she would like to have a mirror in her bathroom so she can put herself together in the morning. <BR/>Record review of facilities policy titled Homelike Environment revised February 2021 indicated in part: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on interview and record review, the facility failed to provide effective communications mandatory<BR/>training for 4 of 17 direct care staff (RN E, CNA D, NA C, and DA A) reviewed for training. <BR/>The facility failed to ensure effective communication training was provided to RN E, CNA D, NA C, and DA A.<BR/>This failure could affect residents and place them at risk of miscommunication and social isolation due to lack of staff training. <BR/>Findings included:<BR/>Record review of the personnel file for RN E revealed a hire date of 09/22/2022 and no evidence of new hire training on effective communication. <BR/>Record review of the personnel file for CNA D revealed a hire date of 09/13/2022 and no evidence of new hire training on effective communication. <BR/>Record review of the personnel file for NA C revealed a hire date of 02/26/2021 and no evidence of new hire training on effective communication.<BR/>Record review of the personnel file for DA A revealed a hire date of 05/10/2022 and no evidence of new hire training on effective communication.<BR/>During an interview on 11/22/22 at 04:40 PM the Administrator stated her expectations was for all employees to do the trainings when assigned. The Administrator stated she was responsible for making sure new employees were entered into the training system and the password works. The Administrator explained employees received an email when a training module was available and when it was due. She stated department heads were responsible for tracking incomplete training modules and reminding employees to complete. The Administrator stated the DON was responsible for monitoring the nursing staff and the administrator and/or human resources director were responsible for monitoring all other departments. She stated a problem occurs when employees had more than one email address and the employee failed to check the account the notification of training was sent to. The Administrator stated the effect on residents may be care provided was not as it should be.<BR/>During an interview on 11/22/22 at 04:42 PM, the DON stated she is responsible for monitoring for incomplete training modules of the nursing staff. The DON stated one reason for staff failing to complete training was a breakdown in communication. She stated the consequences to residents was they may not receive the care expected.<BR/>Review of the facility's titled In-Service Training Program, Nurse Aide, dated May 2019 revealed item #3. In-service training is based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews. Item #4. Annual in-services: a) Ensure the continuing competence of nurse aides; b) Are no less than 12 hours per employment year; c) Address areas of weakness as determined by nurse aide performance reviews; d) Address the special needs of the resident, as determined by the facility assessment; e) Include training that addresses the care of residents with cognitive impairment; and f) include training in dementia management and abuse prevention.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections reviewed for 3 of 7 staff (TNA-C, TNA-D, LVN-B) reviewed for infection control. <BR/>1. The facility failed to perform fit tests for staff (LVN-B) to ensure their N95 face coverings were worn appropriately while providing care for or near residents during a COVID-19 outbreak per facility response plan<BR/>2. The facility failed to ensure staff were wearing masks in the common area (TNA-A, TNA-B) per their facility response plan.<BR/>These failures could place residents, and staff at risk of the spread of infections, including COVID-19.<BR/>Findings included: <BR/>During an observation and interview on 01/03/2023 at 9:30 AM, there was tape in front of resident rooms. LVN-B stated the tape distinguised between hot zone and warm zone of COVID. She stated the hallway was considered warm and the COVID positive resident rooms were considered hot.<BR/>During an interview on 01/03/2023 at 09:50 AM, the Admin stated the MCU was considered the warm zone (quarantined, exposed hall) with resident positive rooms considered to be hot zones (COVID-19 positive). The Admin also stated outside of COVID-19 positive rooms (common areas), the staff were to wear surgical masks at all times.<BR/>During an observation and interview on 01/03/2023 at 11:05 AM, two residents were in the hallway warm zone of the MCU. TNA-C and TNA-D were without a surgical mask and within 3 feet of residents. They both stated they were supposed to be wearing masks in the common areas of the warm unit. <BR/>During an observation and interview 01/03/2023 at 1:21PM, LVN-B was observed wearing a surgical mask under and N-95 mask prior to entering a COVID positive residents room. LVN-B stated no one on the MCU had been fit tested for the proper seal of their mask nor had been educated on how to perform seal check of wearing her N95.<BR/>During an interview 01/03/2023 at 1:22 PM, DON stated she was the facility's Infection Preventionist. She stated the negative impact of staff not being fit tested was that COVID-19 positive residents could spread the virus to staff members, visitors and other residents if masks (N95's) were not sealed correctly. She stated the failures would be the spread of COVID-19 to others. She stated her expectations were for more education to be done and for staff to follow through with what they are taught.<BR/>During an interview 01/03/2023 at 4:39 PM, the Admin stated she was not aware of a fit testing of N-95 masks being performed at the facility for staff. She also stated fit testing was only to be done in hospitals. She stated the facility policy did not include fit testing n95 masks for staff. She stated the residents would be impacted if staff did not have a good seal of an N-95 mask. She stated that the COVID-19 virus could also impact other residents, visitors, staff members and family to contract. <BR/>Admin stated the facility doesn not have fit testing equipment for N-95 masks. She stated her expectations were for staff to follow the Infection Control policy and for PPE to be available at all times. Admin also stated all staff were to wear surgical masks in all common areas including the hallways of the MCU. <BR/>Record review of facility's COVID Tracking log date 01/03/2022 revealed: 2 positive staff, and 5 positive residents.<BR/>Record review facility's Infection Prevention and Control Program dated 11/28/2022 reflected in part: Texas Health and Human Services, COVID-19 Response for Nursing Facilities most current version, should be referred to and followed by centers located in the state of Texas. <BR/>Record review of the facility's Covid Response dated 09/26/2022 under Implement Source Control Measures, reflected in part: Source Control refers to use of respirators or well-fitting facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control options for health care professionals include; .A well-fitted facemask <BR/>Record review of the facility's COVID-19 Response for Nursing Facilities, Version 4.3, dated 06/27/2022, pg 52 concerning fit testing, reflected in part: N95 respirator fit testing -NFs must make every effort to ensure HCP who need to use tight-fitting respirators are fit-tested to identify the right respirator for the HCP and remember that OSHA requirements for adequate fit-testing are fundamental to any respiratory protection program . Under serious outbreak conditions, there may be limited availability of respirators or fit-test kits. However, PPE production and supplies have increased throughout the pandemic and there is now an adequate supply of respirators and test kits, according to the CDC and FDA. NFs must make every effort to perform fit-testing as respirator supplies allow.

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 17 employees (RN E, CNA D, NA C, DA A,) reviewed for training.<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 RN E, CNA D, NA C, and DA A. <BR/>This failure could affect residents and place them at risk of being uninformed due to lack of staff training. <BR/>Findings included:<BR/>Record review of the personnel file for RN E revealed a hire date of 09/22/2022 and no evidence of new hire training on resident rights and facility responsibilities.<BR/>Record review of the personnel file for CNA D revealed a hire date of 09/13/2022 and no evidence of new hire training on resident rights and facility responsibilities.<BR/>Record review of the personnel file for NA C revealed a hire date of 02/26/2021 and no evidence of new hire training on resident rights and facility responsibilities.<BR/>Record review of the personnel file for DA A revealed a hire date of 05/10/2022 and no evidence of new hire training on resident rights and facility responsibilities.<BR/>During an interview on 11/22/22 at 04:40 PM, the Administrator stated her expectations was for all employees to do the trainings when assigned. The Administrator stated she was responsible for making sure new employees were entered into the training system and the password works. The Administrator explained employees received an email when a training module was available and when it was due. She stated department heads were responsible for tracking incomplete training modules and reminding employees to complete. The Administrator stated the DON was responsible for monitoring the nursing staff and the administrator and/or human resources director were responsible for monitoring all other departments. She stated a problem occurs when employees had more than one email address and the employee failed to check the account the notification of training was sent to. The Administrator stated the effect on residents may be care provided was not as it should be.<BR/>During an interview on 11/22/22 at 04:42 PM, the DON stated she is responsible for monitoring for incomplete training modules of the nursing staff. The DON stated one reason for staff failing to complete training was a breakdown in communication. She stated the consequences to residents was they may not receive the care expected.<BR/>Review of facility titled In-Service Training Program, Nurse Aide, dated May 2019 revealed item #3. In-service training is based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews. Item #4. Annual in-services: a) Ensure the continuing competence of nurse aides; b) Are no less than 12 hours per employment year; c) Address areas of weakness as determined by nurse aide performance reviews; d) Address the special needs of the resident, as determined by the facility assessment; e) Include training that addresses the care of residents with cognitive impairment; and f) include training in dementia management and abuse prevention.

Based on interview and record review, the facility failed to provide the required training on activities that constitute abuse, neglect, and exploitation and misappropriation of resident property and procedures for reporting related incidents for 4 of 17 employees (RN E, CNA D, NA C, DA A) reviewed for training.<BR/>The facility failed to ensure training on activities that constitute abuse, neglect, and exploitation and misappropriation of resident property and procedures for reporting related incidents was provided to RN E, CNA D, NA C and DA A. <BR/>This failure could affect residents and place them at risk of abuse, neglect, exploitation or misappropriation of property due to lack of staff training. <BR/>Findings included:<BR/>Record review of the personnel file for RN E revealed a hire date of 09/22/2022 and no evidence of new hire training on abuse, neglect, and exploitation and misappropriation.<BR/>Record review of the personnel file for CNA D revealed a hire date of 09/13/2022 and no evidence of new hire training on abuse, neglect, and exploitation and misappropriation.<BR/>Record review of the personnel file for NA C revealed a hire date of 02/26/2021 and no evidence of new hire training on abuse, neglect, and exploitation and misappropriation.<BR/>Record review of the personnel file for DA A revealed a hire date of 05/10/2022 and no evidence of new hire training on abuse, neglect, and exploitation and misappropriation.<BR/>During an interview on 11/22/22 at 04:40 PM, the Administrator stated her expectations was for all employees to do the trainings when assigned. The Administrator stated she was responsible for making sure new employees were entered into the training system and the password works. The Administrator explained employees received an email when a training module was available and when it was due. She stated department heads were responsible for tracking incomplete training modules and reminding employees to complete. The Administrator stated the DON was responsible for monitoring the nursing staff and the administrator and/or human resources director were responsible for monitoring all other departments. She stated a problem occurs when employees had more than one email address and the employee failed to check the account the notification of training was sent to. The Administrator stated the effect on residents may be care provided was not as it should be.<BR/>During an interview on 11/22/22 at 04:42 PM, the DON stated she is responsible for monitoring for incomplete training modules of the nursing staff. The DON stated one reason for staff failing to complete training was a breakdown in communication. She stated the consequences to residents was they may not receive the care expected.<BR/>Review of facility titled In-Service Training Program, Nurse Aide, dated May 2019 revealed item #3. In-service training is based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews. Item #4. Annual in-services: a) Ensure the continuing competence of nurse aides; b) Are no less than 12 hours per employment year; c) Address areas of weakness as determined by nurse aide performance reviews; d) Address the special needs of the resident, as determined by the facility assessment; e) Include training that addresses the care of residents with cognitive impairment; and f) include training in dementia management and abuse prevention.

Based on interview and record review the facility failed to provide an activities program directed by a qualified professional for 1 of 1 activity directors (AD) reviewed for qualifications.<BR/>The facility failed to ensure the AD was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements.<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 included:<BR/>Record review of the AD's employee file revealed the AD took the position on 06/03/2024, and evidence of training beginning 02/13/2025 as a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. Record review revealed once the course was done (May 2025), it would have been almost a year since being hired to be certified.<BR/>During an interview on 04/03/2025 at 11:23 AM, the AD stated she was hired 8 months ago. She stated she had no prior experience nor prior SW experience. The AD stated she did not have her AD certification upon hire. She stated she was supposed to have started her certification in October of 2024, but the company changed the course they used which in turn pushed them back to January 2025. The AD stated the ADMN stated to her when hired, she needed to get certified as soon as possible. She stated she felt there was no harm to the residents. <BR/>During an interview on 04/03/2025 at 1:08 PM, the ADMN stated she had never been told the time frame but assumed during the first year. She stated she worked with the AD as a CNA and felt with her leading the residents in attending AD events was enough to be hired for the position. The ADMN stated it was HR who monitored the certifications and the paperwork for staff members. She stated her expectations would be for AD to have her certification within a year of being hired. She stated she did not feel there was a failure nor a negative impact to residents. <BR/>During an interview on 04/03/2025 at 5:01 PM, HR stated there was not a check off list for the AD staff member's hiring. She stated she was unaware of her certification status.<BR/>Record review of the AD's application dated 08 May 2024 with an updated date of 03 June 2024, revealed:<BR/>License and Education: Valid professional license or certification-yes<BR/>License /certification: (was unanswered)<BR/>License/number: (was unanswered)<BR/>Issuing Organization: (was unanswered)<BR/>State: (was unanswered)<BR/>Issue date: (was unanswered)<BR/>Expiration date: (was unanswered)<BR/>Record Review of the facility Activity Director's job application agreement dated and signed on 08 May 2024 revealed:<BR/>I understand that, if hired, (a) I am required to abide by all rules and regulations .<BR/>Record review of the facility's job description for Activity Director signed on 6/3/24 revealed, I will perform the duties and responsibilities of that position and further agree to conform to the rules and regulation

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 3 of 17 employees (RN E, CNA D, and DA A) reviewed for training.<BR/>The facility failed to ensure infection prevention and control training was provided to RN E, CNA D, and DA A. <BR/>This failure could affect residents and place them at risk of illness due to lack of staff training. <BR/>Findings included:<BR/>Record review of the personnel file for RN E revealed a hire date of 09/22/2022 and no evidence of new hire training on infection prevention and control.<BR/>Record review of the personnel file for CNA D revealed a hire date of 09/13/2022 and no evidence of new hire training on infection prevention and control.<BR/>Record review of the personnel file for DA A revealed a hire date of 05/10/2022 and no evidence of new hire training on infection prevention and control.<BR/>During an interview on 11/22/22 at 04:40 PM, the Administrator stated her expectations was for all employees to do the trainings when assigned. The Administrator stated she was responsible for making sure new employees were entered into the training system and the password works. The Administrator explained employees received an email when a training module was available and when it was due. She stated department heads were responsible for tracking incomplete training modules and reminding employees to complete. The Administrator stated the DON was responsible for monitoring the nursing staff and the administrator and/or human resources director were responsible for monitoring all other departments. She stated a problem occurs when employees had more than one email address and the employee failed to check the account the notification of training was sent to. The Administrator stated the effect on residents may be care provided was not as it should be.<BR/>During an interview on 11/22/22 at 04:42 PM, the DON stated she is responsible for monitoring for incomplete training modules of the nursing staff. The DON stated one reason for staff failing to complete training was a breakdown in communication. She stated the consequences to residents was they may not receive the care expected.<BR/>Review of facility titled In-Service Training Program, Nurse Aide, dated May 2019 revealed item #3. In-service training is based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews. Item #4. Annual in-services: a) Ensure the continuing competence of nurse aides; b) Are no less than 12 hours per employment year; c) Address areas of weakness as determined by nurse aide performance reviews; d) Address the special needs of the resident, as determined by the facility assessment; e) Include training that addresses the care of residents with cognitive impairment; and f) include training in dementia management and abuse prevention.

Based on interview and record review, the facility failed to provide the required compliance and ethics training for 3 of 17 employees (RN E, CNA D, and DA A) reviewed for training.<BR/>The facility failed to ensure compliance and ethics training was provided to RN E, CNA D, and DA A. <BR/>This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. <BR/>Findings included:<BR/>Record review of the personnel file for RN E revealed a hire date of 09/22/2022 and no evidence of new hire training on compliance and ethics.<BR/>Record review of the personnel file for CNA D revealed a hire date of 09/13/2022 and no evidence of new hire training on compliance and ethics.<BR/>Record review of the personnel file for DA A revealed a hire date of 05/10/2022 and no evidence of new hire training on compliance and ethics.<BR/>During an interview on 11/22/22 at 04:40 PM, the Administrator stated her expectations was for all employees to do the trainings when assigned. The Administrator stated she was responsible for making sure new employees were entered into the training system and the password works. The Administrator explained employees received an email when a training module was available and when it was due. She stated department heads were responsible for tracking incomplete training modules and reminding employees to complete. The Administrator stated the DON was responsible for monitoring the nursing staff and the administrator and/or human resources director were responsible for monitoring all other departments. She stated a problem occurs when employees had more than one email address and the employee failed to check the account the notification of training was sent to. The Administrator stated the effect on residents may be care provided was not as it should be.<BR/>During an interview on 11/22/22 at 04:42 PM, the DON stated she is responsible for monitoring for incomplete training modules of the nursing staff. The DON stated one reason for staff failing to complete training was a breakdown in communication. She stated the consequences to residents was they may not receive the care expected.<BR/>Review of facility titled In-Service Training Program, Nurse Aide, dated May 2019 revealed item #3. In-service training is based on the outcome of the annual performance reviews, addressing weaknesses identified in the reviews. Item #4. Annual in-services: a) Ensure the continuing competence of nurse aides; b) Are no less than 12 hours per employment year; c) Address areas of weakness as determined by nurse aide performance reviews; d) Address the special needs of the resident, as determined by the facility assessment; e) Include training that addresses the care of residents with cognitive impairment; and f) include training in dementia management and abuse prevention.