HEREFORD NURSING & REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents have the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 15 (Resident #19) reviewed for Resident Rights.The facility failed to ensure Resident #19 had a DNR in place which was signed by a physician and dated by the notary public.This failure could cause the loss of valuable time when dealing with a Resident's medical emergency and possible unwarranted death.Findings included:Review of Resident #19's admission record reflected Resident #19 was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, unspecified, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Type 2 Diabetes Mellitus with Hypoglycemia without coma, Adult Failure to Thrive, Anxiety Disorder, unspecified, Covid-19, Insomnia, and Major Depressive Disorder, Single Episode, unspecified. Review of Resident #19's Quarterly MDS dated [DATE] revealed she required partial to moderate assistance with all elements of self-care and mobility. She had an indwelling catheter related to neuromuscular dysfunction of the bladder and was occasionally incontinent of bowel. Resident #19 had no nutritional issues with swallowing of liquids and solid foods but indicated some discomfort when chewing solid foods. Resident #19 received constant oxygen via nasal cannula at 2-5 lt./min. to keep oxygen saturation rates above 90% related to hypoxia and received Hospice services twice per week related to Diabetes Mellitus, Unknown Sepsis and Chronic Kidney Disease. Resident #19 had a BIMS score of 04, indicating severe cognitive impairment. Review of Resident #19's care plan dated 08/05/2025 reflected Resident #19 has an order for Do Not Resuscitate (DNR) with a Goal of Resident/Responsible Party decision for DNR will be honored over the next 90 days and an Intervention of In absence of blood pressure, pulse, respiration, CPR will not be initiated, notify MD of change of condition and Resident will be maintained at a level of comfort as ordered by physician.Review of Resident #19's physician orders revealed her active comfort medications were Fentanyl Transdermal Patch 72-Hour, 25MCG/HR, apply one patch transdermal every 72-hours for Pain and remove per schedule, and Morphine Sulfate (Concentrate) Oral Solution 20MG/ML, give 0.1ml. by moth every 4 hours as needed for pain level 7-10.Review of Resident #19's DNR revealed it was signed by the resident on 07/14/2021. The DNR was also signed by two witnesses on 07/14/2021 and notarized. The notary's signature and seal were not dated, and the DNR was not signed and dated by a physician.An interview with LVN A on 08/07/2025 at 10:28AM reflected Resident #19's DNR was not valid as it was not signed by a physician. She stated if the resident went into cardiac arrest, she would have to ask the DON for clarification of the DNR and how to proceed with Resident #19's care.An interview with the DON on 08/07/2025 at 10:35AM reflected the DNR was not valid as it was not signed by a physician and the notary had not dated her signature and seal. She stated if the resident went into cardiac arrest, the facility would have to send her to the ER via ambulance. The DON stated staff give EMS personnel the resident's code status while they prepare the resident for transport to the hospital. She stated the negative outcome of not having the DNR signed and dated by the physician and notary would be the loss of valuable life-saving time while the resident's representative was called to discuss the resident's code status wishes.An interview with the Administrator on 08/07/2025 at 11:21AM reflected Resident #19's DNR was not valid due to no signature and date by a physician, and the notary had not dated her signature and seal. He stated the facility had a book at the nurse's station with all the resident's code statuses and if Resident #19 had a red page in the book it indicated Do Not Resuscitate. If the book had a green page for the resident, it indicated the resident had requested CPR as a life-saving measure. He stated if Resident #19 went into cardiac arrest, staff would refer to the book instead of the resident's chart to determine the resident's code status. He stated he would not assume what would happen if Resident #19 went into cardiac arrest, since the DNR was not signed and dated by the physician and notary. The Administrator stated the resident's current sheet in the code status book would be invalid for these reasons.Review of the facility's undated policy Advance Directives Policy and Acknowledgment revealed the following:It is the Health Care Center's policy to provide all residents and/or responsible party members with information relating to an individual's rights under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment, and the right to formulate Advance Directives. The Health Care Center respects the implementation of such rights and will follow all physicians' orders respecting such rights. Without physician's orders, Health Care Center's staff may be required to institute interventions that differ from the Advance Directive.The Health Care Center will clearly document in each resident's chart whether the resident has executed an Advanced Directive, and if so, what the directives will be. The Health Care Center will not discriminate against an individual based on whether the resident has executed an Advanced Directive. The Health Care Center agrees to provide the resident and/or responsible party with information regarding; Decisions concerning medical care, including the right to accept and refuse treatment when made in accordance with stated law. Valid Advance Directives made in accordance with stated law.If the resident has an invalid Advance Directive or no Advance Directive and the resident or the resident representative wishes to refuse, withhold, or withdraw life-sustaining medical treatment, such decisions shall be made consistent with state law and in conjunction with the Health Care Center's staff, management staff, and the attending physician. Full consideration shall be given to the applicable state law as interpreted by the Legal Department.Review of the facility's Code Status Listing Policy dated 01/28/2017 revealed the following:The facility will provide residents the opportunity to file an Advance Directive document declaring the resident/family/responsible party's end of life wishes and will provide education on options available.Procedure:Resident will be informed of their opportunity to file an Advance Directive document upon admission.The facility will utilize a colored sheet of paper at the front of each resident's chart to assist the staff in quickly identifying code status.Resident/family/responsible party electing DNR will have a red sheet.Resident/family/responsible party electing Full Code (CPR) will have a green sheet.Interdisciplinary team will discuss Advance Directive with the resident/family/responsible party during care plan meetings annually, when there is a significant positive change or a significant deterioration in the resident's clinical condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 (Resident #8 and Resident #30) of 15 residents reviewed for abuse, neglect, exploitation, and misappropriation of resident property.1. The facility failed to implement their policy titled Abuse/Neglect and report Resident #8's black eye to state authorities.2. The facility failed to implement their policy titled Abuse/Neglect and report Resident #30's missing diamond ring to state authorities.This failure placed residents at increased risk of abuse, neglect, exploitation and misappropriation of their property.Findings Included:1. Record review of Resident #8's admission record dated 08/06/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning) and dementia (a group of thinking and social symptoms that interferes with daily functioning) in other diseases classified elsewhere mild with mood disturbance.Record review of Resident #8's quarterly MDS completed on 06/16/25 revealed a BIMS score of 8 which indicated moderate cognitive impairment. Resident #8 was noted to require setup or clean-up assistance or supervision/touching assistance across all ADLs.Record review of Resident #8's care plan completed on 06/17/25 revealed he was not able to measure his pain on a pain scale from 0-10 due to cognitive impairment and he had limited physical mobility. Resident #8 was noted to have Dementia with cognitive impairment as evidence by: Memory problems.Record review of Resident #8's orders revealed the following: Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day related to ACUTE COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGETSTIVE) HEART FAILURE. with start date of 11/27/24. Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day for blood clot prevention related to ACUTE COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE. with start date of 11/27/24.Record review of Resident #8's progress notes from 07/07/25 to 08/07/25 revealed the following note written by LVN D on 07/31/25 at 12:41 PM: [Initials of dialysis center] called concerning black eye to resident explained it was from a shower head that fell onto his eye.Further review revealed no other progress notes were found pertaining to the black eye.Record review of incident by incident report for May-July of 2025 revealed Resident #8 had a bruise incident on 07/30/25.Record review of incident report found in EHR under Clinical and Risk Management revealed the following: . Bruise Date 7/30/2025 11:00 (AM)Resident: [Name of Resident #8]Incident Location: ShowerPerson Preparing Report: [Name of LVN A]Incident DescriptionNursing Description: Resident noticed with a bruise to right eye underneath. Resident noted earlier was self showering in shower and then noted with bruise. Resident denies falling. No other injuries noted.Resident Description: I don't knowWas this incident witnessed: N .Description: Resident noted to go in shower and shower self, Showerhead is a removeable sprayer and comes off the wall.Injuries Observed at Time of IncidentInjury Type BruiseInjury Location 4) FaceLevel of Pain:Numerical: 0 .Mental Status Lack of Safety Awareness .Agencies/People NotifiedPhysician . 7/30/2025 11:05 (AM)DON/RN . 7/30/25 15:49 (03:49 PM)Family Member . 7/30/2025 11:10 (AM)During an observation and interview on 08/06/25 at 09:18 AM LVN A stated when a resident has an injury nurses document in the EHR under Clinical and Risk Management. She demonstrated how to find incident reports in the EHR.During an observation and interview on 08/06/25 at 09:45 Resident #8 was standing near the nurses' station. He had fading, yellowish, green bruising approximately the size of a quarter underneath his right eye. He stated no one hit him. When asked about the bruise he stated a garlic was growing above his right eyebrow (gestured to the area) and it slid down his face. He also mentioned that his right ear was falling. When asked directly if a shower head had fallen on his eye, he stated it had not.2. Record review of Resident #30's admission record dated 08/06/25 revealed a [AGE] year-old female most recently admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), and other signs and symptoms involving cognitive functions and awareness.Record review of Resident #30's admission MDS completed on 07/15/25 revealed a BIMS score of 10 which indicated moderately impaired cognition.Record review of Resident #30's care plan completed on 07/15/25 revealed she had impaired communication due to cognitive impairment. Resident #30 was noted to have dementia with cognitive impairment Record review of Resident #30's progress notes from 07/06/25 to 08/06/25 revealed no mention of her missing diamond ring. It did reveal the following progress note written by LVN D on 08/02/25 at 09:06 AM: resident is slapping and hitting staff and other residents. making accusations that staff and other residents are stealing her stuff.Record review of incident by incident report for May-July 2025 revealed no mention of Resident #30's ring or any incident of misappropriation of resident property.Record review of grievance for the last three months revealed a grievance written by ADM on 07/28/25 regarding Resident #30's missing ring.During an observation and interview on 08/05/25 at 11:06 AM Resident #30 wheeled herself in her wheelchair down the hall to speak to this surveyor. She stated she had a diamond ring stolen. She stated it was a diamond solitaire and it was given to her by a family member. She stated she did not know who took it but she did know it was missing.During an interview on 08/05/25 at 02:49 PM Resident #30's family member stated Resident #30's diamond solitaire ring disappeared on 07/28/25. He stated the ring was on her finger and in a ring keeper with her two wedding diamond rings and a gold band. He stated the ring keeper was a plastic ring that went through all of her rings to keep them together and on her finger.During an observation and interview on 08/06/25 at 10:21 AM Resident #30 was seated in her wheelchair at the nurses' station. She had a gold band and a larger silver ring with purple stones in it on her finger but no ring keeper. She stated the ring with the purple stones was fake. She stated she was very sad her diamond ring had been stolen.During an interview on 08/06/25 at 10:33 AM Resident #30's family member stated after her diamond solitaire ring was stolen, he cut the ring protector and took her other two diamond rings home leaving her with the gold band only. He stated the silver ring with the purple stones was his way of giving her something pretty to wear that was not valuable. He stated he visited Resident #30 on 07/26/25 and her diamond solitaire ring was on her finger with her other rings inside the ring keeper. He stated he visited her on 07/28/25 and the ring was not on her finger, but the other three rings (gold band and two wedding diamond rings) were still inside the ring keeper on her finger. He stated someone would have had to cut the band of the diamond solitaire ring to get it out of the ring keeper and off her finger. He stated as soon as he noticed the diamond solitaire ring was missing, he told MDS LVN and she went and got [first name of ADM]. He stated ADM called the owner of the local pawn shop regarding Resident #30's missing ring.During an interview on 08/07/25 at 09:17 AM CNA B stated when a resident had an injury of unknown origin or a new bruise, she reported the injury to her charge nurse and ADM. She stated she had been trained and was regularly trained on reporting injuries of unknown origin to her charge nurse and ADM. CNA B stated if a resident told her they were missing personal property she would report it to her charge nurse and DON. She stated she had been trained on this procedure. She stated she heard about Resident #30's missing ring when ADM asked staff if they had seen the ring. She stated she was not working the day Resident #8 acquired his black eye and she was told by the CNA going off the night shift that it happened due to a fall. CNA B stated residents could be hurt more than we see if injuries and missing property were not properly reported.During an interview on 08/07/25 at 09:29 AM LVN A stated if a CNA drew her attention to, or she noticed on her own an injury of unknown origin on a resident she would notify the physician, DON, and ADM. She stated she had been trained and was regularly trained on this procedure. LVN A stated, Once a month we go through the reporting process. She stated a possible negative outcome for a resident if injuries of unknown origin were not properly reported was, If they have a bruise we don't know if they fell, or it was caused by an object or something. Sometimes the bruises cause blood clots, and they could have a fracture or something and we don't take care of it. She stated she did not see the shower head fall on Resident #8's eye. She stated Resident #8 had been in the shower by himself. She stated, When staff are not looking, he will go in there by himself to shower and we knew he was in there because he opened the door to tell us he needed a towel. LVN A stated later in the day she noticed the bruise to Resident #8's right eye. She stated when she first interviewed him and filled out the incident report, he told her he did not know how it happened. She stated later when she spoke to him about it again, he told her the shower head fell on his eye. LVN A stated she forgot to document that conversation anywhere. She stated when a resident's property went missing the procedure was to report to DON and ADM. LVN A stated she had been trained on this procedure probably every month. She stated she heard about Resident #30's missing ring when ADM was asking staff if they had seen the ring. LVN A stated a possible negative outcome of not reporting residents missing property was, This is their home and if we don't report it, and it is valuable to the resident, they will feel neglected that we didn't do anything about it.During an interview on 08/07/25 at 09:46 PM DON stated she expects her staff to report injuries of unknown origin and missing resident property to her. She stated, We investigate it. She stated staff had been trained on these reporting procedures at hire and about every 6 months during in-services. She stated she did not think there was a negative outcome to a resident if an injury of unknown origin was not reported to the state. She stated Resident #8 was in the shower with an aide and the aide believed he hit himself with the shower head. She stated she was not sure which aide was with him in the shower. DON stated it was not okay for staff to assume what happened with an injury of unknown origin. She stated Resident #8 told her the shower head bruised his eye. When asked where she documented that conversation she stated, I haven't completed his note on his event report yet, but it would be in there. DON stated she did not know of a possible negative outcome of not reporting resident's missing property to the state. She stated Resident #30's family member told her about the missing diamond ring. She stated ADM was notified and he investigated. DON stated ADM wrote a grievance regarding the ring and that was why it was not reported to the state. DON stated ADM was usually responsible for reporting incidents to the state.During an interview on 08/07/25 at 09:59 AM MDS LVN stated she had been trained 3-4 times a year on reporting injuries of unknown origin and missing resident property. She stated a resident could be negatively impacted if an injury of unknown origin was not reported. MDS LVN stated, It could affect their health, it cold affected their mobility. She stated staff might not give proper care to the resident if they were unaware of the injury. MDS LVN stated if a resident's missing property was reported to her, she would tell DON and ADM. She stated there was a clause in the admission packet that stated the facility was not responsible for lost or stolen property. She stated at admission the residents and families were encouraged not to bring items of value to the facility. She stated if misappropriation of resident property was not reported the resident and the family could be upset. She stated Resident #30's family member reported the missing diamond ring to her and she immediately let DON and ADM know. She stated she and ADM went to Resident #30's room and began to search everywhere for the ring. MDS LVN stated ADM and DON were responsible for reporting misappropriated resident property to the state.During an interview on 08/07/25 at 10:33 AM ADM stated he expected his staff to report injuries of unknown origin and missing resident property to him or the charge nurse. He stated staff were trained on reporting procedure at hire and biannually. He stated he would not speculate on something that had not happened. ADM stated Resident #8 was fine when he went into the shower and had a black eye when he came out. He stated he would speculate on that because Resident #8 was tall and the shower head is right there, and he probably turned and bumped his head on it (the shower head). He stated he looked for Resident #30's ring and wrote a grievance. ADM stated he spoke to staff who worked the days the ring disappeared, but he did not document any of those conversations or his search for the ring. He stated he called the owner of the local pawn shop and described the ring and asked for a call if it came into the pawn shop, but he did not document his call to the pawn shop. He stated he told Resident #30's family member to file a police report. ADM stated he did not know he was supposed to report Resident #8's black eye and Resident #30's missing ring to the state. ADM stated, Do I need to report it when a resident loses their glasses? Because glasses cost a lot more than that diamond ring, I guarantee. He stated he was responsible for reporting incidents to the state.During exit conference on 08/07/25 at 01:35 PM after preliminary findings were read, ADM stated, I guess I'll start reporting lost pajamas and lost glasses, then.Record review of facility policy titled Abuse/Neglect and dated 11/15/2016 revealed the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Injury of Unknown Source any injury to a resident where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury . All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator and per policy. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of residents . Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services . Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. 1. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #8 and Resident #30) of 15 residents reviewed for reporting abuse, neglect, exploitation, and misappropriation of resident property.1. The facility failed to report Resident #8's black eye to state authorities.2. The facility failed to report Resident #30's missing diamond ring to state authorities.These failures could place residents at risk of continued abuse/misappropriation of property in the facility.Findings Included:1. Record review of Resident #8's admission record dated 08/06/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning) and dementia (a group of thinking and social symptoms that interferes with daily functioning) in other diseases classified elsewhere mild with mood disturbance.Record review of Resident #8's quarterly MDS completed on 06/16/25 revealed a BIMS score of 8 which indicated moderate cognitive impairment. Resident #8 was noted to require setup or clean-up assistance or supervision/touching assistance across all ADLs.Record review of Resident #8's care plan completed on 06/17/25 revealed he was not able to measure his pain on a pain scale from 0-10 due to cognitive impairment and he had limited physical mobility. Resident #8 was noted to have Dementia with cognitive impairment as evidence by: Memory problems.Record review of Resident #8's orders revealed the following: Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day related to ACUTE COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGETSTIVE) HEART FAILURE. with start date of 11/27/24. Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day for blood clot prevention related to ACUTE COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE. with start date of 11/27/24.Record review of Resident #8's progress notes from 07/07/25 to 08/07/25 revealed the following note written by LVN D on 07/31/25 at 12:41 PM: [Initials of dialysis center] called concerning black eye to resident explained it was from a shower head that fell onto his eye.Further review revealed no other progress notes were found pertaining to the black eye.Record review of incident by incident report for May-July of 2025 revealed Resident #8 had a bruise incident on 07/30/25.Record review of incident report found in EHR under Clinical and Risk Management revealed the following: . Bruise Date 7/30/2025 11:00 (AM)Resident: [Name of Resident #8]Incident Location: ShowerPerson Preparing Report: [Name of LVN A]Incident DescriptionNursing Description: Resident noticed with a bruise to right eye underneath. Resident noted earlier was self showering in shower and then noted with bruise. Resident denies falling. No other injuries noted.Resident Description: I don't knowWas this incident witnessed: N .Description: Resident noted to go in shower and shower self, Showerhead is a removeable sprayer and comes off the wall.Injuries Observed at Time of IncidentInjury Type BruiseInjury Location 4) FaceLevel of Pain:Numerical: 0 .Mental Status Lack of Safety Awareness .Agencies/People NotifiedPhysician . 7/30/2025 11:05 (AM)DON/RN . 7/30/25 15:49 (03:49 PM)Family Member . 7/30/2025 11:10 (AM)During an observation and interview on 08/06/25 at 09:18 AM LVN A stated when a resident has an injury nurses document in the EHR under Clinical and Risk Management. She demonstrated how to find incident reports in the EHR.During an observation and interview on 08/06/25 at 09:45 Resident #8 was standing near the nurses' station. He had fading, yellowish, green bruising approximately the size of a quarter underneath his right eye. He stated no one hit him. When asked about the bruise he stated a garlic was growing above his right eyebrow (gestured to the area) and it slid down his face. He also mentioned that his right ear was falling. When asked directly if a shower head had fallen on his eye, he stated it had not.2. Record review of Resident #30's admission record dated 08/06/25 revealed a [AGE] year-old female most recently admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), and other signs and symptoms involving cognitive functions and awareness.Record review of Resident #30's admission MDS completed on 07/15/25 revealed a BIMS score of 10 which indicated moderately impaired cognition.Record review of Resident #30's care plan completed on 07/15/25 revealed she had impaired communication due to cognitive impairment. Resident #30 was noted to have dementia with cognitive impairment Record review of Resident #30's progress notes from 07/06/25 to 08/06/25 revealed no mention of her missing diamond ring. It did reveal the following progress note written by LVN D on 08/02/25 at 09:06 AM: resident is slapping and hitting staff and other residents. making accusations that staff and other residents are stealing her stuff.Record review of incident by incident report for May-July 2025 revealed no mention of Resident #30's ring or any incident of misappropriation of resident property.Record review of grievance for the last three months revealed a grievance written by ADM on 07/28/25 regarding Resident #30's missing ring.During an observation and interview on 08/05/25 at 11:06 AM Resident #30 wheeled herself in her wheelchair down the hall to speak to this surveyor. She stated she had a diamond ring stolen. She stated it was a diamond solitaire and it was given to her by a family member. She stated she did not know who took it but she did know it was missing.During an interview on 08/05/25 at 02:49 PM Resident #30's family member stated Resident #30's diamond solitaire ring disappeared on 07/28/25. He stated the ring was on her finger and in a ring keeper with her two wedding diamond rings and a gold band. He stated the ring keeper was a plastic ring that went through all of her rings to keep them together and on her finger.During an observation and interview on 08/06/25 at 10:21 AM Resident #30 was seated in her wheelchair at the nurses' station. She had a gold band and a larger silver ring with purple stones in it on her finger but no ring keeper. She stated the ring with the purple stones was fake. She stated she was very sad her diamond ring had been stolen.During an interview on 08/06/25 at 10:33 AM Resident #30's family member stated after her diamond solitaire ring was stolen, he cut the ring protector and took her other two diamond rings home leaving her with the gold band only. He stated the silver ring with the purple stones was his way of giving her something pretty to wear that was not valuable. He stated he visited Resident #30 on 07/26/25 and her diamond solitaire ring was on her finger with her other rings inside the ring keeper. He stated he visited her on 07/28/25 and the ring was not on her finger, but the other three rings (gold band and two wedding diamond rings) were still inside the ring keeper on her finger. He stated someone would have had to cut the band of the diamond solitaire ring to get it out of the ring keeper and off her finger. He stated as soon as he noticed the diamond solitaire ring was missing, he told MDS LVN and she went and got [first name of ADM]. He stated ADM called the owner of the local pawn shop regarding Resident #30's missing ring.During an interview on 08/07/25 at 09:46 PM DON stated she did not think there was a negative outcome to a resident if an injury of unknown origin was not reported to the state. DON stated she did not know of a possible negative outcome of not reporting resident's missing property to the state. DON stated ADM wrote a grievance regarding the ring and that was why it was not reported to the state. DON stated ADM was usually responsible for reporting incidents to the state.During an interview on 08/07/25 at 09:59 AM MDS LVN stated Resident #30's family member reported the missing diamond ring to her and she immediately let DON and ADM know. She stated ADM and DON were responsible for reporting misappropriated resident property to the state.During an interview on 08/07/25 at 10:33 AM ADM stated Resident #8 was fine when he went into the shower and had a black eye when he came out. He stated, I will speculate on that. ADM stated Resident #8 was tall and the shower head is right there, and he probably turned and bumped his head on it (the shower head). He stated he looked for Resident #30's ring and wrote a grievance. He stated he told Resident #30's family member to file a police report. ADM stated he did not know he was supposed to report Resident #8's black eye and Resident #30's missing ring to the state. ADM stated, Do I need to report it when a resident loses their glasses? Because glasses cost a lot more than that diamond ring, I guarantee. He stated he was responsible for reporting incidents to the state.During exit conference on 08/07/25 at 01:35 PM after preliminary findings were read, ADM stated, I guess I'll start reporting lost pajamas and lost glasses, then.Record review of facility policy titled Abuse/Neglect and dated 11/15/2016 revealed the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . Misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Injury of Unknown Source any injury to a resident where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury . Appropriate notification to state and home office will be the responsibility of the administrator and per policy. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of residents . Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services . Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. 1. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated for 2 (Resident #8 and Resident #30) of 15 residents reviewed for investigating abuse, neglect, exploitation, and misappropriation of resident property.1. The facility failed to complete a thorough investigation of Resident #8's injury of unknown source (black eye).2. The facility failed to complete a thorough investigation of misappropriation of Resident #30's property (missing diamond ring).These failures could place residents at risk of continued abuse/misappropriation of property in the facility.Findings Included:1. Record review of Resident #8's admission record dated 08/06/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning) and dementia (a group of thinking and social symptoms that interferes with daily functioning) in other diseases classified elsewhere mild with mood disturbance.Record review of Resident #8's quarterly MDS completed on 06/16/25 revealed a BIMS score of 8 which indicated moderate cognitive impairment. Resident #8 was noted to require setup or clean-up assistance or supervision/touching assistance across all ADLs.Record review of Resident #8's care plan completed on 06/17/25 revealed he was not able to measure his pain on a pain scale from 0-10 due to cognitive impairment and he had limited physical mobility. Resident #8 was noted to have Dementia with cognitive impairment as evidence by: Memory problems.Record review of Resident #8's orders revealed the following: Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day related to ACUTE COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGETSTIVE) HEART FAILURE. with start date of 11/27/24. Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day for blood clot prevention related to ACUTE COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE. with start date of 11/27/24.Record review of Resident #8's progress notes from 07/07/25 to 08/07/25 revealed the following note written by LVN D on 07/31/25 at 12:41 PM: [Initials of dialysis center] called concerning black eye to resident explained it was from a shower head that fell onto his eye.Further review revealed no other progress notes were found pertaining to the black eye.Record review of incident by incident report for May-July of 2025 revealed Resident #8 had a bruise incident on 07/30/25.Record review of incident report found in EHR under Clinical and Risk Management revealed the following: . Bruise Date 7/30/2025 11:00 (AM)Resident: [Name of Resident #8]Incident Location: ShowerPerson Preparing Report: [Name of LVN A]Incident DescriptionNursing Description: Resident noticed with a bruise to right eye underneath. Resident noted earlier was self showering in shower and then noted with bruise. Resident denies falling. No other injuries noted.Resident Description: I don't knowWas this incident witnessed: N .Description: Resident noted to go in shower and shower self, Showerhead is a removeable sprayer and comes off the wall.Injuries Observed at Time of IncidentInjury Type BruiseInjury Location 4) FaceLevel of Pain:Numerical: 0 .Mental Status Lack of Safety Awareness .Agencies/People NotifiedPhysician . 7/30/2025 11:05 (AM)DON/RN . 7/30/25 15:49 (03:49 PM)Family Member . 7/30/2025 11:10 (AM)During an observation and interview on 08/06/25 at 09:18 AM LVN A stated when a resident has an injury nurses document in the EHR under Clinical and Risk Management. She demonstrated how to find incident reports in the EHR.During an observation and interview on 08/06/25 at 09:45 Resident #8 was standing near the nurses' station. He had fading, yellowish, green bruising approximately the size of a quarter underneath his right eye. He stated no one hit him. When asked about the bruise he stated a garlic was growing above his right eyebrow (gestured to the area) and it slid down his face. He also mentioned that his right ear was falling. When asked directly if a shower head had fallen on his eye, he stated it had not.2. Record review of Resident #30's admission record dated 08/06/25 revealed a [AGE] year-old female most recently admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), and other signs and symptoms involving cognitive functions and awareness.Record review of Resident #30's admission MDS completed on 07/15/25 revealed a BIMS score of 10 which indicated moderately impaired cognition.Record review of Resident #30's care plan completed on 07/15/25 revealed she had impaired communication due to cognitive impairment. Resident #30 was noted to have dementia with cognitive impairment Record review of Resident #30's progress notes from 07/06/25 to 08/06/25 revealed no mention of her missing diamond ring. It did reveal the following progress note written by LVN D on 08/02/25 at 09:06 AM: resident is slapping and hitting staff and other residents. making accusations that staff and other residents are stealing her stuff.Record review of incident by incident report for May-July 2025 revealed no mention of Resident #30's ring or any incident of misappropriation of resident property.Record review of grievance for the last three months revealed a grievance written by ADM on 07/28/25 regarding Resident #30's missing ring.During an observation and interview on 08/05/25 at 11:06 AM Resident #30 wheeled herself in her wheelchair down the hall to speak to this surveyor. She stated she had a diamond ring stolen. She stated it was a diamond solitaire and it was given to her by a family member. She stated she did not know who took it but she did know it was missing.During an interview on 08/05/25 at 02:49 PM Resident #30's family member stated Resident #30's diamond solitaire ring disappeared on 07/28/25. He stated the ring was on her finger and in a ring keeper with her two wedding diamond rings and a gold band. He stated the ring keeper was a plastic ring that went through all of her rings to keep them together and on her finger.During an observation and interview on 08/06/25 at 10:21 AM Resident #30 was seated in her wheelchair at the nurses' station. She had a gold band and a larger silver ring with purple stones in it on her finger but no ring keeper. She stated the ring with the purple stones was fake. She stated she was very sad her diamond ring had been stolen.During an interview on 08/06/25 at 10:33 AM Resident #30's family member stated after her diamond solitaire ring was stolen, he cut the ring protector and took her other two diamond rings home leaving her with the gold band only. He stated the silver ring with the purple stones was his way of giving her something pretty to wear that was not valuable. He stated he visited Resident #30 on 07/26/25 and her diamond solitaire ring was on her finger with her other rings inside the ring keeper. He stated he visited her on 07/28/25 and the ring was not on her finger, but the other three rings (gold band and two wedding diamond rings) were still inside the ring keeper on her finger. He stated someone would have had to cut the band of the diamond solitaire ring to get it out of the ring keeper and off her finger. He stated as soon as he noticed the diamond solitaire ring was missing, he told MDS LVN and she went and got [first name of ADM]. He stated ADM called the owner of the local pawn shop regarding Resident #30's missing ring.During an interview on 08/07/25 at 09:29 AM LVN A stated she did not see the shower head fall on Resident #8's eye. She stated Resident #8 had been in the shower by himself. She stated, When staff are not looking, he will go in there by himself to shower and we knew he was in there because he opened the door to tell us he needed a towel. LVN A stated later in the day she noticed the bruise to Resident #8's right eye. She stated when she first interviewed him and filled out the incident report, he told her he did not know how it happened. She stated later when she spoke to him about it again, he told her the shower head fell on his eye. LVN A stated she forgot to document that conversation anywhere. During an interview on 08/07/25 at 09:46 PM DON stated she expects her staff to report injuries of unknown origin and missing resident property to her. She stated, We investigate it. She stated Resident #8 was in the shower with an aide and the aide believed he hit himself with the shower head. She stated she was not sure which aide was with him in the shower. DON stated it was not okay for staff to assume what happened with an injury of unknown origin. She stated Resident #8 told her the shower head bruised his eye. When asked where she documented that conversation she stated, I haven't completed his note on his event report yet, but it would be in there. She stated staff were to report missing resident property to her and we do an investigation. Seh stat4ed Resident #30's family member told her about the missing diamond ring. She stated ADM was notified and he investigated. DON stated ADM wrote a grievance regarding the ring.During an interview on 08/07/25 at 09:59 AM MDS LVN stated Resident #30's family member reported the missing diamond ring to her and she immediately let DON and ADM know. She stated she and ADM went to Resident #30's room and began to search everywhere for the ring. During an interview on 08/07/25 at 10:33 AM ADM stated Resident #8 was fine when he went into the shower and had a black eye when he came out. He stated Resident #8 was tall and the shower head is right there, and he probably turned and bumped his head on it (the shower head). He stated he looked for Resident #30's ring and wrote a grievance. ADM stated he spoke to staff who worked the days the ring disappeared, but he did not document any of those conversations or his search for the ring. He stated he called the owner of the local pawn shop and described the ring and asked for a call if it came into the pawn shop, but he did not document his call to the pawn shop. He stated he told Resident #30's family member to file a police report. Record review of facility policy titled Abuse/Neglect and dated 11/15/2016 revealed the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Injury of Unknown Source any injury to a resident where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury . All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. 1. The administrator in consultation with the Risk Management Department will be responsible for investigating and reporting cases to the HHSC. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a significant change assessment within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition for 2 (Resident #4 and Resident #39) of 15 residents reviewed for timing of assessments.1. The facility failed to complete Resident #4's significant change MDS within 14 days of her admission to hospice care on 07/16/25.2. The facility failed to complete Resident #39's significant change MDS within 14 days of her admission to hospice care on 12/26/24.These failures could place residents at risk of not receiving necessary care/coordination of care.Findings Included:1. Record review of Resident #4's admission record dated 08/06/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease. Her admission record did not mention hospice.Record review of Resident #4's significant change MDS assessment completed on 08/05/25 revealed a BIMS score of 3 which indicated severely impaired cognition. Resident #4 was noted to be receiving hospice care While a Resident. The RN signature at Z0500 which indicated the assessment was complete was DON's signature.Record review of Resident #4's care plan completed on 05/14/25 revealed Resident #4 was on hospice and required hospice as evidenced by terminal illness.Record review of Resident #4's order summary dated 08/06/25 revealed no mention of hospice.Record review of Resident #4's hospice paperwork under the miscellaneous tab in her EHR revealed a certification for hospice care signed by her physician on 07/14/25 with an election date and effective date of 07/16/25. A voice order for hospice care was noted from Resident #4's attending physician on 07/16/25 at 09:30 AM.2. Record review of Resident #39's admission record dated 08/06/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease, anxiety disorder, and Parkinsonism. Her admission record revealed her primary payer was Hospice Medicaid and listed the name of her hospice care provider.Record review of Resident #39's quarterly MDS completed 07/23/25 revealed a BIMS of 3 which indicated severely impaired cognition. Resident #39 was noted to be receiving hospice care While a Resident. The RN signature at Z0500 which indicated the assessment was complete was DON's signature.Record review of Resident #39's significant change MDS completed on 01/20/25 revealed a BIMS of 3 which indicated severely impaired cognition. Resident #39 was noted to be receiving hospice care While a Resident. The RN signature at Z0500 which indicated the assessment was complete was DON's signature.Record review of Resident #39's care plan completed on 06/03/25 revealed she required hospice as evidence by terminal illness.Record review of Resident #39's order summary dated 08/06/25 revealed one mention of hospice as noted in the following order: Ativan Oral Tablet 0.5 MG (Lorazepam) Give 0.5 mg by mouth every 4 hours as needed for anxiety/hospice related to ANXIETY DISORDER, UNSPECIFIED (F41.9) for 365 Days. Start date of order was 07/30/25.Record review of Resident #39's hospice paperwork under the miscellaneous tab in her EHR revealed a certification for hospice care with an election date of 12/26/24 and effective date of 12/26/24. A voice order for hospice care was noted from Resident #39's attending physician on 12/26/24 at 10:00 AM.During an interview on 08/07/25 at 09:29 AM LVN A stated MDS LVN was responsible for completing MDS assessments timely. She stated a possible negative outcome of a MDS assessment not being completed timely was staff would not have the correct information regarding resident care.During an interview on 08/07/25 at 09:46 AM DON stated MDS LVN was responsible for completing MDS assessments timely. She stated she (DON) signed off on the assessments as complete because she was an RN. DON stated MDS LVN sent her (DON) an email or came to her (DON's) office to let her know which MDS assessments were ready to be signed as completed. She stated she did not know why Resident #4 and Resident #39's significant change assessments were not signed as completed within the 14-day time frame provided by the RAI manual. She stated she could not think of a negative outcome to a resident if a significant change MDS was not completed timely. She stated it would affect facility funding which could, in turn, affect resident care negatively.During an observation and interview on 08/07/25 at 09:59 MDS LVN stated she was responsible for ensuring MDS assessments were completed timely. She stated the policy she followed when completing MDS assessments was the RAI. MDS LVN stated residents could be negatively impacted if a significant change MDS was not completed timely. She stated staff's ability to give the proper care to that resident could be negatively impacted. MDS LVN stated when an MDS assessment was ready for DON's signature she would let DON know. She demonstrated how DON could go into EHR and see which assessments were ready for her signature. MDS LVN stated she believed Resident #4 and Resident #39's significant change MDS assessments were completed timely. She stated the work for the assessments was completed within the 14 days allowed and it did not matter what date DON signed the assessments as complete.During an interview on 08/07/25 at 10:33 AM ADM stated MDS LVN was responsible for ensuring MDS assessments were completed timely. He stated, I'm not gonna speculate on what didn't happen regarding a possible negative outcome for residents when MDS assessments were not completed timely.Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed a chart on page 38 with the following: Assessment Type.Significant Change.MDS Completion Date.no later than 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). Significant Change in Status Assessment . Must be completed (item Z0500B) within 14 days after the determination that the criteria are met for a Significant Change in Status assessment.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 (LVN D, LVN E, CNA G, and CNA H) of 4 staff members and 2 of 2 residents (Resident #2 and Resident #45) in that: <BR/>LVN E did not don PPE gown before administering ordered medications via Peg-tube to Resident #2<BR/>LVN E did not don PPE gown before administrating Foley Catheter Care, Incontinent Care, and Wound Care-Stage 3 pressure ulcer to coccyx on Resident #45<BR/>CNA G did not don PPE gown before assisting LVN E with Foley Catheter Care, Incontinent Care and Wound Care Stage 3 pressure ulcer to coccyx on Resident #45<BR/>CNA H did not don PPE gown before, assisting LVN E with Foley Catheter Care, Incontinent Care, and Wound Care-Stage 3 pressure ulcer to coccyx on Resident #45<BR/>LVN D did not don PPE gown before administering liquid feeding via Peg-tube to Resident #2<BR/>These deficient practices have the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, communicable diseases. <BR/>Findings include:<BR/>Observation on 7/17/24 at 8:50AM revealed LVN E did not don PPE gown for the administration of ordered medications for Resident #2's PEG-tube. PPE gown was not present inside room or in hallway outside the door of Resident #2's room. <BR/>Record review of Resident #2's admission Record states Resident #2 is a 48 y/o female admitted to facility on 7/1/2007. Medical diagnoses include a diagnosis of Cerebral Palsy. Care Plan dated 7/9/24 states Resident requires total assist with ADL needs, is incontinent of bowel and bladder, must maintain nutritional status via tube feeding related to inability to swallow, and receives all medications, feedings, and fluids via peg tube.<BR/>Observation on 7/17/24 at 9:33AM revealed that LVN E, CNA G, and CNA H did not don PPE gowns during Foley catheter care, Incontinent bowel care followed by Wound care for Stage 3 pressure ulcer to coccyx for Resident #45. No gowns were used in any of the procedures performed. No gowns were in Resident #45's room or in the hallway outside Resident #45's door. <BR/>Record review of Resident #45 admission Record states Resident #45 is a 61 y/o male initially admitted to facility on 2/8/24. Medical diagnoses include Pressure Ulcer of Sacral Region Stage 3 and Obstructive and Reflux Uropathy. Care Plan dated 5/28/24 states; Resident is incontinent of bladder and requires an indwelling Foley catheter, Sacral pressure ulcer stage 3, needs staff assistance for ADLs, and 2 staff members to transfer. <BR/>Observation on 7/17/24 at 11:45AM revealed LVN D did not don PPE gown, before administration of ordered feeding for Resident #2 via her Peg-tube. PPE gown was not present inside room or in hallway outside her room. <BR/>Interview on 7/17/24 at 11:55AM LVN D stated she had not been told to wear a gown as part of PPE when using Peg-tube for feeding residents. She did not know what Enhanced Barrier Protection (EBP) meant. She stated a negative outcome of not donning a PPE gown during care is that germs can spread.<BR/>Interview on 7/17/24 at 1:01PM CNA G stated she had never been told to wear a gown when changing or assisting with any resident care. She did not know what Enhanced Barrier Precautions (EBP) were. She stated a negative outcome of not donning a PPE gown could be Spread of Infection.<BR/>Interview on 7/17/24 at 1:08PM CNA H stated she had heard talk about wearing a gown, she could not remember who had told her. She stated a negative outcome of not donning a PPE gown ring resident care could be, Infection to the resident.<BR/>Interview on 7/17/24 at 1:28PM Charge Nurse LVN A stated she had never heard of Enhanced Barrier Precautions (EBP). She did not remember an in-service on EBP being done. She stated a negative outcome of not donning a PPE gown during resident care could be, Possibility of getting bacteria on clothes and transferring. <BR/>Interview on 7/17/24 at 1:33PM DON stated she was not aware of EBP policy. She was not aware of any in-service or training for staff. When asked what a possible negative outcome could be for not donning a PPE gown during resident care she first stated, I don't know. Administrator was in room and stated to her, Organisms if there are any, and she repeated to Surveyor, Organisms if there are any.<BR/>Interview on 7/17/24 at 1:38PM with Administrator. He stated he was aware of EBP policy. He stated there had been an in-service on it and he would find it. He stated he had gotten a resignation from facilities former DON who had been at facility for 14 years, on March 31, 2024. The current DON started in April of 2024. Current DON may not have known about EBP policy he stated. When asked what a possible negative outcome could be for not donning a PPE gown during resident care he stated, Possibility of transfer of organisms.<BR/>Interview with LVN E attempted. Tried to contact by phone on 7/17/24 at1:45PM, 1:46PM and 7/18/24 at 9:49AM. Left Voicemails requesting call back. Unable to contact LVN E and she was not working at facility after 12:00PM on 716/24. Did not work through 7/18/24. <BR/>Record review of facility provided policies, procedures, CMS, and CDC updates received, and in-service: <BR/>Inservice Titled 'Infection Control, [NAME] & Doffing, Enhanced Barrier Precaution-catheter/wound/peg-tube,' <BR/>which included:<BR/>Record review of facility provided Inservice document titled CMS OSO-24-08-NH Dated March 20,2024 effective April 1, 2024, revealed the following: <BR/> .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO's) that employs targeted gown and glove use during high contact resident care activities.' <BR/> .Examples of chronic wounds include, but not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.<BR/> .Indwelling medical device examples include central lines, urinary catheters, feeding tubes <BR/> .EBP is employed when performing the following: Providing hygiene, Changing briefs or assisting with toileting, <BR/> Device care or use .urinary catheter, feeding tube, wound care any skin opening requiring a dressing. <BR/>Record Review of Facility provided Inservice document titled; 'CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO's)' updated July 12, 2022, under Key Points revealed:<BR/> 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. <BR/>4. Effective implementation of EBP requires staff training on proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at point of care. <BR/>Record review of Facility provided Policy Titled: 'Enteral and Parenteral Feeding' dated 12/02/2017 under Procedure revealed:<BR/>12. Standard precautions, clean techniques, applicable nursing policies, and manufacturer's recommendations are followed by nursing personnel when dealing with nutrition support residents. <BR/>DON and/or designee are responsible for training and monitoring of nursing personnel on Nutritional Support procedures, documentation, and orders. <BR/>Record review of Facility provided Policy Titled: 'Administering Medications' dated December 2012 under Policy and implementation revealed:<BR/>22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications as applicable. <BR/> Record review of Facility Policy Titled: 'Perineal Care Male' dated December 8, 2009, under Gather Supplies revealed: <BR/>Gather needed supplies:<BR/>i. <BR/>Washcloths or Pre-moistened cleaning wipes<BR/>ii. <BR/>Towels<BR/>iii. <BR/>Soap or no-rinse perineal cleanser<BR/>iv. <BR/>Clean wash basin(s) or comfortably warm water<BR/>v. <BR/>Clean, disposable examination gloves<BR/>vi. <BR/>Overbed table<BR/>vii. <BR/>Disposable plastic bags for trash and linen<BR/>viii. <BR/>Incontinence pad(s) or brief<BR/>ix. <BR/>Additional supplies as needed if heavy soiling is present, i.e., toilet paper.<BR/>Record review of Facility provided Policy Titled: 'Catheter Care dated February 13, 2007, under Procedure revealed:<BR/>1. <BR/> Gather Supplies:<BR/>a. <BR/>Gloves<BR/>b. <BR/>Pre-moistened no-rinse disposable wash cloths<BR/>c. <BR/>Or wash cloths and basin (if using soap and water)<BR/>Record review of Facility provided Policy Titled: 'Infection Control Plan': Overview dated 2018 under Facility Assessment revealed:<BR/>At least annually and on an as needed basis the facility will conduct a facility wide assessment to determine the resources needed to maintain and efficient and up to date infection control program. The facility assessment can assist in determining the types of residents being cared for, what is needed to care for those residents, and what education facility staff need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 14 residents (Resident #4) reviewed for accommodation of needs. <BR/>Resident #4's call light was not within her reach.<BR/>This failure could place residents at risk of not having their needs met and a decline in their quality of care and life.<BR/>Findings included:<BR/>Record review of Resident #4's face sheet, dated 07/17/2024, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, parkinsonism (slowed movements, tremors), urinary tract infection, dementia (memory loss), anxiety disorder, neuromuscular dysfunction of bladder (incomplete bladder emptying), and a history of falling.<BR/>Record review of Resident #4's quarterly MDS, dated [DATE], revealed a BIMS score of 00 out of 15 which indicated Resident #4 had severe cognitive impairment. Resident #4 required extensive two-person staff assistance with toileting hygiene, upper and lower body dressing, and personal hygiene.<BR/>Record review of Resident #4's care plan, dated 05/07/2024, revealed, in part, Resident #4 had urinary/bowel incontinence with interventions to keep call light in easy reach and remind resident to call for assistance when urgency to eliminate was noted. Resident #4 was at risk for injuries from falling related to physical mobility and generalized weakness with interventions to ensure call light was in reach and answered promptly.<BR/>During an observation and interview on 07/17/2024 at 8:34 AM, Resident #4 was sitting in her recliner in the middle of her room, she had a blanket covering her body. Resident #4 stated she needed to go to the bathroom. Observation of Resident #4's private room revealed that her designated call light located closest to her bed was on the floor. A second call light for that room that would have been designated for a roommate was located on Resident #4's bed out of reach from Resident #4. When asked about how long she was in the recliner needing help, Resident #4 did not answer the question. <BR/>In an interview and observation on 07/17/2024 at 8:43 AM, CNA B stated that Resident #4 could not transfer herself and that she and another aide transferred her into her recliner. CNA B walked into Resident #4's room and noticed the call light was not in residents reach. CNA B apologized to surveyor for the call light being on the bed and not near Resident #4. CNA B stated that a possible negative outcome for not having the call light in reach could be that a resident could fall and would not be able to call for help. <BR/>In an interview on 07/17/2024 at 9:40 AM, LVN A stated that it was protocol for call lights to be in reach of residents and the negative outcome for a resident not having a call light in reach would be that a resident could try to get up on their own and could hurt themselves. <BR/>In an interview on 07/17/2024 at 2:37 PM, the ADON stated that it was protocol when residents were transferred from their bed to a chair in their room that the call light was to be placed near the resident. The ADON stated that the possible negative outcome for a call light out of reach of a resident could be that they could fall and need help. <BR/>In an interview on 07/17/2024 at 2:40 PM, the DON stated that staff had been inserviced on call light placement and that a possible negative outcome for a resident that was not able to reach their call light could be that the resident would need help and not be able to call for help.<BR/>Record Review of the policy titled Call light-use of dated 12/2017 revealed the following in part:<BR/> .It is the policy of this home to ensure residents have a call light win reach that they are physically able to access and that have been instructed on its use.<BR/> .All nursing personnel must be aware of call lights at all times. <BR/> .When providing care to residents, be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light.<BR/> .Be sure call lights are placed near the resident, never on the floor or bedside stand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for1 of 14 (Resident #13) residents reviewed for bed rails. <BR/>Resident #13 had (1) one-third bed rail, on the right side of her bed with no documentation of resident consent, or safety assessment prior to installation.<BR/>This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living.<BR/>Findings included:<BR/>Record Review of Resident #13's Face Sheet dated July 16, 2024revealed that a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include but not limited to weakness, cognitive communication deficit, unspecified dementia (memory loss) and major depressive order. <BR/>Record Review of Resident #13's Quarterly MDS assessment dated [DATE] revealed Resident #13 had a BIMS score of 01 indicating that resident had severe cognitive impairment. The MDS revealed that Resident #13 required a 2 person assist with lying to sitting on side of bed, sitting to standing and chair to bed transfer.<BR/>Record Review of Resident #13's Care plan dated 5/01/2024 revealed the following with no documentation relating to side/bed rail use.<BR/> Focus: Dementia with cognitive impairment<BR/> Interventions: Reorient resident as needed.<BR/> Focus: Limited physical mobility<BR/> Interventions: Provide supportive care, assistance with mobility as needed. <BR/>Record Review of Resident #13's clinical record dated 10/09/2023 revealed physician's standing orders of side rails to be used when assessment revealed necessary.<BR/>Record Review of Resident #13's clinical record under Assessments revealed no documentation of bed rail safety assessment for 1/3 size bed rails. <BR/>Record Review of Resident #13's clinical record under Assessments revealed an assessment was completed on 10/09/2023 for 1/8 size bed rails.<BR/>Record Review of Resident #13's clinical record for bed rail consents revealed no documentation of a signed bed rail consent for 1/3 size bed rails. <BR/>Observation on 07/16/2024 at 10:42AM of Resident #13's bed revealed (1) 1/3 size bed rail on the right side of bed.<BR/>Observation on 07/17/2024 at 8:30 AM of Resident #13's bed revealed bed rail was no longer on the bed.<BR/>In an interview on 07/17/2024 at 9:40 AM, LVN A stated that assessment and consents were required for bed rail use. LVN A stated she did know that the bed rail had been taken off the bed but stated that maintenance was responsible for bed rails installation and removal. LVN A stated that a possible negative outcome for bedrails being used without assessments could be that it could cause entrapment, or a resident could try to crawl over the bed rail and get hurt. LVN A stated she did not know what size bed rails were on Resident #13's bed.<BR/>In an interview/observation on 07/17/2024 at 2:00 PM, Resident #13 was sitting in her recliner. When asked about the bed rails being on her bed, Resident #13 waved her hands back and forth to the side saying, it doesn't matter. Resident #13 was bilingual and to ensure she understood surveyor, CNA C entered the room and relayed the question in Spanish concerning the bed rails. CNA C stated that that Resident #13 didn't care if bedrails were on or off the bed. <BR/>In an interview on 07/17/2024 at 2:06 PM, the MS stated that he was directed by ADON to take bed rails off the bed on 07/16/2024. The MS stated that the bed rail on Resident #13's bed was 1/3 in size. <BR/>In an interview on 07/17/2024 at 2:38 PM, the ADON stated she directed MS to take the bed rail off the bed because the family requested the removal. The ADON stated she did not know what size of bed rail was on Resident #13's bed. The ADON stated that a possible negative outcome for having bed rails on the bed was that a resident could be stuck in the bed. <BR/>In an interview on 07/17/2024 at 2:40 PM, the DON stated that she did not know what size of the bed rails that were on the bed and stated that a possible negative outcome for unneeded bed rails on the bed would be that the resident wouldn't be able to get out of bed. <BR/>Record Review of facility policy title Bed Rails dated November 8, 2016, revealed the following:<BR/>Assessment-Prior to use of a bed rail the resident will be assessed to ensure the proper rail is utilized for the resident's need.<BR/>The facility will re-evaluate the use of the rail on a periodic basis.<BR/>Based on the resident assessment, the interdisciplinary team will make the determination for the plan of care as it relates to bed rail.<BR/>Consent-The resident or resident representative will provide consent for the use of rails prior to installation.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 (LVN D, LVN E, CNA G, and CNA H) of 4 staff members and 2 of 2 residents (Resident #2 and Resident #45) in that: <BR/>LVN E did not don PPE gown before administering ordered medications via Peg-tube to Resident #2<BR/>LVN E did not don PPE gown before administrating Foley Catheter Care, Incontinent Care, and Wound Care-Stage 3 pressure ulcer to coccyx on Resident #45<BR/>CNA G did not don PPE gown before assisting LVN E with Foley Catheter Care, Incontinent Care and Wound Care Stage 3 pressure ulcer to coccyx on Resident #45<BR/>CNA H did not don PPE gown before, assisting LVN E with Foley Catheter Care, Incontinent Care, and Wound Care-Stage 3 pressure ulcer to coccyx on Resident #45<BR/>LVN D did not don PPE gown before administering liquid feeding via Peg-tube to Resident #2<BR/>These deficient practices have the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, communicable diseases. <BR/>Findings include:<BR/>Observation on 7/17/24 at 8:50AM revealed LVN E did not don PPE gown for the administration of ordered medications for Resident #2's PEG-tube. PPE gown was not present inside room or in hallway outside the door of Resident #2's room. <BR/>Record review of Resident #2's admission Record states Resident #2 is a 48 y/o female admitted to facility on 7/1/2007. Medical diagnoses include a diagnosis of Cerebral Palsy. Care Plan dated 7/9/24 states Resident requires total assist with ADL needs, is incontinent of bowel and bladder, must maintain nutritional status via tube feeding related to inability to swallow, and receives all medications, feedings, and fluids via peg tube.<BR/>Observation on 7/17/24 at 9:33AM revealed that LVN E, CNA G, and CNA H did not don PPE gowns during Foley catheter care, Incontinent bowel care followed by Wound care for Stage 3 pressure ulcer to coccyx for Resident #45. No gowns were used in any of the procedures performed. No gowns were in Resident #45's room or in the hallway outside Resident #45's door. <BR/>Record review of Resident #45 admission Record states Resident #45 is a 61 y/o male initially admitted to facility on 2/8/24. Medical diagnoses include Pressure Ulcer of Sacral Region Stage 3 and Obstructive and Reflux Uropathy. Care Plan dated 5/28/24 states; Resident is incontinent of bladder and requires an indwelling Foley catheter, Sacral pressure ulcer stage 3, needs staff assistance for ADLs, and 2 staff members to transfer. <BR/>Observation on 7/17/24 at 11:45AM revealed LVN D did not don PPE gown, before administration of ordered feeding for Resident #2 via her Peg-tube. PPE gown was not present inside room or in hallway outside her room. <BR/>Interview on 7/17/24 at 11:55AM LVN D stated she had not been told to wear a gown as part of PPE when using Peg-tube for feeding residents. She did not know what Enhanced Barrier Protection (EBP) meant. She stated a negative outcome of not donning a PPE gown during care is that germs can spread.<BR/>Interview on 7/17/24 at 1:01PM CNA G stated she had never been told to wear a gown when changing or assisting with any resident care. She did not know what Enhanced Barrier Precautions (EBP) were. She stated a negative outcome of not donning a PPE gown could be Spread of Infection.<BR/>Interview on 7/17/24 at 1:08PM CNA H stated she had heard talk about wearing a gown, she could not remember who had told her. She stated a negative outcome of not donning a PPE gown ring resident care could be, Infection to the resident.<BR/>Interview on 7/17/24 at 1:28PM Charge Nurse LVN A stated she had never heard of Enhanced Barrier Precautions (EBP). She did not remember an in-service on EBP being done. She stated a negative outcome of not donning a PPE gown during resident care could be, Possibility of getting bacteria on clothes and transferring. <BR/>Interview on 7/17/24 at 1:33PM DON stated she was not aware of EBP policy. She was not aware of any in-service or training for staff. When asked what a possible negative outcome could be for not donning a PPE gown during resident care she first stated, I don't know. Administrator was in room and stated to her, Organisms if there are any, and she repeated to Surveyor, Organisms if there are any.<BR/>Interview on 7/17/24 at 1:38PM with Administrator. He stated he was aware of EBP policy. He stated there had been an in-service on it and he would find it. He stated he had gotten a resignation from facilities former DON who had been at facility for 14 years, on March 31, 2024. The current DON started in April of 2024. Current DON may not have known about EBP policy he stated. When asked what a possible negative outcome could be for not donning a PPE gown during resident care he stated, Possibility of transfer of organisms.<BR/>Interview with LVN E attempted. Tried to contact by phone on 7/17/24 at1:45PM, 1:46PM and 7/18/24 at 9:49AM. Left Voicemails requesting call back. Unable to contact LVN E and she was not working at facility after 12:00PM on 716/24. Did not work through 7/18/24. <BR/>Record review of facility provided policies, procedures, CMS, and CDC updates received, and in-service: <BR/>Inservice Titled 'Infection Control, [NAME] & Doffing, Enhanced Barrier Precaution-catheter/wound/peg-tube,' <BR/>which included:<BR/>Record review of facility provided Inservice document titled CMS OSO-24-08-NH Dated March 20,2024 effective April 1, 2024, revealed the following: <BR/> .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO's) that employs targeted gown and glove use during high contact resident care activities.' <BR/> .Examples of chronic wounds include, but not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.<BR/> .Indwelling medical device examples include central lines, urinary catheters, feeding tubes <BR/> .EBP is employed when performing the following: Providing hygiene, Changing briefs or assisting with toileting, <BR/> Device care or use .urinary catheter, feeding tube, wound care any skin opening requiring a dressing. <BR/>Record Review of Facility provided Inservice document titled; 'CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO's)' updated July 12, 2022, under Key Points revealed:<BR/> 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. <BR/>4. Effective implementation of EBP requires staff training on proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at point of care. <BR/>Record review of Facility provided Policy Titled: 'Enteral and Parenteral Feeding' dated 12/02/2017 under Procedure revealed:<BR/>12. Standard precautions, clean techniques, applicable nursing policies, and manufacturer's recommendations are followed by nursing personnel when dealing with nutrition support residents. <BR/>DON and/or designee are responsible for training and monitoring of nursing personnel on Nutritional Support procedures, documentation, and orders. <BR/>Record review of Facility provided Policy Titled: 'Administering Medications' dated December 2012 under Policy and implementation revealed:<BR/>22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications as applicable. <BR/> Record review of Facility Policy Titled: 'Perineal Care Male' dated December 8, 2009, under Gather Supplies revealed: <BR/>Gather needed supplies:<BR/>i. <BR/>Washcloths or Pre-moistened cleaning wipes<BR/>ii. <BR/>Towels<BR/>iii. <BR/>Soap or no-rinse perineal cleanser<BR/>iv. <BR/>Clean wash basin(s) or comfortably warm water<BR/>v. <BR/>Clean, disposable examination gloves<BR/>vi. <BR/>Overbed table<BR/>vii. <BR/>Disposable plastic bags for trash and linen<BR/>viii. <BR/>Incontinence pad(s) or brief<BR/>ix. <BR/>Additional supplies as needed if heavy soiling is present, i.e., toilet paper.<BR/>Record review of Facility provided Policy Titled: 'Catheter Care dated February 13, 2007, under Procedure revealed:<BR/>1. <BR/> Gather Supplies:<BR/>a. <BR/>Gloves<BR/>b. <BR/>Pre-moistened no-rinse disposable wash cloths<BR/>c. <BR/>Or wash cloths and basin (if using soap and water)<BR/>Record review of Facility provided Policy Titled: 'Infection Control Plan': Overview dated 2018 under Facility Assessment revealed:<BR/>At least annually and on an as needed basis the facility will conduct a facility wide assessment to determine the resources needed to maintain and efficient and up to date infection control program. The facility assessment can assist in determining the types of residents being cared for, what is needed to care for those residents, and what education facility staff need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to keep resident rooms free from accident hazards for 3 of 3 residents (Residents #13, #19, #20) who were observed.<BR/>The facility failed to follow smoking policy by Resident #13, Resident #19 and Resident #20 having smoking materials of lighters and cigarettes in rooms.<BR/>This failure could place residents at risk of accident hazards. <BR/>Findings included:<BR/>Resident #13<BR/>Record review of Resident #13's face sheet dated 6/8/23 revealed a [AGE] year-old male admitted into the facility on 5/29/2018. Resident #13's diagnoses included: aphasia (communication deficiencies), muscle wasting and atrophy, cognitive communication deficit, mood disorder, chronic embolism and thrombosis (deep veins in the lower extremities), vascular dementia, nicotine dependence, and major depressive disorder.<BR/>Record review of Resident #13's MDS assessment dated [DATE] revealed a BIMS score of 02 and required extensive assistance or two-person assist in all areas of daily living except locomotion on and off unit with limited assistance. <BR/>Record review of Resident #13's care plan dated 5/23/23 revealed a focused goal for smoking and was at risk for injury with additional information that resident can smoke independently.<BR/>Record review of Resident #13's smoking assessment dated [DATE] revealed that all resident's smoking materials will be kept at the nurses' station. <BR/>Observation on 6/8/23 at 11:19 AM revealed two lighters, one pink and one yellow, sitting on Resident #13's rolling bed side table. <BR/>Interview with Resident #13 on 6/8/23 at 11:19 AM revealed that Resident #19's cigarettes were kept in the med cart but can keep lighters. Resident #13 indicated that they are allowed to smoke independently.<BR/>Resident #19<BR/>Record review of Resident #19's face sheet dated 6/8/2023 revealed resident was a [AGE] year-old female whose diagnoses included: malignant neoplasm of vertebral column (cancer of the spine), complications after genitourinary (reproductive) surgery, muscle wasting and atrophy (shrinkage), cognitive communication deficit, hyperglycemia (high blood sugar), lack of coordination, abnormalities of gait and mobility, ataxia (loss of coordination), anxiety disorder, gastro-esophageal reflux disorder, quadriplegia, major depressive disorder, c4 level cervical spinal cord, malignant neoplasm of brain (cancer).<BR/>Record review of MDS assessment for Resident #19 dated 03/31/23 indicated a BIMS of 14.<BR/>Record review of Resident #19's smoking assessment dated [DATE] revealed that all resident's smoking materials will be kept at the nurses' station.<BR/>On 6/8/23, observation and at 7:49 AM revealed Resident #19 sitting in her wheelchair in her room. Resident #19 stated lighter was in room and a red lighter was observed to be on Resident #19's bed. <BR/>In an interview on 6/8/23 at 7:49 AM with Resident #19, resident stated the lighter was in her room even though Resident #19 knew it was not supposed to be there. Resident #19 indicated that they were at the nurse's station. Resident #19 stated that assistance was needed to go smoke as Resident #19 was not able to transport independently outside.<BR/>Record review of Resident #19's chart shows smoking assessment where Resident #19 is unable to smoke independently and uses assistive devices.<BR/>Resident #20<BR/>Record review of Resident #20's face sheet dated 6/8/23 revealed a [AGE] year-old woman admitted into the facility on 8/26/2019. Resident #20 had diagnoses: morbid obesity, generalized anxiety disorder, heart failure, hypercholesterolemia (high cholesterol), schizoaffective disorder; depressive type, Type 2 Diabetes, nicotine dependence, and schizophrenia. <BR/>Record review of Resident #20's care plan dated 5/16/23 revealed a focused goal of smoking without assistance.<BR/>Record review of Resident #20's MDS assessment dated [DATE] revealed that resident had a BIMS score of 11 indicating cognitively intact. Resident #20 needed minimal/supervising assistance with areas of daily living. <BR/>Record review of Resident #20's smoking assessment dated [DATE] revealed that resident smoking materials will be kept at nurses' station.<BR/>Interview and observation with Resident #20 on 6/8/23 at 7:36 AM revealed that Resident #20 was allowed to smoke alone. Resident #20 showed smoking materials ofa blue lighter in left hand. Resident #20 also advised that cigarettes were kept at the medication cart.<BR/>Observation on 6/8/23 at 11:35 AM showed two packages of Montego Gold 100's-one opened and one unopened.<BR/>Observation on 6/8/23 at 11:48 AM, LVN E opened the medication cart to reveal one pack of Montego Blue 100's in the left drawer behind liquid items.<BR/>Interview with LVN B at 11:32 AM revealed that there was one smoker on four hall at that time. LVN B stated Resident #20's smoking materials were kept in the facility at the medication cart. LVN B showed the surveyor where Resident #20's cigarettes were in the medication cart which was the top right corner. LVN B indicated that there were only two smokers in the building. LVN B stated that a negative outcome would be Fire hazard. LVN B indicated that Resident #19 had a lighter and cigarettes in room. LVN B stated, I know they are not supposed to. LVN B revealed that the Smoking policy stated they were not supposed to have anything in their rooms, and they were either kept in the medication cart or the medication room because they are locked. <BR/>Interview with CNA F on 6/8/23 at 11:45 AM revealed one resident that smokes in five hall. Inquired which resident and identified Resident #13. CNA F stated that cigarettes were in the medication cart. CAN F stated Resident #13 keeps lighter and a negative outcome of the resident keeping the lighter would be a fire hazard. CNA F also stated that resident was allowed to have a lighter when resident was of sound mind. CNA F stated smoking policy revealed they were to be supervised while outside. <BR/>Interview with LVN E on 6/8/23 at 11:48 AM revealed LVN E was not aware of Resident #13's lighter location and that resident has never had a lighter on him. LVN E stated a fire hazard as a possible negative outcome. LVN E indicated that lighters were not allowed in rooms. LVN E stated the smoking policy revealed, not without going back and looking at it.<BR/>Interview on 6/8/23 at 1:49 PM with LVN B revealed new cigarettes in the med cart labeled Marlboro Red 100's with Resident #19's name in black marker in top right-hand corner. LVN B advised that cigarettes were brought back to the medication cart LVN B advised that CNA went into resident's room and returned them to the medication cart. <BR/>Interview on 6/8/23 at 1:54 PM with DON. The DON advised there were no in-services on the smoking policy and training is completed upon initial hire date. DON advised the smoking policy is the residents are not allowed to go out without a staff member. DON indicated that smoking materials are kept in the medication cart. DON indicated that a negative outcome of residents keeping smoking materials in their room was would be confiscated; I don't know what you're asking. The DON responded with I don't know what you are asking, a lot of things can happen.<BR/>Interview with the DON on 6/8/23 at 2:06 PM revealed that smoking assessments were completed upon admission and quarterly. Advised that RNs completed them upon admission and the ADON completed them quarterly.<BR/>Interview with the ADON on 6/8/23 at 2:08 PM revealed that in-service for smoking was done upon hire. ADON advised that smoking policy stated smoking materials are in the medication carts separated from other items. The ADON also stated that there were three smokers in the building and a negative outcome of smoking materials being in resident's rooms would be a fire. <BR/>Interview and record review with the DON, ADM, and ADON on 6/9/23 at 8:55 AM revealed that three policies were provided for smoking. One policy labeled Smoking Policy Resident/Family Copy (no date) identified residents were allowed to keep smoking paraphernalia in their room when supervised. DON indicated supervised meant they don't go by themselves, so they are supervised. The ADM indicated it meant that they know they have their smoking materials on them. The ADON walked into the room at 8:58 AM and indicated that the smoking assessment asked if they can be unsupervised, and verbiage is found on smoking assessment. ADM stated about smoking materials in resident's room, the care plan says that. ADON confirmed with head shake up and down.<BR/>Interview with the ADM on 6/9/23 at 9:01 AM and inquired about record of policy in admission packet, policy provided to family, and facility policy with conflicting wording. Inquired which policy to go by since two were the same and Smoking Policy Resident/Family Copy (no date) stated smoking paraphernalia can be kept in room when supervised. The ADM stated, we will get that changed. <BR/>Record review of policy named Items Not Allowed in Resident Room (no date), under Safety Hazards, last statement indicated Smoking or smoking materials-not allowed.<BR/>Record review of policy named It is the policy of [the facility] to abide by the rules and regulations set forth by the Texas department of Aging and Disabilities, (no date), line 13 stated- Smoking tobacco, matches, lighters or other smoking paraphernalia are not permitted to be kept or stored in a resident's room or in their possession.<BR/>Record review of Smoking Policy Resident/Family Copy (no date) revealed the following: Line 1, line (a) Smoking tobacco, matches, lighters or other smoking paraphernalia are not permitted to be kept or stored in a resident's room or in their possession with supervision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 14 residents (Resident #1) reviewed for immunization records. <BR/>The facility failed to ensure records regarding patient care, including bed rails, was accurate and complete. <BR/>This deficient practice placed residents at risk for inaccurate records to ensure continuity of and appropriate care.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated on 6/8/23 revealed a [AGE] year-old woman who was admitted into the facility on 3/26/23. Diagnoses included encephalopathy (disease that affects the brain causing altered mental status), hyperlipidemia (elevated lipids), unspecified psychosis, disorientation, cardiac arrhythmia, hypo-osmolality and hyponatremia (low plasma).<BR/>Record review of Resident #1's MDS assessment dated [DATE] indicated a brief interview for mental status of 05 indicating severe cognitive impact.<BR/>Record review of Resident #1's bed rail assessment dated [DATE] showed not completed by the admitting nurse. <BR/>Record review of Resident #1's bed rail consent dated 3/6/23 showed not completed by the admitting nurse and signed by the resident representative. <BR/>Record review of Resident #1's Influenza Informed Consent (no date) showed not completed but signed by the resident representative.<BR/>Record review of Resident #1's Pneumococcal Informed Consent dated 3/6/23 showed not completed but signed by the admitting nurse and resident representative. <BR/>Interview with the DON on 06/09/23 at 10:52 AM revealed that the charge nurse did bed rail assessments when a resident was admitted . The DON stated what information was on the Bed Rail assessment. DON indicated the size of rail, if there was one, and what side. The DON revealed LVN C was a charge nurse. DON looked at the form, confirmed it was LVN C's signature and it was not completed correctly. The DON stated a negative outcome could be with an uncompleted assessment, she could have a rail and not need one.<BR/>Interview with LVN C on 06/09/23 at 11:04 AM revealed needing a bed rail assessment is the reason for needing it and the patient's ok if they want to use them or not. The reasons why it would help them LVN C identified the resident or resident representative could sign the consent. LVN C stated a negative outcome could be entrapment if they are caught in the bed rail. If something was to happen to them. LVN C confirmed that LVN C's signature was on Resident #1's Bed Rail Assessment form dated 3/6/23.<BR/>Interview and record review with the DON on 6/9/23 at 11:08 AM revealed the charge nurse completed bed rail assessments upon admission. The DON stated the type of rail that had been determined and the resident signature or the person giving consent was needed. The DON revealed that a negative outcome for an incomplete form if signed by both nurse and Representative/Resident meant it was completed without something being fully assessed. The DON confirmed the consent for Resident #1's bed rails was not completed and confirmed the signature on the form was LVN C's.<BR/>Interview and record review with LVN C on 6/9/23 at 2:25 PM revealed Resident #1's influenza and pneumococcal consents were not completed. LVN C revealed obtaining the signatures before completing the forms. LVN C confirmed completed admission paperwork for Resident #1. LVN C stated LVN C called the clinic but it was close to end of shift. Told them (employees) if they call this is what we are looking for. I told them I just needed a record for chart. I know I messed up. It's my fault. LVN C confirmed did not get a yes or no on the Influenza Consent and that the Pneumococcal Consent was not filled out correctly with her signature at the bottom. LVN C identified a negative outcome of being unable to tell if resident has had the vaccine or needs the vaccine since forms were not completed.<BR/>Record review of policy titled Documentation dated 2003 with a revision on 2/13/2007 indicates that documentation is the recording of all information in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. <BR/>Record review of policy titled Documentation dated 2003 with a revision on 2/13/2007 Under heading Goal-Line (1) states the facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. <BR/>Record review of policy titled Documentation dated 2003 with a revision on 2/13/2007 under heading Procedure Line (3) Place all required and appropriately signed forms in the clinical record. Items such as copies of .consent for treatment, consents for specific procedures . will be placed behind labeled dividers inside the clinical record. Line (6) document completed assessments in a timely manner and per policy.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>1. <BR/>The facility failed to ensure stored food was properly stored per food label.<BR/>2. <BR/>The facility failed to practice proper hand sanitation while preparing food. <BR/>Findings Included:<BR/>Observation of shelved foods on 6/7/2023 at 10:00am revealed the following:<BR/>1. <BR/>Plastic bottle labeled tartar sauce no expiration date noted ??? sitting on shelf with spice containers with a label on back indicated refrigerate after opening.<BR/>Observation on 6/7/23 <BR/>During an observation on 6/7/23 at 10:30 AM, observed [NAME] A preparing puree food. [NAME] A stopped prepping puree food, walked to trash can to discard a can, and returned to preparing puree food. Gloves were not worn, and no hand hygiene was practiced between these actions. <BR/>During an interview on 6/8/2023 at 2:30pm with [NAME] A, DM, translated due to language barrier, stated that all kitchen staff are responsible for safe food preparation per their policy. [NAME] A stated that she would go to the Facility policy to see what the policy stated. [NAME] A stated that the negative outcome for not practicing hand hygiene would be cross contamination.<BR/>Record review of in-service dated 1/9/23 at 1:30 PM, training contained hand washing and sanitation. <BR/>Record review of policy titled Hand Washing, dated 2012, it stated that employees are too frequently perform hand washing.<BR/>Record review of policy titled Handwashing: A Healthy Habit in the Kitchen, dated September 1, 2021, the policy stated : Clean: Wash Hands, Utensils, and Surfaces Often-Wash your hands often, especially during these key times when germs can spread: After touching garbage<BR/>Record review of recommendations of the Food and Drug Administration (FDA), dated 1997, it states that the FDA has evaluated the labeling on foods that must be refrigerated to prevent outgrowth of pathogens- February 1997.<BR/>Record review of FDA recommendations on Are You Storing Food Safely, dated 1/18/23, it stated Check storage directions on labels. Many items other than meats, vegetables, and dairy products need to be kept cold. If you've neglected to properly refrigerate something, it's usually best to throw it out.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>1. <BR/>The facility failed to ensure stored food was properly stored per food label.<BR/>2. <BR/>The facility failed to practice proper hand sanitation while preparing food. <BR/>Findings Included:<BR/>Observation of shelved foods on 6/7/2023 at 10:00am revealed the following:<BR/>1. <BR/>Plastic bottle labeled tartar sauce no expiration date noted ??? sitting on shelf with spice containers with a label on back indicated refrigerate after opening.<BR/>Observation on 6/7/23 <BR/>During an observation on 6/7/23 at 10:30 AM, observed [NAME] A preparing puree food. [NAME] A stopped prepping puree food, walked to trash can to discard a can, and returned to preparing puree food. Gloves were not worn, and no hand hygiene was practiced between these actions. <BR/>During an interview on 6/8/2023 at 2:30pm with [NAME] A, DM, translated due to language barrier, stated that all kitchen staff are responsible for safe food preparation per their policy. [NAME] A stated that she would go to the Facility policy to see what the policy stated. [NAME] A stated that the negative outcome for not practicing hand hygiene would be cross contamination.<BR/>Record review of in-service dated 1/9/23 at 1:30 PM, training contained hand washing and sanitation. <BR/>Record review of policy titled Hand Washing, dated 2012, it stated that employees are too frequently perform hand washing.<BR/>Record review of policy titled Handwashing: A Healthy Habit in the Kitchen, dated September 1, 2021, the policy stated : Clean: Wash Hands, Utensils, and Surfaces Often-Wash your hands often, especially during these key times when germs can spread: After touching garbage<BR/>Record review of recommendations of the Food and Drug Administration (FDA), dated 1997, it states that the FDA has evaluated the labeling on foods that must be refrigerated to prevent outgrowth of pathogens- February 1997.<BR/>Record review of FDA recommendations on Are You Storing Food Safely, dated 1/18/23, it stated Check storage directions on labels. Many items other than meats, vegetables, and dairy products need to be kept cold. If you've neglected to properly refrigerate something, it's usually best to throw it out.

Based on observation, interview, and record review; the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 2 medication carts (Hall 200) and 1 of 1 medication room reviewed for drug labeling and storage and expired drugs. <BR/>4.5 pills were loose in the bottom of medication cart drawers of Hall 200 Medication cart. <BR/>Medication room revealed a medication for Resident #36 that expired in June of 2023. <BR/>These failures could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level. <BR/>Findings included:<BR/>Observation and interview on 07/16/2024 at 10:26 AM of medication room revealed a medication for Resident #36 that had an expiration date of 06/2023. LVN D stated that the medication was discontinued and was not sure why the medication was still in the medication room. LVN D was unable to give a negative outcome for having expired medication in the medication room. <BR/>Observation on 07/16/2024 at 10:46 AM revealed 4.5 pills were found loose on the bottom of the medication cart drawers for medication cart for 200 Hall. MA was not able to identify any of the medications.<BR/>Interview on 07/16/2024 at 10:54 AM, MA stated that the negative outcome for having lose medication could result in the resident not receiving their medications. <BR/>Interview on 07/17/2024 at 11:11 AM with DON, requested policy for medication storage. DON was asked what a negative outcome would be for having loose medications in the medication cart. DON stated, missed dose. No further information was provided by DON. <BR/>Record review of facility provided policy, titled Storage of Medications, revised April 2007, revealed the following:<BR/>1. Drugs and biological shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. <BR/>2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. <BR/> . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.<BR/>Record review of facility provided policy, titled Labeling of Medication Containers, revised April 2007, revealed the following:<BR/>Policy Statement<BR/>All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations.<BR/>Record review of facility provided policy, titled Drug Destruction Policy, revised May 9, 2010, revealed the following:<BR/>It is the policy of this facility to destroy dangerous and controlled medications according to the State of Texas law.<BR/> .3. Nursing staff will submit to Director of Nursing any medication and any applicable log that has expired, been discontinued by physician or that had been prescribed to a resident who no longer resides at the facility.