YOAKUM NURSING AND REHABILITATION CENTER

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: <BR/>1. There were seven one-gallon containers of milk that had been opened and were without labels indicating the dates opened.<BR/>2. There were six one-lb. containers of strawberries that all contained rotten and moldy berries.<BR/>3. There was rust and debris on the table-top can opener.<BR/>4. There was a carton of mashed potato pearls that had been opened and was not properly sealed.<BR/>These deficient practices could place residents who ate food from the kitchen at risk for food borne illness.<BR/>The findings included:<BR/>1. Observation on 01/31/2023 at 9:30 AM in the cooler used to store milk revealed seven one-gallon containers of milk. Six of the gallons were whole milk, of which 2 had a best by date of 2/02/23, two had a best by date of 2/09/2023 and two had a best by date of 2/14/2023. One gallon was 2% milk with a best by date of 2/01/2023. All seven gallons of milk had been opened and were &frac12; to &frac34; full. There was no date on any of the containers of milk indicating the date they were opened.<BR/>Interview on 01/31/2023 at 9:33 AM with the FSS revealed all the milk had been received the previous day (Monday, 01/30/2023) because that was when they received their milk delivery. The FSS confirmed there were no dates indicating when the milk containers had been opened. When asked why several containers of the same product had been opened and were partially full, the FSS said sometimes nursing staff came in and grabbed a new container without seeing that one had already been opened. The FSS stated she knew it was important to indicate the date on the containers that the milk was opened regardless of the best by date because the milk started to deteriorate from that time. The FSS further stated that whoever opened the milk was responsible for dating it, and all dietary employees were trained on that during orientation and throughout the year. <BR/>2. Observation on 01/31/2023 at 9:40 AM of the reach-in produce cooler revealed six one-lb. containers of fresh strawberries. All six containers contained rotten and moldy berries and removing them from the cooler resulted in red liquid draining to the floor. The labels on the containers of strawberries indicated they had been received on 01/23/2023.<BR/>Interview on 01/31/2023 at 9:42 AM with the FSS confirmed the majority of the strawberries were rotten or had mold on them and were not fit for service. The FSS stated she hadn't had an opportunity to inspect them for quality and remove product that had gone bad. <BR/>3. Observation on 01/31/2023 at 10:03 AM revealed that the blade of the table-top can opener had a buildup of debris. The debris was black, brown and off-white in color. <BR/>Interview on 01/31/2023 at 10:03 AM with the FSS confirmed the presence of the buildup of debris on the can opener blade, and the FSS also noted there was rust on the blade. When asked who was responsible for cleaning the can opener blade, the FSS responded that it was on the cooks' list to clean daily, and that both she and the consultant dietitian do in-services on kitchen sanitation.<BR/>4. Observation on 02/02/2023 at 10:30 AM in the kitchen revealed a 3.5 lb. cardboard carton of mashed potato pearls on a shelf above the preparation table. The carton (similar to a cardboard milk carton) had been opened and was not properly sealed in a zip top bag or another similar enclosed container. The date written on the container was 01/25/2023.<BR/>Interview on 02/02/2023 at 10:30 AM with the FSS confirmed the carton of mashed potato pearls was not properly sealed. The FSS further stated it was important that food items be sealed to maintain product quality, prevent cross contamination and potential pest infestation.<BR/>Review of the facility's policy 03.003 Food Storage revised 06/01/2019, revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to state, Federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms. D. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators. d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. <BR/>Review of the facility's policy 04.009 Can Opener dated 10/01/2018, revealed: The facility will maintain can openers free of food particles and dirt to minimize the risk of food hazards. Can openers be cleaned after each use. Procedure: 1. Hand held or table top. A. Remove can opener shank from base. B. Wash shank in sink with warm water and detergent or in the dishwasher. C. Give close attention to the blade and moving parts. D. Rinse in clean, hot water. e. Sanitize with approved sanitizer. Follow manufacturer's instructions for immersion times. F. Air dry. G. Wash base of can opener with clean cloth soaked in warm water and detergent, removing all food particles and dirt. H. Rinse with clean cloth soaked in clear hot water.<BR/>Review of the facility's Daily Cleaning Schedule, Nutrition & Foodservice Policies & Procedures Manual, 2018, Section 4-8, revealed: Item: Can Opener. When: After Each use.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. Except as specified in paragraphs (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and: <BR/>(1) The day the original container is opened in the food establishment shall be counted as Day 1; and<BR/>(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as those which had not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay for 1 of 3 residents (Resident #1) reviewed for having their grievances heard. LVN A failed to generate a grievance report for Resident #1's Representative's grievance made on 10/20/2025 when Resident #1's representative complained that Resident #1 had blood on his linens as observed through a bedroom camera. LVN A failed to generate a grievance report for Resident #1's Representative's grievance made on 10/25/2025 at 6:05 AM when Resident #1's Representative complained that Resident #1 did not have the use of a bedside table. These failures could place residents at risk for demoralized spirits and low self-esteem. The findings included: A record review of Resident #1's admission record dated 11/4/2025 revealed an admission date of 4/11/2025 and a discharge date of 11/1/2025; with diagnoses which included dementia (a general term for a decline in cognitive function, affecting memory, thinking, and social abilities to the extent that it interferes with daily life.). review revealed Resident #1 was a [AGE] year-old male admitted for long term care with ADL needs for dementia. A record review of Resident #1's care plan dated 11/4/2025 revealed, (Resident #1) has an ADL self-care performance deficit related to dementia . Resident requires substantial / maximal assistance for personal hygiene. A record review of Resident #1's physicians orders dated 7/5/2025 revealed the physician ordered for Resident to receive care related to his indwelling urinary catheter twice a day and as needed. A record review of Resident #1's medication administration record for October 2025 revealed LVN A documented she provided urinary indwelling Catheter care on the evening of 10/20/2025. A record review of Resident #1's nursing progress notes dated 10/25/2025 at 6:05 AM, revealed LVN A documented, Note Text: resident's (representative) called upset wanting to know why did his bedside table get taken out of his room. wanted to know if we had put him off to eat on his own, I explained to her that her (resident #1) had eaten in the dining room that it was being borrowed it was not used for him.[sic] During an interview on 11/4/2025 at 11:00 AM Resident #1's Representative stated she was unsatisfied with the care provided for Resident #1. Resident #1's Representative stated she had made many grievances to the facility regarding Resident #1's care and gave 2 examples:1. On October 20th, 2025, she reviewed the evening video footage captured by the bedroom camera which revealed at 7:02 PM LVN A entered Resident #1's room and discovered Resident #1 was seated on his bedside. LVN A redirected Resident #1 back to bed and covered him with blankets. Resident #1's Representative stated she observed some blood to Resident #1's linens and blankets. Resident #1's Representative stated she called the facility sometime that evening approximately around 10:00 PM and spoke to LVN A and inquired about Resident #1's bleeding and complained about LVN A's care, specific for urinary indwelling catheter.2. Resident #1's Representative stated on 10/25/2025 at 6:00 AM she called the facility and spoke to LVN A and complained that Resident #1's bedside table was not at the bedside as observed with the in-room camera.Resident #1's Representative stated her grievances were not resolved.During an interview on 11/4/2025 at 5:50 PM LVN A stated she was a nurse for the facility and usually worked the 6:00 PM to 6:00 AM shift and had cared for Resident #1. LVN A stated Resident #1 was a [AGE] year-old male under hospice and facility care. LVN A stated Resident #1 had a need for a urinary indwelling catheter related to his enlarged prostate urinary retention. LVN A stated she was familiar with Resident #1's Representative who had a camera in the resident's' bedroom and often made complaints. LVN A stated she recalled sometime late last month, October 2025, Resident #1's representative called the facility late in the evening and complained she had reviewed the camera footage and saw some blood on the bed linens. LVN A stated she had rounded on Resident #1's several times that evening and redirected him back to bed when she would find him sitting on his bedside. LVN a stated Resident #1 had a history of tugging / pulling on his urinary indwelling catheter and had caused some bleeding. LVN A stated she had assessed Resident #1 without any bleeding to the urinary indwelling catheter and redirected him back to bed. LVN A stated Resident #1's Representative called the morning of 10/25/2025 and spoke with her to complain that Resident #1 was not in his room, and neither was his bedside table. LVN A speculated Resident #1's Representative believed Resident #1 was put aside and not cared for. LVN A stated she reported to Resident #1's Representative that Resident #1 was attending the breakfast service and his bedside table was moved temporarily. LVN A stated she had not documented Resident #1's complaints but had training to help residents and their representatives to generate a grievance report to have their grievances reviewed by the leadership and have their grievances resolved. During a joint interview on 11/05/2025 at 3:20 PM the Administrator and the DON stated the expectation for grievances was for staff who hear a grievance should assist the complainant to generate a grievance form and submit the grievance form to the Administrator and/ or the DON. The Administrator and DON stated LVN A had not generated a grievance form for Resident #1's Representative's complaints. The Administrator and the DON stated the potential negative outcomes for residents was their grievances may go unresolved. A record review of the facility's Resident and Family Grievances policy dated 10/4/2025 revealed, Policy: It is the policy of this facility to support each residents and family members right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their long term care facility stay. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to be free from misappropriation of resident property for 2 of 3 Residents (Resident #4 and Resident #5) whose records were reviewed for misappropriation of medications.<BR/>1. Nursing staff did not follow procedures when re-ordering Ativan for Resident #4; two Ativan tabs were unaccounted for after an exchange of a 30 day blister pack between MA G and LVN A .<BR/>2. MA G failed to sign off after administering Resident #5's scheduled Ativan 0.5 MG tab. <BR/>These deficient practices could affect residents prescribed controlled medications and could result in the misappropriation of resident's medications.<BR/>The findings were:<BR/>1. Review of Resident #4's face sheet, dated 2/14/25, revealed he was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Bipolar Disorder and Anxiety Disorder, Unspecified. <BR/>Review of Resident #4's quarterly MDS assessment, dated 12/0/24, revealed his BIMS score was 6 of 15 reflective of severe cognitive impairment and he had diagnoses of Anxiety, Depression and Bipolar and he received anti-anxiety and anti-depression medications.<BR/>Review of Resident #4's Care Plan, revised 10/18/24, revealed he was receiving anti-anxiety medications related to Anxiety. One of the interventions read: Administer ANTI-ANXIETY Ativan medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT.<BR/>Review of Resident #4's consolidated physician orders for April 2024 revealed he an order for Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth one time a day related to OTHER SPECIFIED ANXIETY DISORDERS. <BR/>Review of Resident #4's MAR for April 2024 revealed he received Ativan daily per physician orders.<BR/>Review of Provider Investigation Report, dated 4/30/24, read in part: Incident:<BR/>On April 23, 2024, at approximately 7:45 p.m. Administrator [name] was notified by Director of Nursing [name] that a blister pack of Ativan was not accurately accounted for in medication cart and when located at nurses' station two pills were missing from blister pack. Further review of the investigation revealed MA G and LVN A were both interviewed. MA G's interview read: Administrator and Treatment Nurse interviewed Certified Medication Aide G [name]. [name] MA G states that at approximately 9:30 a.m. on April 23, 2024, she gave her Charge Nurse, LVN A [name] a blister pack of Ativan for Resident #4 [name] with two pills in the blister pack. She states that she informed Charge Nurse that the resident had two pills left and needed to be re ordered. MA G [name] states that at 7:15 p.m. she began to count her cart with Charge Nurse, LVN H [name]. At this time LVN H [name] would not take over the cart because the blister pack of Ativan was missing from the cart. MA G [name] recalled giving the blister pack to LVN A [name] and it not being returned. Charge Nurse, LVN H, [name] began looking for it at the nurses station and it was located between a stack of papers. The blister pack was missing two pills and was empty. Charge Nurse, LVN H [name] immediately notified Director of Nursing [name]. LVN A interview read: Administrator and Treatment Nurse interviewed LVN A [name]. LVN A [name] states that at approximately 10 a.m.-12<BR/>p.m. MA G [name] brought her a blister pack of Ativan for Resident #4 [name]. LVN A [name] states that she reviewed the blister pack and it stated no refills. At that time she wrote a note to Dr. [name] to be faxed requesting refills. LVN A [name] states that when she looked at the blister pack there were no pills in the blister pack. LVN A [name] states that she put the blister pack with her fax and set it at nurses station. <BR/>Interview on 2/14/25 at 12:59 PM with MA G revealed she remembered the incident with the missing Ativan for Resident #4. She stated she pulled the card, blister pack, because she noticed there were only 2 tabs left. She took LVN A the card and let the nurse know there were only 2 tabs left. MA G stated LVN A took the card without question. MA G stated she knew she was not supposed to pull a narcotic card out of the cart under any circumstances unless another nurse verified the count with her prior to pulling it. She stated she wanted to show LVN A that she needed to re-order the Ativan for Resident #4. She stated she could have called her on the phone but did not. MA G stated she understood 2 tablets went missing and again stated she saw 2 tablets left in the Ativan card. MA G stated she did not take the 2 tablets. <BR/>Interview on 2/12/25 at 4:50 PM with the DON revealed she vaguely remembered the incident because it was after hours and the ADM took the lead with the investigation. She stated she understood 2 Ativan tabs were not accounted for Resident #4. She reiterated MA G pulled the card and gave it to LVN A. When the relieving nurse, LVN H, reported for shift, she noted the card was not in the cart and asked MA G about it. MA G reported she gave it to LVN A with 2 tabs left. The DON stated she called LVN A who reported it was at the nurses station with paperwork but stated the card had 2 remaining Ativan tabs. LVN A stated she called the PCP who reordered Resident #4's medications. Resident #4 did not miss any scheduled doses of Ativan. The DON stated the relieving LVN H found the card and it did not have the 2 tabs in question. The DON stated MA G should have never removed the card from the cart. She stated MA G should have let the nurse know Resident #4 needed a re-order for the Ativan. The DON stated checks and balances included: MA G and LVN H would sign off when all narcotics were administered from a blister pack. They would then remove the empty blister pack and they would give her the narcotic count sheet. The DON stated she would waste the card (empty blister pack) and count sheets were added to the Resident's hard chart and a copy was scanned and uploaded into the Resident's electronic Health Record. The DON stated ultimately, they were not able to determine what happened to the 2 missing Ativan tabs. She stated Resident #4 did not miss any Ativan doses.<BR/>Left VM for LVN A on 2/12/25 at 5:10 PM requesting she return the call. She did not return the call before the investigation was completed.<BR/>Left VM for LVN A on 2/13/25 at 2:13 PM requesting she return the call. She did not return the call before the investigation was completed.<BR/>Observation and interview on 2/14/25 at 9:17 AM revealed Resident #4 was lying in bed watching TV (volume very loud), eating chips. Resident #4 stated he had lived in the facility for about 2 years. He stated he received his medications regularly and had not missed any medications. <BR/>Interview on 2/14/25 at 4:34 PM with the ADM revealed she remembered the incident with the two missing Ativan tabs for Resident #4. The ADM stated she interviewed staff involved. She stated MA G pulled the Ativan card blister pack from the cart and took it to LVN A. MA G reported there were 2 tabs left in the card. During interview, LVN A stated when MA G handed her the card, she noted there were no tablets left in it. LVN A reported she noted there were no refills left so she called the doctor for a re-order. LVN A reported she left the empty card at the nurse's station. LVN H, who was scheduled for duty found the card at the nurse's station and it was empty. The ADM stated during interviews all the staff was upset and claimed they did not know what happened to the two tablets. The ADM stated they were not able to determine what happened to the two missing Ativan tablets. The ADM stated nursing staff should not have pulled the Ativan card before administering all the tablets. She stated there were processes in place for this reason, to avoid discrepancies, medication errors or diversion of medications.<BR/>2. Review of Resident #5's face sheet, dated 2/14/25, revealed he was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia and Anxiety Disorder. <BR/>Review of Resident #5's quarterly MDS, dated [DATE], revealed staff was not able to interview him to determine BIMS score; he had a diagnoses of Bipolar and Anxiety and was receiving anti-anxiety medication.<BR/>Review of Resident #5's Care Plan, revised on 12/16/24 read: he was receiving anti-anxiety medications related to Anxiety. One of the interventions read: Administer ANTI-ANXIETY Ativan medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT.<BR/>Review of Resident #5's consolidated physician orders revealed an order: Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth two times a day for ANXIETY.<BR/>Review of Resident #5's MAR for February 2025 revealed he received Ativan per physician orders.<BR/>Observation and interview of MA G counting controlled medications on 2/14/25 at 1:10 PM revealed MA G pulled Resident #5's Ativan card. She compared it to the narcotic count sheet and the count was correct. However, there was no signature of the person who administered the medication. MA G stated she administered the Ativan to Resident #5 but she did not sign off when she administered it on 2/14/25 during the 9:00 AM medication pass. MA G stated it was important that she follow processes to prevent discrepancies which could lead to medication errors or diversion of medications. She stated she meant to sign off on it but was distracted and forgot. <BR/>Interview on 2/14/25 at 1:16 PM with the DON revealed anytime nursing staff did not follow processes when administering medications it could cause a medication error, discrepancy and or diversion of medications. If given incorrectly it could cause a resident to have a decline in condition. The DON stated it was important to pay attention and for staff to follow the processes per facility policy.<BR/>Review of facility policy, Medication Administration, dated 10/24/22, read in relevant part: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 14. Administer medication as ordered in accordance with manufacturer specifications. 17. Sign MAR after administered. 18. If medication is a controlled substance, sign narcotic book.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment, and written standards, policies, and procedures for the program, which must include, but are not limited to: . (ii) When and to whom possible incidents of communicable disease or infections should be reported, for 1 of 1 facility reviewed for infection control, in that:<BR/>The facility failed to have written standards that include when and to whom possible incidents of communicable disease or infection should be reported.<BR/>These failures could place residents at risk of a delay in identification of infectious outbreaks and lack of timely follow-up on recommended interventions to prevent harm, or impairment.<BR/>The findings included:<BR/>1. Record review of Resident #2's face sheet, dated 2/11/25 revealed a 94 -year-old female admitted [DATE] with diagnoses that included: UNSPECIFIED DEMENTIA, ENCEPHALOPATHY (enlargement of the brain), UNSPECIFIED MACULAR DEGENERATION (blindness over time), and GLAUCOMA (eye damage).<BR/>Record review of Resident #2's most recent quarterly MDS assessment, dated 11/13/24 revealed,<BR/>the resident's BIMS score was zero (severely cognitively impaired) and required limited assistance with mobility and transfers.<BR/>Record review of Resident #2's Order Summary Report, dated 12/13/24 revealed the following:<BR/>- Enhanced Barrier Precautions - PPE: Gloves/Gown during high-contact resident care activities<BR/>every shift with order <BR/>- Skin Scraping Test one time only to rule out scabies for one day, with order date 12/13/24. <BR/>-biopsy 12/16/24 one positive for scabies<BR/>- Ivermectin Oral Tablet 3 MG, give 3 mg tablet by mouth one time only for scabies for 1 day,<BR/>with order date 12/24/24 and 12/31/24.<BR/>-permethrin 5% cream two doses 12/20/24 and 12/27/24<BR/>Record review of Resident #2's microbiology report dated 12/16/24 revealed the resident was positive for scabies.<BR/>Record review of Resident #2's comprehensive care plan dated 12/13/24 revealed the resident had a rash to the torso and was prescribed Triamcinolone Acetonide Cream 0.5 %. <BR/>2. Record review of Resident #3's face sheet, dated 2/11/25 revealed a 94 -year-old female admitted to the facility on [DATE] with diagnoses that included: UNSPECIFIED DEMENTIA, RIGHT FEMALE BREAST CANCER, and MAJOR DEPRESSION.<BR/>Record review of Resident #3's most recent quarterly MDS assessment, dated 12/26/24 revealed,<BR/>the resident's BIMS score was 3, which indicated she was severely cognitively impaired and required extensive assistance with mobility and transfers.<BR/>Record review of Resident #3's Order Summary Report, dated 1/3/25 revealed the following:<BR/>- Enhanced Barrier Precautions - PPE: Gloves/Gown during high-contact resident care activities<BR/>every shift with order <BR/>- Skin Scraping Test one time only to rule out scabies for one day, with order date 1/2/25<BR/>- permethrin 5% cream two doses 1/3/25<BR/>Record review of Resident #3's microbiology report dated 1/2/25 revealed the resident was positive for scabies.<BR/>Record review of Resident #3's comprehensive care plan dated 1/2/25 revealed the resident had Scabies and was prescribed permethrin 5% cream two doses.<BR/>During an interview on 2/11/25 at 11:46 AM, the DON (IC Preventionist) stated: the outbreak started with Resident #2 on December 16, 2024, and subsequent infection of Resident #3 was January 2, 2025 (end of scabies outbreak). The DON stated no other resident tested positive. The DON stated the treatment given for Resident #2 on 12/19/24 was permethrin 5 % cream one application neck to toe and second application one week later. DON stated the treatment for Resident #3 was permethrin 5 % cream one application neck to toe. The DON stated the spread was contained by skin assessments for all residents. The DON stated the physician orders were given for prophylactic treatment of Hall 200 and 400. The DON stated all linen in Halls 200 and 400 were removed and replaced and washed, and deep cleaning in every room was conducted by housekeeping. The DON stated that 100% training on infection control and scabies was given to the staff from the time 12/16/24-01/2/25. The DON stated that the RP/family and MD were notified for the residents that tested positive for scabies. The DON stated that scabies was not a reportable event to the local health department. The DON stated that no staff presented with positive scrapings for scabies, but staff could have received prophylactic treatment in the community during the outbreak. The DON stated that the positive residents were placed in isolation. The DON stated that no self-report to HHS was made about the scabies outbreak. The DON stated that the facility did not know the source of the scabies.<BR/>During an interview on 2/11/25 at 4:11 PM, LVN A stated she worked with Resident #3 since the resident was admitted . LVN A stated that the resident had dementia with no behaviors exhibited and nursing care involved medication administration and ADL services. Also, LVN A stated nursing care involved weekly skin assessments and daily observation of skin integrity. LVN A stated scabies was a mite that got under the skin and was contagious and formed skin clusters LVN A stated that Resident #3 had scabies and treatment involved cream and an PO (by mouth) medication. The LVN stated the MD and RP were notified. LVN A stated that HHS should have been notified because scabies was a parasite, and it could spread to other residents and cause an infection. <BR/>During an interview on 2/12/25 at 8:56 AM, LVN B stated: she did not know the source of the scabies in December 2024 and January 2025. LVN B stated the interventions put in place included: treatment for Resident #2 and Resident #3; handwashing, PPE (contact isolation), and in-service for all staff on scabies. LVN B stated the outbreak ended around 1/3/25. LVN B state preventative measures put in place were continued education on IC for staff and residents, and weekly skin assessments. LVN B stated at the time of the outbreak RPs, MD C, and families were notified of the outbreak; but did not know whether HHS was notified. LVN B stated that Resident #2 had a rash, and MD C was making rounds and assessed the rash and ordered the skin scraping which was negative. The resident had a second appointment with MD C and a procedure (biopsy) which revealed one site (middle back) positive for scabies and the other site was negative (upper middle). Regarding Resident #3, LVN B stated that her family was changing the resident and noticed a few spots on the resident's abdomen area and informed the charge nurse. LVN B stated that Resident #3 was sent out for a medical appointment the same day with MD D and skin scraping was done which revealed a positive result for scabies. LVN B was not sure about reporting requirements to HHS.<BR/>During an interview on 2/12/25 at 10:08 AM, the Housekeeping Supervisor stated: housekeeping did deep cleaning of halls 200 and 400 in the months of December 2024 and January 2025 because there were cases of scabies. The Housekeeping Supervisor stated that deep cleaning involved: clothing out of closets was washed, curtains and bed linen were washed, and surface cleaning with DC-33 (disinfectant) done in the residents' rooms. <BR/>During a telephone interview on 2/12/25 at 10:20 AM, MD E stated: there was an outbreak of scabies in the facility that started December 2024 and ended in January 2025. MD E stated the source of the scabies was likely a visitor or a staff member that brought the scabies into the facility. MD E stated that he treated the infected residents (Resident #2 and #3) with permethrin 5% cream and/or Ivermectin Oral Tablet. MD E stated that the facility put in place preventative measures which included: contact precautions, monitoring, and skin assessments. <BR/>During an interview on 2/12/25 at 11:20 AM, the Administrator stated: the timeline of confirmed cases of scabies was 12/19/24 to 1/2/25. The Administrator stated there had been no other confirmed cases based on scrapings after 1/3/25. The Administrator stated that preventative measures included: education, employees to fill out incident reports if they had scabies, IC training, Plan of Correction to capture rash and skin issues, proper IC measures and rooms were cleaned. The Administrator stated that she could not determine the source of the scabies. The Administrator stated that another preventative measure for residents was prophylactic treatment for residents in hall 200 and 400; and the halls were deep cleaned. In December 2024 and January 2025. The Administrator stated that the outbreak was reported to the MD (C), RP, and residents and families. The Administrator stated the outbreak was not reported to the local health department because it was not a reportable event. The Administrator stated the outbreak was not reported to HHS because it was not a self-report, and the source was not known. <BR/>Observation and interview on 2/11/25 at 4:30 PM, Resident #3 was sitting in a wheelchair in the dining room alert and not oriented. There were no signs of skin tears, bruises, or injury. The resident revealed no signs of itching or a rash. The resident stated that she did not want an interview with the surveyor. <BR/>Observation and interview on 2/11/25 at 4:40 PM, Resident #2 was in the secured unit. The resident was ambulatory with visual impairment. The Resident had no skin tears, bruises, or injuries present. The resident was not itching or scratching and did not have a rash. The resident stated that she received the care needed and had no complaints about care. The resident stated she could not remember having scabies. The resident stated she was not itching. <BR/>Record review of the facility's policy and procedure titled, Infection Prevention program dated 5/13/23, revealed in part, This facility has established and maintains 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 as per accepted national standards and guidelines . [Policy did not address reporting communicable diseases to HHSC.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 residents (Resident #52) whose assessments were reviewed, in that:<BR/>Resident #52's quarterly MDS assessment incorrectly documented the resident as having received an insulin injection.<BR/>This failure could place residents at risk for inadequate care due to inaccurate assessments. <BR/>The findings were:<BR/>Record review of Resident #52's face sheet, dated 05/28/2025, revealed an admission date of 11/20/2019 with diagnoses including: Dementia (progressive cognitive decline, affecting thinking, memory, and reasoning, impacting daily life), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (elevated level of any or all fat in the blood), and anxiety disorder (a group of mental illnesses that cause constant fear and worry).<BR/>Record review of Resident #52's Physician orders and Medication administration records for March 2025 revealed an order for: Trulicity Solution Pen-injector 0.75 MG/0.5ML (Dulaglutide) Inject 0.75 mg subcutaneously one time a day every Thu related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. There was no order for insulin or record of insulin administration.<BR/>Record review of Resident #52's Significant Change MDS, dated [DATE], revealed a BIMS score of 09, indicating moderate cognitive impairment. The assessment further indicated in Section N0300. Injections, A. Insulin injections, Resident #52 received one insulin injection during the previous seven days. <BR/>During an interview on 05/29/2025 at 3:13 PM, the MDS LVN and the Regional Care Manager both stated they were unaware the medication Trulicity was not considered insulin since it was an injectable medication, and Resident #52's MDS dated [DATE] was incorrectly coded as the resident having received insulin. <BR/>During an interview on 05/30/2025 at 12:30 PM, the Administrator stated Resident #52's Significant Change MDS dated [DATE] was incorrectly marked as the resident having received insulin when the resident received the medication Trulicity, which was not insulin. The entire nursing staff was unaware of the properties of this medication and would be subsequently trained on the difference between this medication and insulin. The facility used the RAI manual in lieu of a separate policy on coding MDS.<BR/>Record review of Trulicity fact sheet, accessed on 06/05/2025, revealed, Trulicity is a non-insulin option that helps your body release the insulin it's already making. <BR/>Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.11, October 2024 revealed, N0350: Insulin. 1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Determine if the resident received insulin injections during the look-back period. 3. Determine if the physician (or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) changed the resident's insulin orders during the look-back period. 4. Count the number of days insulin injections were received and/or insulin orders changed. Coding Instructions for N0350A <BR/>o Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 resident (Resident #63) reviewed for incontinent care, in that: <BR/> While providing incontinent care for Resident #63, CNA B used a back to front motion to clean Resident #63's buttocks. <BR/>This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. <BR/>The findings were:<BR/>Record review of Resident #63's face sheet, dated 05/30/2025, revealed an admission date of 04/17/2023, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension (High blood pressure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure).<BR/>Record review of Resident #'63's Significant change MDS, dated [DATE], revealed the resident had a BIMS score of 12 indicating moderate impairment. Resident #63 required limited to extensive assistance and was frequently incontinent of bladder and bowel. <BR/>Review of Resident #63''s care plan, dated 05/01/2023, revealed a problem of has occasional bladder incontinence r/t not making it in time and dx of BPH. Uses a urinal at times but will not keep it in a bag. and an intervention of Clean peri-area with each incontinence episode.<BR/>Observation on 05/29/2025 at 2:30 p.m. revealed while providing incontinent care for Resident #63, CNA B wiped Resident #63's buttocks in a back to front motion.<BR/>During an interview on 05/29/2025 at 2:40 p.m. with CNA B, she confirmed she had wiped Resident #63's buttocks in a back to front motion She said she thought she was using the correct technique. She confirmed receiving training on incontinent care from the facility. <BR/>During an interview with the DON on 05/29/2025 at 3:00 p.m., she confirmed the correct motion to clean the residents during perineal care was front to back to prevent fecal matter from contacting the urethra and possibly cause an infection. The DON revealed the staff received training on infection control and incontinent care at least annually. The staff skills were checked yearly. The DON and ADON spot check the staff while they provided care for infection control and quality of care. <BR/>Review of annual skills check for CNA B revealed CNA B passed competency for Perineal care/incontinent care on 03/06/2025. <BR/>Review of facility policy, titled Incontinent care skills checklist, undated, revealed Wash from front to towards rectum, front to back, using clean stroke [ .] cleanse the entire buttock area and surrounding hip area.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: <BR/>1. There were seven one-gallon containers of milk that had been opened and were without labels indicating the dates opened.<BR/>2. There were six one-lb. containers of strawberries that all contained rotten and moldy berries.<BR/>3. There was rust and debris on the table-top can opener.<BR/>4. There was a carton of mashed potato pearls that had been opened and was not properly sealed.<BR/>These deficient practices could place residents who ate food from the kitchen at risk for food borne illness.<BR/>The findings included:<BR/>1. Observation on 01/31/2023 at 9:30 AM in the cooler used to store milk revealed seven one-gallon containers of milk. Six of the gallons were whole milk, of which 2 had a best by date of 2/02/23, two had a best by date of 2/09/2023 and two had a best by date of 2/14/2023. One gallon was 2% milk with a best by date of 2/01/2023. All seven gallons of milk had been opened and were &frac12; to &frac34; full. There was no date on any of the containers of milk indicating the date they were opened.<BR/>Interview on 01/31/2023 at 9:33 AM with the FSS revealed all the milk had been received the previous day (Monday, 01/30/2023) because that was when they received their milk delivery. The FSS confirmed there were no dates indicating when the milk containers had been opened. When asked why several containers of the same product had been opened and were partially full, the FSS said sometimes nursing staff came in and grabbed a new container without seeing that one had already been opened. The FSS stated she knew it was important to indicate the date on the containers that the milk was opened regardless of the best by date because the milk started to deteriorate from that time. The FSS further stated that whoever opened the milk was responsible for dating it, and all dietary employees were trained on that during orientation and throughout the year. <BR/>2. Observation on 01/31/2023 at 9:40 AM of the reach-in produce cooler revealed six one-lb. containers of fresh strawberries. All six containers contained rotten and moldy berries and removing them from the cooler resulted in red liquid draining to the floor. The labels on the containers of strawberries indicated they had been received on 01/23/2023.<BR/>Interview on 01/31/2023 at 9:42 AM with the FSS confirmed the majority of the strawberries were rotten or had mold on them and were not fit for service. The FSS stated she hadn't had an opportunity to inspect them for quality and remove product that had gone bad. <BR/>3. Observation on 01/31/2023 at 10:03 AM revealed that the blade of the table-top can opener had a buildup of debris. The debris was black, brown and off-white in color. <BR/>Interview on 01/31/2023 at 10:03 AM with the FSS confirmed the presence of the buildup of debris on the can opener blade, and the FSS also noted there was rust on the blade. When asked who was responsible for cleaning the can opener blade, the FSS responded that it was on the cooks' list to clean daily, and that both she and the consultant dietitian do in-services on kitchen sanitation.<BR/>4. Observation on 02/02/2023 at 10:30 AM in the kitchen revealed a 3.5 lb. cardboard carton of mashed potato pearls on a shelf above the preparation table. The carton (similar to a cardboard milk carton) had been opened and was not properly sealed in a zip top bag or another similar enclosed container. The date written on the container was 01/25/2023.<BR/>Interview on 02/02/2023 at 10:30 AM with the FSS confirmed the carton of mashed potato pearls was not properly sealed. The FSS further stated it was important that food items be sealed to maintain product quality, prevent cross contamination and potential pest infestation.<BR/>Review of the facility's policy 03.003 Food Storage revised 06/01/2019, revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to state, Federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms. D. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators. d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. <BR/>Review of the facility's policy 04.009 Can Opener dated 10/01/2018, revealed: The facility will maintain can openers free of food particles and dirt to minimize the risk of food hazards. Can openers be cleaned after each use. Procedure: 1. Hand held or table top. A. Remove can opener shank from base. B. Wash shank in sink with warm water and detergent or in the dishwasher. C. Give close attention to the blade and moving parts. D. Rinse in clean, hot water. e. Sanitize with approved sanitizer. Follow manufacturer's instructions for immersion times. F. Air dry. G. Wash base of can opener with clean cloth soaked in warm water and detergent, removing all food particles and dirt. H. Rinse with clean cloth soaked in clear hot water.<BR/>Review of the facility's Daily Cleaning Schedule, Nutrition & Foodservice Policies & Procedures Manual, 2018, Section 4-8, revealed: Item: Can Opener. When: After Each use.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. Except as specified in paragraphs (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and: <BR/>(1) The day the original container is opened in the food establishment shall be counted as Day 1; and<BR/>(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #1) of 8 residents reviewed, in that:<BR/>The facility failed to ensure the thermometer inside Resident #1's personal refrigerator was functioning properly and the staff recorded the accurate temperatures of the refrigerator for five months.<BR/>This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled. <BR/>The findings included: <BR/>Record review of Resident #1's face sheet, dated 05/27/2025, reflected the resident was a [AGE] year-old female and was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: Alzheimer's disease (the most common type of dementia, a progressive brain disorder that damages memory, thinking, and other cognitive abilities), dementia (a decline in mental abilities severe enough to interfere with daily life, and it is caused by damage to the brain), hypertension (high blood pressure), and depression (a persistent feeling of sadness, loss of interest, and changes in thinking, sleeping, eating, and acting). <BR/>Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident's BIMS score was 08 out of 15, indicating moderately impaired cognition. The resident required supervision or touching assistance with eating (helper provided verbal cues or touching/steadying assistance as resident completed activity).<BR/>Observation on 05/27/2025 at 2:30 PM revealed Resident #1 was sitting in her wheelchair in her room. The resident had a personal refrigerator, and inside the refrigerator was an analogue thermometer. The interior temperature of the refrigerator according to the thermometer was 26 degrees F. Further observation inside the refrigerator revealed an open can of soda approximately half-full. Shaking the can revealed the soda was not frozen, indicating the thermometer was not accurate. <BR/>Record review of the temperature log attached to the side of the refrigerator revealed temperatures taken for the months of January through May 2025. The temperatures ranged from 32 - 12 degrees F in January, 26 - 22 degrees F in February, 32 - 18 degrees F in March, 20 - 12 degrees F in April and 34 -12 degrees F in May 2025. <BR/>During an interview on 05/27/2025 at 2:35 PM, LVN E stated Housekeeping was responsible for recording the temperatures of the refrigerator on the temperature log.<BR/>During an interview on 05/27/2025 at 2:40 PM, the DON stated the thermometer inside Resident #1's read 26 degrees F, indicating it was not working properly, as the contents of the refrigerator were not frozen. The Housekeeping staff recorded the temperatures of this thermometer on a Temperature log placed in a document protector and posted on the left side of the refrigerator from January - May 2025 without noting the thermometer was broken and failed to bring the situation to the attention of nursing staff. She would ensure a new thermometer was placed in the refrigerator.<BR/>Observation on 05/27/2025 at 3:30 PM inside Resident #1's refrigerator revealed the new analogue thermometer read 40 degrees F, indicating the previous thermometer was broken and the refrigerator was functioning properly.<BR/>During an interview on 05/27/2025 at 3:20 PM, the Housekeeping Director and Administrator stated they understood the thermometer in Resident #1's facility was not functioning properly and had not been for several months. The facility's policy needed to be clearer, as it stated at the top of the temperature log form Resident Room or nourishment refrigerators should have temperatures 40 degrees F or lower. Housekeeping staff needed education on the proper range for refrigerator temperatures.<BR/>Record review of https://www.kitchenaid.com/pinch-of-help/major-appliances/refrigerator-temperature.html<BR/>accessed on 06/05/2025 revealed, .the ideal refrigerator temperature is around 37&deg;F (3&deg;C). That said, a range of 33-40&deg;F (0-4&deg;C) is typically considered safe for most purposes. Temperatures that fall below 33&deg;F can freeze foods while temperatures above 40&deg;F may contribute to food spoilage.<BR/>Record review of facility policy 02.005 Potluck Meals and Foods from Home approved 10/18/2018 revealed, Policy: Residents have a right to participate in potluck events and consume foods brought into the facility from outside sources. The facility will provide the resident and family education on the basics of food safety and the use and storage of food to ensure safe consumption. 2. The facility must ensure safe food handling techniques once the food is brought into the facility including safe reheating to 165 degrees for 15 seconds, holding cold items &lt;41 degrees .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 4 residents (Resident #1) reviewed for notification of changes, in that:<BR/>Resident #1 developed new wounds on 08/01/24 and the resident representative (RP) was not informed until 08/02/24 by facility staff. <BR/>This failure could lead to the facility making decisions without the resident's right to designate a surrogate or representative to make treatment or transfer decisions for the resident; and could deny the resident through the resident representative their wishes and preferences.<BR/>The findings included:<BR/>Record review of Resident #1's face sheet, dated 8/13/24, male age [AGE], reflected, the resident was admitted on [DATE] and discharge 8/2/24 to home with diagnoses that included: POSTCHOLECYSTECTOMY SYNDROME (removal of the gall bladder at admissions); CALCULUS OF KIDNEY WITH CALCULUS OF URETER (kidney stone), TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING LEFT NON-DOMINANT SIDE [from history of stroke], PERIPHERAL VASCULAR DISEASE, UNSPECIFIED [poor blood circulation], COLOSTOMY STATUS, UNSPECIFIED OSTEOARTHRITIS [weak bones]. RP (responsible party) was listed as: a family member. <BR/>Record review of Resident #1's Significant Change (weight loss) MDS (minimum data set), dated 7/30/24, reflected: A BIMS (brief interview of mental status) Score was 8 meaning (moderate impairment); and the ADLs (activities of daily living) reflected : B/B (bowel and bladder)- and Resident #1 had a colostomy and was incontinent for urine. Transfer was mechanical lift for Resident #1. Bed Mobility was total assist and the ROM (range of motion) was total; to upper and lower.<BR/>Record review of Resident #1's CP (care plan), undated, reflected: Resident#1 had the potential for pressure ulcer development related to immobility and history of CVA (cerebrovascular accident) Hemiplegia, and Hemiparesis (stroke). Resident #1 has the potential for pressure ulcer development related to Immobility: and a history of CVA Hemiplegia, and Hemiparesis (stroke). <BR/>Record review of Resident #1's Wound Physician Assessments, dated below, reflected:<BR/>7/8/24: Right Second Toe: measurements: 7 (L) X 7 (W) X 0.1 (D).<BR/>7/25/24: Right Second Toe: measurements: .6X 6X.1. Left lateral leg 4X4X no depth (dead tissue).<BR/>8/1/24: Right second Toe: measurements .6X.6X Depth (not measurable) (dead tissue and narcosis) Left lateral measurements:4X4X (Depth) not measurable Buttocks 4.5X2.5X0.1 Right heel 3.5X3.0XDepth (not measurable) (necrosis). <BR/>During an interview on 8/13/24 at 10:29 AM, LVN A stated: on 8/1/24 the Wound Care Specialist identified left buttocks (8/1/24) wound, left lateral leg (7/25/24) wound and right second toe (7/18/24). LVN A stated the resident was not admitted with any wounds. LVN A stated that the wounds developed because of Resident's diabetes, stroke, and poor blood circulation. Resident could not move his left lateral leg (side of stroke). LVN A stated the wounds were All arterial wounds. LVN A stated the wounds were unavoidable because of the resident's comorbidities and declining health. LVN A stated the resident did not want to be in the nursing home and refused to eat. LVN A stated that PT (physical therapy), SP (speech therapy) and OT (occupational therapy) were all working with the resident to encourage eating, strength building, and mobility. LVN A stated that she had no information as to whether the RP was notified on 08/01/24 when Resident #1 was found to have developed new wounds. <BR/>During an interview on 6/13/24 at 1:19 PM, LVN B stated: the resident (Resident #1) was developing wounds due to not eating, poor vascular circulation, diabetes, dementia, and refused care (not wanting to leave his bed) LVN B stated she kept the RP verbally informed but may not have documented the 8/1/24 communications with the RP. LVN B stated that RP was informed on 7/25/24 about the new arterial left lateral leg wound. LVN B stated she did not know the reason the RP wanted to discharge the resident home. <BR/>During an interview on 8/13/24 at 1:41 PM, NA C stated: she provided bed baths to the resident (Resident #1) in the month of July 2024. NA C stated that part of giving a bed bath was documenting any wounds in the POC (point of care used by nurse aides to document activities of daily living)). NA C stated that she saw a wound on the Resident #1's buttocks and on his leg in July 2024. NA C stated, I did not know I had to tell the nurse about the wounds I saw except to document in POC. NA C stated that she often saw the RP present in the resident's room. NA C stated that as part of HIPAA she did not communicate to the RP about the wounds she saw. <BR/>During an interview on 8/13/24 at 1:55 PM, LVN D stated: she provided nursing care to Resident #1 which included: medication administration, monitoring, vital signs and assessments every day, and coordination of care. LVN D stated that the RP was present almost every day. LVN D stated she kept the RP informed about the resident's refusal not to eat and the loss of weight and the interventions attempted by the physician. LVN D stated that the verbal communications about the Resident's wounds were not documented. LVN stated that it (new wounds) needed to be documented otherwise it didn't happen. <BR/>During an interview on 8/13/24 at 2:19 PM, the DON stated: Resident #1 refused to eat, and interventions included: referral to SP, weekly weights, getting the RP involved, orders for ensure (supplement) and milkshakes. The DON stated that Resident #1 developed wounds after 30 days not eating and not wanting to get out of bed. The DON stated that the RP had been informed about the resident's decline on 7/25/24 and that the resident would accrue more wounds. The DON stated that the new wounds assessed by the Wound Care Specialist on 8/1/24, she stated she needed to check to determine whether the RP was informed on 8/1/14. <BR/>During a telephone interview on 8/13/24 at 2:57 PM, the RP stated that the facility never told her about the new wounds identified by the wound physician on 8/1/24. The RP stated the wounds were totally new and the staff never told me. The RP stated that during a mechanical lift on 7/30/24 she noticed the buttock wound. <BR/>During a telephone interview on 8/13/24 at 3:05 PM, the Wound Care Specialist stated: the resident (Resident #1) loss weight because he did not want to eat. Interventions were attempted to include IV fluids. The Wound Care Specialist. The Wound Care Specialist The Wound Care Specialist. The Wound Care Specialist, The Wound Care Specialist stated: the resident developed wounds because or arterial vascular issues, co-morbidities, and did not want to leave his bed. The Wound Care Specialist. The Wound Care Specialist stated: that his belief was that the RP was kept informed about the resident's refusal to eat and worsening condition. <BR/>During observation and interview on 8/14/24 at 8:30 AM, reflected Resident #1 was in bed in a community rehabilitation hospital. Observation revealed the resident was alert and oriented to person, place and time. The resident received by IV an antibiotic (daptomycin 500 mg); and right toe was bandaged, and there was a pressure release boot on the left leg. Resident #1 stated that the care at the nursing home was not good [but provided no specifics]. The resident stated he lost weight at the nursing home because he did not like the food and stopped eating for 30 days. The resident stated the facility offered him milkshakes and appetite stimulants and alternate diets; but he did not want to eat. The resident stated he developed wounds in the nursing home but did not know the cause of the wounds. The resident stated that he preferred to stay in bed and had a wound to his buttocks which caused him to want to be in bed. The Resident stated the facility made efforts to move him out of bed; and he did not remember about staff re-positioning him. The resident stated his right toe was amputated and he had a history of diabetes. Resident #1 stated his plan was to return home after the current hospital and rehab stays. When asked about the RP being kept informed about changes in his medical condition, Resident #1 stated: I do not think so . they were not notifying my (RP) as my condition was worsening. <BR/>Record review of facility's Resident Rights policy dated 10/24/22 reflected: .The facility will periodically assess the resident for decision making abilities and approach the health care proxy or legal representative if the resident is determined not to make decision making capacities. <BR/>After exit on 8/14/24, the facility provided by email Resident #1's Weekly Wound Progress Note authored by LVN B which reflected resident developed new wounds on 08/01/2024 and the RP was notified on 08/02/2024 00:00 (midnight).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents' right to be free from abuse for one (Resident #1) of 7 residents reviewed for abuse. <BR/>The facility failed to prevent Resident #1 from being abused when a rubber band was discovered wrapped 4-5 times around the shaft of his penis on 6/07/2024 at approximately 2:00 AM. <BR/>The non-compliance was identified as past non-compliance (PNC). The PNC IJ began on 06/07/24 and ended on 06/08/24. The facility had corrected the non-compliance before the state's investigation began on 6/08/2024 8:00 AM. <BR/>This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.<BR/>The findings included:<BR/>Record review of the admission Record, dated 6/09/2024, reflected Resident #1 was a [AGE] year-old male originally admitted on [DATE].<BR/>Record review of the quarterly MDS assessment, dated 3/27/2024, reflected Resident #1 had a BIMS summary score of 3, indicative of severe cognitive impairment. Under section E - Behavior, Resident #1 was documented with a lack of behavioral symptoms: did not exhibit the behavior of rejection of care; did not exhibit physical behavioral symptoms directed toward others. Under section GG - Functional Abilities and Goals, Resident #1 was documented as impairment on one side of both upper and lower extremities; Resident #1 routinely used a wheelchair for mobility; Resident #1 was coded as dependent for eating, oral hygiene, toileting hygiene, shower/bathe self. Resident #1 was coded as dependent in the following activities: lower body dressing, putting on/taking off footwear, personal hygiene, sit to lying transition, lying to sitting on one side transition, chair/bed-to-chair transfer. Resident #1 was coded as dependent in the following activities: wheel 50 feet with two turns, wheel 150 feet. Under section H - Bladder and Bowel, Resident #1 was coded as always incontinent of bowel and bladder and was not utilizing a toileting program to manage continence. Resident #1's primary medical condition category that best described the primary reason for admission was coded as medically complex conditions related to unspecified dementia without behavioral disturbance. Other active diagnoses included diabetes mellitus, hemiplegia or hemiparesis [weakness to one side of the body], seizure disorder or epilepsy, contractures [permanent tightening of the muscles, tendons, skin and surrounding tissues that causes the joints to shorten and stiffen] : right hand, left and right knee, left and right hip, and right elbow. Resident #1 was coded as unable to answer, Have you had pain or hurting at any time in the last 5 days? Under section M - skin conditions, Resident #1 had a clinical assessment that determined he was a risk of developing pressure ulcers/injuries. <BR/>Record review of the Care Plan reflected Resident #1 had a focus area of [Resident #1] was subjected to allegations of abuse as evidenced by a rubber band found wrapped around penis with a date initiated of 6/07/2024, and a revision on 6/08/2024. Interventions included the following: administer clobetasol [potent corticosteroid topical treatment for inflammation and pain] and solumedrol [intramuscular corticosteroid that reduces inflammation, pain, swelling, redness, heat]; apply ice packs; monitor and provide patient with as needed pain medication; monitor for swelling and follow orders; monitor penis for change in condition; monitor for urinary output; notify the medical doctor of any further complications/new developments of adverse effects. Further focus areas included: [Resident #1] was passive and receives one-on-one visits . with a revision on 1/25/2022; [Resident #1] had an ADL self-care performance deficit related to .confusion, hemiplegia . with a revision date of 4/20/2021. Interventions included the following: totally dependent on staff to provide shower and or bed bath; totally dependent on staff for repositioning and turning in bed; totally dependent on staff for dressing; extensive to total assistance by staff to eat; totally dependent on staff for personal hygiene and oral care; incontinent of bowel and bladder causing Resident #1 to be totally dependent on staff for toilet use; required mechanical Hoyer lift with 2 staff for transfers. Additional focus areas, [Resident #1] had limited physical mobility related to contractures and stroke, with a revision date of 3/29/2024. [Resident #1] had a history of stroke affecting cognition, communication ability and right sided hemiplegia with a revision date of 11/07/2018. [Resident #1] had bowel/bladder incontinence related to cognitive impairment diagnosis of dementia with a revision date of 4/20/2021. Interventions included the following: use disposable briefs, change every 2 hours, and as needed; check every 2 hours and as required for incontinence. <BR/>Record review of the Nurses Note, authored by RN D dated 6/07/2024 at 3:21 AM reflected, called to Residents Room by [CNA B]; found resident with rubber band wrapped around shaft of penis 4 to 5 times. Thick rubber band constricting resident from urinating .unable to remove rubber band by hand; had to use scissors to cut [rubber band] off; upon release resident started urinating large amount of urine . Resident #1's responsible party was left a message regarding the incident. NP I was notified as she was on-call for MD H. Resident #1 was administered 1000 milligrams of Tylenol [a medication used to treat fever, pain and inflammation]. <BR/>Record review of Nurses Note, authored by RN C late entry for 6/7/2024 at 2:00 AM reflected, initiation of incident report and notification of the abuse coordinator. RN C reassessed Resident #1 an hour after initial incident and noted no signs or symptoms of discomfort and penis noted to not be as swollen. RN C documented urination and bowel movement between discovery of the incident and the reassessment at 3:00 AM. <BR/>In an observation on 6/08/2024 at 9:40 AM, revealed Resident #1 was lying supine in bed, with the head of bed elevated 30-45 degrees, with the linens pulled up to axillae [arm pit]. Resident #1 had his eyes open but did not respond to verbal stimuli. Resident #1 did not maintain eye contact or tract movement with his eyes. Resident #1 appeared awake but was not responsive to the surveyor. He exhibited slow deep breaths, and a relaxed body and facial expression with no overt signs of distress. <BR/>In an interview on 6/08/2024 at 11:00 AM, NA A stated she was the staff member responsible for providing care to Resident #1 on the 6A-6P shift on Thursday 6/06/2024. NA A stated she had been working at the facility for almost 6 months so far. NA A stated she had no other interventions she knew of to make caring for Resident #1 easier. NA A stated that Resident #1 was easy to care for; he was incontinent of bowel and bladder; and could not really converse, he would just repeat back what he heard [echolalia]. NA A stated she was new and had not yet learned how to document in the electronic health record, so that other staff would enter her tasks as completed for her. NA A stated she had provided him a shower after lunch but was unsure of the time. NA A stated that during the shower Resident #1 was incontinent of bowel and bladder. NA A stated at that time there was no rubber band around his penis. NA A stated she did not know how the rubber band got around Resident #1's penis. NA A stated she did not believe that Resident #1 would be able to do that himself. NA A stated that after showering Resident #1, she had an in-service that took approximately half an hour and then she had her 30-minute lunch break at 2:40 PM. Upon returning from lunch [approximately 3:15 PM], it was then time to assist Resident #1 to the dining room for dinner. [Subsequent interviews with more tenured staff indicate that seating for the evening meal starts no earlier than 4:30 PM.] NA A stated she was not the person that assisted Resident #1 to return to his room after dinner, or assist him from his wheelchair to bed, which was his known preference. NA A stated she was assisting Resident #2 after dining and noted that Resident #1 was in bed at the end of her shift. NA A stated she did not know who put Resident #1 to bed the evening of 6/06/2024. NA A stated she assumed that whoever had assisted Resident #1 to bed had also provided incontinence checks to Resident #1 as that task was supposed to be done before the end of the shift as per facility practice. NA A stated she left the floor at approximately 6:10-6:15 PM the evening of 6/06/2024. NA A stated the last time she provided any care to Resident #1 was when she showered him, and during that shower Resident #1 had a bowel movement and was incontinent of urine in the shower. <BR/>In an interview on 6/08/2024 at 11:20 AM, the DON stated as she was walking by, she saw Resident #1 was sliding down his wheelchair in his room after dinner on 6/06/2024. The DON stated she called out to CNA F to assist her with getting Resident #1 repositioned from his wheelchair on to his bed. The DON stated she and CNA F used a mechanical lift to place Resident #1 on the bed, on top of the fitted sheet without providing an incontinence check. The DON stated she expected the person assigned to provide care for Resident #1 to check for incontinence and assist Resident #1 into his night clothes before the end of the shift. The DON stated that would have been NA A on the 6A-6P shift on 6/06/2024. The DON stated, It was pushing close to the end of shift, maybe 5:50 to 6 o'clock [in the evening] when we [the DON and CNA F] assisted [Resident #1] to the bed . <BR/>In a joint interview on 6/08/2023 at 12:30 PM, the ADM stated she was the abuse coordinator for the facility. The ADM stated she was notified just after 2:00 or 2:30 AM on 6/07/2024 that Resident #1 had been discovered with a rubber band around his penis. The DON stated she was notified around 2:30 AM on 6/07/2024. The ADM stated that she initiated an investigation immediately by interviewing staff on site and then by telephone. The ADM stated that there were inconsistencies in the explanation NA A provided detailing when she provided care to Resident #1. Additionally, the DON stated it was unusual that NA A did not document any provision of care to any resident on 6/06/2024. The ADM stated that NA A indicated that CNA F was present during all provision of care to Resident #1 on 6/06/2024. This prompted the ADM to re-interview CNA F. The ADM stated that CNA F denied being asked to help NA A by NA A or any other staff on 6/06/2024. The ADM stated at this point she suspended NA A pending the outcome of the investigation. The DON stated in-service trainings were initiated with all nursing staff working the 6A-6P shift on Friday 6/07/2024 before they were allowed to work with residents. The DON stated she included non-nursing but direct care, such as habilitation therapy staff and non-direct care staff, such as laundry personnel, with that training. The DON stated she trained each on coming shift there after before they were allowed to work with residents. The DON stated she did not believe Resident #1 had the cognitive acuity or the physical dexterity to put a rubber band around his penis. The DON stated she inspected carts and nurses' station for access to rubber bands, but could not find any that would be accessible to Resident #1. <BR/>In an interview on 6/08/2024 at 2:42 PM, RN J stated she was the nurse assigned to Resident #1 on 6/06/2024 6A-6P shift. RN J stated Resident #1 can sometimes answer very simple and immediate yes/no type questions. RN J stated Resident #1 had a stroke and had cognitive deficits and only had use of one arm. RN J stated she did not believe that Resident #1 would be able to figure out how to put a rubber band around his penis and did not think he had the manual dexterity to do so. RN J stated that Resident #1 was always incontinent of bowel and bladder and needed frequent incontinent care. RN J stated she rounded on Resident #1 several times on 6/06/2024 and did not observe any overt signs of distress, abuse or neglect. RN J stated she did not perform any incontinent care or skin checks on Resident #1 that day. RN J stated Resident #1 had not displayed any subsequent signs of discomfort or distress since the rubber band was discovered. <BR/>In an interview on 6/08/2024 at 5:36 PM, RN D stated she was not the nurse assigned to Resident #1 but had been called over by CNA B at approximately 2:00 AM. RN D stated she entered the room with CNA B and RN C and observed that a rubber band had been tightly wound around Resident #1 penis. RN D stated she attempted to unwind the rubber band, but had to use scissors to release the rubber band. RN D stated Resident #1 did not appear in pain or in any distress, and that he immediately urinated. <BR/>In an interview on 06/08/2024 at 5:47 PM, RN C stated she was the nurse assigned to Resident #1. RN C stated she followed RN D and CNA B into Resident #1's room when she heard CNA B ask for assistance. RN C stated she observed a rubber band around Resident #1's penis. RN C stated it was wrapped so tightly that they were unable to remove it by hand, and it required two snips of scissors to release the rubber band. RN C stated she stayed with and assessed the resident while RN D left the room to start an incident report and make the required notifications. RN C stated once that was complete, RN C and RN D both made rounds on all residents, starting on the 300 hallway and continuing throughout the building, to assess for any other concerns of abuse or neglect on any resident. <BR/>In an interview on 6/08/2024 at 6:10 PM, CNA E stated she was assigned the area of the hallway for Resident #1 on Thursday 6/06/2024 from 6 PM to 10 PM. CNA E stated she did not see the off going aide [NA A] and no shift change report was done. CNA E stated that was not unusual, as not all CNAs talked at shift change, and even then, would only do a mini report if something significant was going on with a particular resident. CNA E stated she had assisted Resident #1's roommate, Resident #5 to bed at around 6:30 PM on Thursday 6/06/2024, when she noticed that Resident #1 was already in bed, with his night gown on, but Resident #1 still had his pants from earlier in the day on but they were pulled down lower on his hips. CNA E stated she was thankful for that because it made it easier to remove his pants and do a check of the brief to get Resident #1 ready for bed. CNA E stated she could see from the outside of the brief there was no urine, and from the back she could tell there was no feces in the brief. CNA E stated she did not open the brief to look inside. CNA E stated she did another check on Resident #1 around 8:30 PM on 6/06/2024 and again there was no bowel movement or urine visible from the outside of his brief, and she did not open the brief to look inside . CNA E stated she was not aware of the rubber band around Resident #1's penis. CNA E stated she had received in-servicing after the incident that included abuse and neglect, the correct way to perform an incontinence check and reporting change in condition requirements. <BR/>In an interview on 6/08/2024 at 6:40 PM, CNA B stated she had started her shift at 10:00 PM on Thursday 6/06/2024. CNA B checked on Resident #1 at about 11:00 PM but did not see any urine or feces in the brief from the outside. CNA B stated she did not open the brief to inspect inside it at that time. CNA B stated she next checked on Resident #1 at about 1:45 AM on 6/07/2024. CNA B stated that when she checked from the outside, Resident #1 still appeared to have no bowel movement or urine in the brief, and that prompted her to investigate further. CNA B stated she had worked at the facility long enough to know that Resident #1 was frequently incontinent of bowel and bladder, and almost always required incontinence care every 2 hours. CNA B stated one dry brief was a favor, but 2 dry briefs in a row felt like something was wrong with Resident #1. CNA B stated that when she opened the brief to check Resident #1, she found a rubber band wrapped tightly around the shaft of Resident #1's penis. CNA B stated she immediately went to get the first nurse she could find. CNA B stated Resident #1 was sleeping lightly and had not seemed distressed at any point during her shift. CNA B stated the nurses (RN D and RN C) were able to quickly get the rubber band off Resident #1 with scissors, and Resident #1 immediately started urinating a strong stream. CNA B stated as soon as Resident #1 was situated, she immediately began checking on all the residents on her workload. CNA B stated the nurses were doing full body checks and looking to see if the residents seemed bothered by anything. CNA B stated she had not worked at the facility since the incident, but had been told that she would have to complete in-service training before starting her next shift. <BR/>In an interview on 6/09/2024 at 12:35 PM, MD H stated that the on-call NP had been notified first, since he was on vacation, but he had been apprised of the situation upon his return. MD H stated that the swelling Resident #1 was still experiencing was not unexpected. MD H stated that over the next 7 to 10 days, barring any complications, the swelling and discoloration should resolve with the current conservative course of treatment. MD H stated it was good that urine was able to flow immediately, and the swelling and discomfort seemed only moderate. MD H stated if the rubber band had not been found when it was and immediately removed, the consequences could have been dire, including total loss of the penis. <BR/>In an interview on 6/9/2024 at 1:15 PM, the DON stated in-service training was initiated on 6/7/2024 at the start of the 6 AM shift with every worker on site since the incident was discovered. The DON stated the in-servicing curriculum was explicit in that nothing should be wrapped around genitalia with out a direct order from the provider. The DON stated the in-service training would change how the facility would approach incontinence checks. The DON stated that briefs would now need to be opened for the interior of the brief and skin of the perineum to be visualized. The DON stated that abuse prohibition policies were included in in-service training that was initiated in response to the incident with Resident #1. The DON stated that no staff would be allowed to work with residents until they had had the in-servicing. The DON stated any new, agency or staff pulled from a sister facility would be trained before being allowed to work with residents. The DON stated the investigation was started immediately upon discovery of the rubber band around Resident #1's penis. All residents were assessed for emotional or physical signs and symptoms of distress, abuse or mistreatment. <BR/>Record review of Abuse Prevention Program policy, updated September 2018, reflected policy statement, committed to protecting our residents from abuse by anyone including but not necessarily limited to: employees, other residents, consultants, volunteers, agents or power of attorney, and or staff from other agencies providing services to our residents. Policies and procedures that govern .identification of occurrences, and patterns of potential mistreatment/abuse, protection of residents. Reporting of Alleged Abuse, updated September 2018, included definition of abuse as: willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. <BR/>Record review of Skin Assessments revealed all 29 residents on 300 hallway received assessments 6/07/2024; followed by the remaining 57 residents of the other hallways, totaling 86 residents assessed. <BR/>Record review of In-Service Sign In sheet started 6/07/2024, reflected the following topics: Abuse and Neglect prohibition and policy; Proper Incontinent Care; Changes in Condition (notify charge nurse immediately). 22 of 22 nursing staff scheduled to work on Friday 6/07/2024 were trained on 6/07/2024 prior to working with residents included: 3 of 3 day shift nurses, the Treatment Nurse, 2 of 2 MAs, 11 of 11 day shift CNAs, 2 of 2 night shift nurses, 4 of 4 night shift CNAs. 6 of 6 nursing staff not previously scheduled to work on Friday 6/07/2024, who worked on Saturday 6/08/2024 were trained on 6/08/2024 prior to working with residents included: 2 of 2 MAs, 3 of 3 day shift CNAs, and 1 of 1 night shift CNAs. 5 of 5 nursing staff not previously scheduled to work on Friday 6/07/2024 or Saturday 6/08/2024, who worked on Sunday 6/09/2024 were trained on 6/09/2024 prior to working with residents included: 3 of 3 dayshift CNAs, and 2 night shift CNAs. A total of 51 staff that included direct and non-direct care/non-Nursing Staff were trained starting on 6/07/2023 prior to the start of their shift, included the following departments: accounting, dietary, habilitation therapy, social services, business office, human resources, receptionist, housekeeping, and laundry. <BR/>In interviews starting on 6/08/2024 8:00 am through 6/09/2024 5:45 PM, 20 staff interviews indicated, if they had worked since the incident with Resident #1, they had received training prior to working with any resident. If they had not been scheduled to work yet, they had been informed they must be in-serviced prior to working with any resident. In-servicing topics included: included: abuse and neglect: definitions, signs and symptoms, reporting requirements; change in conditions; and new protocols for incontinence checks to open brief to visualize interior and residents' perineum. <BR/>Record review of Provider Investigation Report addendum received 6/7/2024 at 12:45 PM revealed ADM was notified at 2:08 AM of incident with Resident #1. ADM arrived at the facility within 15 minutes to initiate investigation. <BR/>Ad-Hoc QAPI meeting held to discuss the incident. Additionally, local police department was notified, and provided a police report number 24-3584. Facility suspended the suspected Alleged Perpetrator, NA A, prior to entrance on 6/08/2024.

Based on observation, interview, and record review, the facility failed to promote and maintain the residents' right to be treated with respect and dignity for 4 of 4 residents (Residents #1, #2, #3, and #4) reviewed for dignity and respect, in that: <BR/>RN A referred to residents who required assistance with dining as feeders within the hearing of residents.<BR/>This deficient practice could place residents at risk of psychosocial harm due to diminished self-image. <BR/>The findings were: <BR/>Observation on 02/27/2024 at 11:40 a.m. revealed RN A was sitting at a dining table with unidentified Residents #1, #2, #3, and #4, two CNAs, and one Medication Aide. RN A was sitting between two residents who require assistance with dining. RN A waved her arm to indicate the residents at the table and stated, These are all feeders in reference to the residents. <BR/>During attempted interviews with unidentified Residents #1, #2, #3, and #4 on 02/27/2024 at 11:40 a.m., Residents #1, #2, #3, and #4 were not responsive to questions and unable to be interviewed due to cognitive deficits. <BR/>During an interview with the DON on 02/27/2024 at 1:00 p.m., the DON stated she would have chosen a more appropriate word in reference to residents who require assistance with dining and that she has provided training to staff regarding dignity and respect. <BR/>During an interview with RN A on 02/27/2024 at 4:30 p.m., RN A stated she could have chosen more respectful phrasing and that she meant no disrespect toward the residents. <BR/>During attempted interviews with unidentified Residents #1, #2, #3, and #4 on 02/27/2024 at 4:55 p.m., Residents #1, #2, #3, and #4 were not responsive to questions and unable to be interviewed due to cognitive deficits. <BR/>During attempted interviews with unidentified Residents #1, #2, #3, and #4 on 02/28/2024 at 11:45 a.m., Residents #1, #2, #3, and #4 were not responsive to questions and unable to be interviewed due to cognitive deficits. <BR/>During attempted interviews with unidentified Residents #1, #2, #3, and #4 on 02/29/2024 at 11:55 a.m., Residents #1, #2, #3, and #4 were not responsive to questions and unable to be interviewed due to cognitive deficits. <BR/>During attempted interviews with unidentified Residents #1, #2, #3, and #4 on 03/01/2024 at 11:45 a.m., Residents #1, #2, #3, and #4 were not responsive to questions and unable to be interviewed due to cognitive deficits. <BR/>During an interview with the Administrator on 03/01/2024 at 11:45 a.m., the Administrator stated that she had begun in-service training regarding maintaining respect and dignity while speaking to and about residents. <BR/>Record review of the facility policy, Maintaining Resident Dignity During Mealtimes, dated 01/13/2023, revealed, All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 1 meal (noon meal) reviewed for food and nutrition services observed in that:<BR/>The facility failed to ensure that the lunch menu was followed<BR/>This failure could place residents at risk for dissatisfaction, poor intake, and diminished quality of life.<BR/>The findings were:<BR/>An observation on 03/26/2024 at 9:55 a.m., of the facility's posted weekly menu, Fall/Winter 2023, Week 2, revealed Chicken and Dumplings, Candied Carrots, Wheat Roll, and Ambrosia Deluxe were to be served for the noon meal on 03/26/2024. The posted weekly menu revealed an alternate of Roast Beef, gravy, and Cheesy Broccoli Rice. The menu revealed no indication for a substitute.<BR/>An observation and interview with the FSS on 03/26/2024 at 10:03 a.m., revealed Beef Tips, Buttered Noodles, Turnip Greens, and Pears were to be served for the noon meal. The alternate for the noon meal was Cheese Pizza and [NAME] Salad. The FSS stated he had not had a chance to change the posted menu to the current week. The FSS further revealed he kept record of substitutions logged in the kitchen however did not know he needed to post the substitutions as well.<BR/>Record review of the facility's, Fall/Winter 2023, Week 1, menu revealed Beef Tips, Buttered Noodles, Spinach, Wheat Roll, and Strawberries w/whip topping were to have been served for the lunch meal on 03/26/2024. The alternate for the Week 1 menu revealed Braised Pork Chop, Roasted New Potatoes and Cauliflower w/Red Peppers were to be available.<BR/>Record review of the facility's policy titled, Menu Planning, revised June 1, 2019, 5. Dated current menus will be posted in all dining areas.<BR/>Record review of the facility's policy titled, Menu Substitutions, revised June 1, 2019, Policy: The facility believes that a well-balanced menu, planned in advanced and served as posted, is important to the well being of its residents. The menus will be served as planned except for emergency situations when a food item is unavailable.

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with facility assessment for 1 of 1 facility reviewed for qualified dietary staff. <BR/>The facility failed to employ a certified dietary manager.<BR/>This failure could place residents at risk of food borne illness and not receiving adequate nutrition.<BR/>The findings were:<BR/>Record Review of the undated Employee Service List, revealed the FSS with a hire date of 05/14/2000.<BR/>In an interview on 03/26/2024 at 11:00 a.m., the FSS revealed he had been hired and worked as a cook at the facility for almost 4 years. When the previous supervisor left somewhat suddenly, 25 days ago, the FSS stated he was offered the position to move into the FSS role. The FSS stated he did not have the certification or degrees as a nursing home dietary manager, so he was enrolled in the course.<BR/>In an interview on 03/26/2024 at 11:23 a.m., the Administrator stated the FSS had recently started when the previous manager left for health reasons. She further stated he was the likely candidate, so the position was offerred and he was enrolled in the course to start in May 2024.<BR/>Record review of the Dietary Manager Registration Form, provided by the facility revealed the FSS was registered on 03/13/2024 and had chosen the semester May-August to begin.<BR/>Record review of the job description for Certified Dietary Manager, provided by the facility revealed a section, Educational/Training Requirements: Graduate of a 2 or 4 year Dietary Manager's Program or is a Registered Dietician. Licensing Requirements: Successful completion of Certified Dietary Manager exam.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: <BR/>1. There were seven one-gallon containers of milk that had been opened and were without labels indicating the dates opened.<BR/>2. There were six one-lb. containers of strawberries that all contained rotten and moldy berries.<BR/>3. There was rust and debris on the table-top can opener.<BR/>4. There was a carton of mashed potato pearls that had been opened and was not properly sealed.<BR/>These deficient practices could place residents who ate food from the kitchen at risk for food borne illness.<BR/>The findings included:<BR/>1. Observation on 01/31/2023 at 9:30 AM in the cooler used to store milk revealed seven one-gallon containers of milk. Six of the gallons were whole milk, of which 2 had a best by date of 2/02/23, two had a best by date of 2/09/2023 and two had a best by date of 2/14/2023. One gallon was 2% milk with a best by date of 2/01/2023. All seven gallons of milk had been opened and were &frac12; to &frac34; full. There was no date on any of the containers of milk indicating the date they were opened.<BR/>Interview on 01/31/2023 at 9:33 AM with the FSS revealed all the milk had been received the previous day (Monday, 01/30/2023) because that was when they received their milk delivery. The FSS confirmed there were no dates indicating when the milk containers had been opened. When asked why several containers of the same product had been opened and were partially full, the FSS said sometimes nursing staff came in and grabbed a new container without seeing that one had already been opened. The FSS stated she knew it was important to indicate the date on the containers that the milk was opened regardless of the best by date because the milk started to deteriorate from that time. The FSS further stated that whoever opened the milk was responsible for dating it, and all dietary employees were trained on that during orientation and throughout the year. <BR/>2. Observation on 01/31/2023 at 9:40 AM of the reach-in produce cooler revealed six one-lb. containers of fresh strawberries. All six containers contained rotten and moldy berries and removing them from the cooler resulted in red liquid draining to the floor. The labels on the containers of strawberries indicated they had been received on 01/23/2023.<BR/>Interview on 01/31/2023 at 9:42 AM with the FSS confirmed the majority of the strawberries were rotten or had mold on them and were not fit for service. The FSS stated she hadn't had an opportunity to inspect them for quality and remove product that had gone bad. <BR/>3. Observation on 01/31/2023 at 10:03 AM revealed that the blade of the table-top can opener had a buildup of debris. The debris was black, brown and off-white in color. <BR/>Interview on 01/31/2023 at 10:03 AM with the FSS confirmed the presence of the buildup of debris on the can opener blade, and the FSS also noted there was rust on the blade. When asked who was responsible for cleaning the can opener blade, the FSS responded that it was on the cooks' list to clean daily, and that both she and the consultant dietitian do in-services on kitchen sanitation.<BR/>4. Observation on 02/02/2023 at 10:30 AM in the kitchen revealed a 3.5 lb. cardboard carton of mashed potato pearls on a shelf above the preparation table. The carton (similar to a cardboard milk carton) had been opened and was not properly sealed in a zip top bag or another similar enclosed container. The date written on the container was 01/25/2023.<BR/>Interview on 02/02/2023 at 10:30 AM with the FSS confirmed the carton of mashed potato pearls was not properly sealed. The FSS further stated it was important that food items be sealed to maintain product quality, prevent cross contamination and potential pest infestation.<BR/>Review of the facility's policy 03.003 Food Storage revised 06/01/2019, revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to state, Federal and US Food Codes and HACCP guidelines. Procedure: 1. Dry storage rooms. D. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators. d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. <BR/>Review of the facility's policy 04.009 Can Opener dated 10/01/2018, revealed: The facility will maintain can openers free of food particles and dirt to minimize the risk of food hazards. Can openers be cleaned after each use. Procedure: 1. Hand held or table top. A. Remove can opener shank from base. B. Wash shank in sink with warm water and detergent or in the dishwasher. C. Give close attention to the blade and moving parts. D. Rinse in clean, hot water. e. Sanitize with approved sanitizer. Follow manufacturer's instructions for immersion times. F. Air dry. G. Wash base of can opener with clean cloth soaked in warm water and detergent, removing all food particles and dirt. H. Rinse with clean cloth soaked in clear hot water.<BR/>Review of the facility's Daily Cleaning Schedule, Nutrition & Foodservice Policies & Procedures Manual, 2018, Section 4-8, revealed: Item: Can Opener. When: After Each use.<BR/>Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed: 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. Except as specified in paragraphs (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and: <BR/>(1) The day the original container is opened in the food establishment shall be counted as Day 1; and<BR/>(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 State Survey Agency for 1 of 11 Residents (Resident #6) who were reviewed for abuse, in that: <BR/>The facility did not report an allegation of abuse per facility policy to the State Survey Agency (HHSC) when Resident #6 alleged Resident #7 that provided unwanted sexual favors.<BR/>This deficient practice could affect any resident and could contribute to further abuse.<BR/>The findings were:<BR/>Record review of the facility policy and procedure titled, Abuse, Neglect and Exploitation dated 8/15/22, revealed in part, .Reporting of all alleged violations to the .state agency .within specified timeframe's . <BR/>1. Review of Resident #6's face sheet, dated 2/11/25, revealed he was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Recurrent, Moderate and Schizoaffective Disorder, Depressive type.<BR/>Review of Resident #6's annual MDS assessment, dated 12/6/24, revealed his BIMS score was 3 of 15 reflective of severe cognitive impairment. <BR/>2. Review of Resident #7's face sheet, dated 2/11/25, revealed he was admitted to the facility on [DATE] with a diagnosis unspecified Dementia.<BR/>Review of Resident #7's admission MDS assessment, dated 2/5/25, revealed his BIMS score was 10 of 15 reflective of moderate cognitive impairment.<BR/>Review of a Provider Investigation Report, dated 2/12/25, revealed an allegation of verbal and physical aggression was investigated. Allegedly, Resident #6 slapped Resident #7 on the leg. Further review revealed Resident #6 stated he did it because Resident #7 crawls over to him in the night and provides sexual favors.<BR/>Record review of Texas Unified Licensure Information Portal (TULIP) revealed that no self-reported incident regarding allegations of sexual abuse <BR/>Interview on 2/13/25 at 11:30 AM with the DON related to the incident between Resident #6 and Resident #7 revealed both made an allegation. Resident #7 alleged that Resident #6 slapped him on the leg. Resident #6 alleged that Resident #7 would suck his [penis] at night which was not solicited or wanted. The DON stated she did not know if the allegation Resident #6 was reported because the ADM was responsible for reporting allegations of abuse to HHSC; however, she stated to her understanding both were reportable allegations of abuse.<BR/>Interview on 2/13/25 at 4:34 PM with the ADM revealed she identified during the investigation involving Resident #6 and Resident #7 there were 2 allegations that should have been reported; physical abuse which she reported and sexual abuse which she did not report. The ADM stated she incorporated both allegations into the investigation for physical aggression but should have reported and investigated each allegation separately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 15 residents (Resident #75) reviewed for call light; in that:<BR/>The facility failed to ensure Resident #75's call light was with in reach. <BR/>This failure could place residents at risk of achieving independent functioning, dignity, and well being. <BR/>Findings include:<BR/>Record review of Resident #75's face sheet, dated 3/27/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities), Benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland), and Peripheral vascular disease (systemic disorder that involves the narrowing of peripheral blood vessels).<BR/>Record review of Resident #75 Quarterly MDS, dated [DATE], reflected a BIMS score of 13, which indicated intact cognition. <BR/>Review of Resident #75's Quarterly MDS, dated [DATE], reflected under section G, G0300, option # 3 which stated, the patient was unsteady on his feet and required assistance X 1. <BR/>Record review of Resident #75's care plan, dated 4/17/23, revealed Resident #75 was at risk for falls related to weakness and unsteadiness. Intervention: Be sure the residents' call light is within reach. <BR/>Observation on 3/27/24 at 10:21 a.m. revealed Resident #75's call light was not visible, and instead the call light was wrapped on the call light box on the wall. <BR/>During an interview with Resident #75 on 3/27/24 at 10:25 a.m., he stated, They always move that call light away from me.<BR/>During an interview on 3/27/2024 at 10:55 a.m, with CNA B, she stated she was the assigned nursing assistant for Resident #75, and the call light was wrapped on the wall call light box. CNA B stated, I must have forgotten to move it back to resident #75's reach when I provided incontinent care this morning. CNA B further stated the lack of accessibility of a call light could negatively affect any resident if they needed assistance. <BR/>During an interview with the DON on 3/27/24 at 11:05 a.m., the DON stated it was her expectation call lights should be within arm's length of all residents. The DON further stated the lack of a call light could possibly lead to a fall if a resident needed something. <BR/>Record review of the facility's policy titled, Call Lights, dated 10/13/22, revealed, staff will ensure the call light is within reach of the resident and secured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were are identified in the comprehensive assessment for 1 of 15 (Resident #24) residents reviewed for comprehensive assessments, in that:<BR/>The facility failed to ensure Resident #24's care plan documented the resident was PASRR positive.<BR/>This deficient practice could place residents at risk of not receiving proper care and services related to PASRR services.<BR/>The findings were: <BR/>Record review of Resident #24's face sheet, dated 03/28/2024, reflected a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included: Mild Intellectual Disability (impairment of cognitive skills, adaptive life skills, and social skills), Bipolar disorder (Disorder with extreme mood swings that include emotional highs and lows), and Type 2 diabetes (Disorder in which the pancreas does not produce enough insulin). <BR/>Record review of Resident #24's Care Plan, dated 03/28/2024, reflected no specific listing for Resident #24 being PASRR positive. <BR/>Record review of Resident #24's Quarterly MDS, dated [DATE], reflected Resident #24 had BIMS score of 07, indicating severe cognitive impairment.<BR/>Record review of Resident #24's PASRR Evaluation, dated 08/22/23, reflected, IDD only, for Type of Assessment. Further review reflected, Yes, was marked for, To your knowledge, does the individual have a Developmental Disability other than an Intellectual Disability that manifested before the age of 22.<BR/>During an interview with the MDS nurse on 3/28/24 at 1:20 p.m., revealed she was responsible for updating the care plans. The MDS nurse stated she did not know why Resident #24's PASRR positive status was not on the resident's care plan as he was receiving services from the local health authority due to his (Mild Intellectual Disability). The MDS nurse stated that by her not updating the care plan, Resident #24 risked not having all team members on same page. <BR/>During an interview with the DON on 3/28/24 at 1:35 p.m. revealed Resident #24 was PASRR positive and it was her expectation the care provided by care planned accordingly to ensure all team members are on the same page when providing care. <BR/>Record review of the facility's policy titled, Comprehensive Care plans, dated 10/24/22, revealed, The comprehensive care plan will describe, at a minimum, the following; c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were are identified in the comprehensive assessment for 1 of 15 (Resident #24) residents reviewed for comprehensive assessments, in that:<BR/>The facility failed to ensure Resident #24's care plan documented the resident was PASRR positive.<BR/>This deficient practice could place residents at risk of not receiving proper care and services related to PASRR services.<BR/>The findings were: <BR/>Record review of Resident #24's face sheet, dated 03/28/2024, reflected a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included: Mild Intellectual Disability (impairment of cognitive skills, adaptive life skills, and social skills), Bipolar disorder (Disorder with extreme mood swings that include emotional highs and lows), and Type 2 diabetes (Disorder in which the pancreas does not produce enough insulin). <BR/>Record review of Resident #24's Care Plan, dated 03/28/2024, reflected no specific listing for Resident #24 being PASRR positive. <BR/>Record review of Resident #24's Quarterly MDS, dated [DATE], reflected Resident #24 had BIMS score of 07, indicating severe cognitive impairment.<BR/>Record review of Resident #24's PASRR Evaluation, dated 08/22/23, reflected, IDD only, for Type of Assessment. Further review reflected, Yes, was marked for, To your knowledge, does the individual have a Developmental Disability other than an Intellectual Disability that manifested before the age of 22.<BR/>During an interview with the MDS nurse on 3/28/24 at 1:20 p.m., revealed she was responsible for updating the care plans. The MDS nurse stated she did not know why Resident #24's PASRR positive status was not on the resident's care plan as he was receiving services from the local health authority due to his (Mild Intellectual Disability). The MDS nurse stated that by her not updating the care plan, Resident #24 risked not having all team members on same page. <BR/>During an interview with the DON on 3/28/24 at 1:35 p.m. revealed Resident #24 was PASRR positive and it was her expectation the care provided by care planned accordingly to ensure all team members are on the same page when providing care. <BR/>Record review of the facility's policy titled, Comprehensive Care plans, dated 10/24/22, revealed, The comprehensive care plan will describe, at a minimum, the following; c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were are identified in the comprehensive assessment for 1 of 15 (Resident #24) residents reviewed for comprehensive assessments, in that:<BR/>The facility failed to ensure Resident #24's care plan documented the resident was PASRR positive.<BR/>This deficient practice could place residents at risk of not receiving proper care and services related to PASRR services.<BR/>The findings were: <BR/>Record review of Resident #24's face sheet, dated 03/28/2024, reflected a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included: Mild Intellectual Disability (impairment of cognitive skills, adaptive life skills, and social skills), Bipolar disorder (Disorder with extreme mood swings that include emotional highs and lows), and Type 2 diabetes (Disorder in which the pancreas does not produce enough insulin). <BR/>Record review of Resident #24's Care Plan, dated 03/28/2024, reflected no specific listing for Resident #24 being PASRR positive. <BR/>Record review of Resident #24's Quarterly MDS, dated [DATE], reflected Resident #24 had BIMS score of 07, indicating severe cognitive impairment.<BR/>Record review of Resident #24's PASRR Evaluation, dated 08/22/23, reflected, IDD only, for Type of Assessment. Further review reflected, Yes, was marked for, To your knowledge, does the individual have a Developmental Disability other than an Intellectual Disability that manifested before the age of 22.<BR/>During an interview with the MDS nurse on 3/28/24 at 1:20 p.m., revealed she was responsible for updating the care plans. The MDS nurse stated she did not know why Resident #24's PASRR positive status was not on the resident's care plan as he was receiving services from the local health authority due to his (Mild Intellectual Disability). The MDS nurse stated that by her not updating the care plan, Resident #24 risked not having all team members on same page. <BR/>During an interview with the DON on 3/28/24 at 1:35 p.m. revealed Resident #24 was PASRR positive and it was her expectation the care provided by care planned accordingly to ensure all team members are on the same page when providing care. <BR/>Record review of the facility's policy titled, Comprehensive Care plans, dated 10/24/22, revealed, The comprehensive care plan will describe, at a minimum, the following; c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations.

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with facility assessment for 1 of 1 facility reviewed for qualified dietary staff. <BR/>The facility failed to employ a certified dietary manager.<BR/>This failure could place residents at risk of food borne illness and not receiving adequate nutrition.<BR/>The findings were:<BR/>Record Review of the undated Employee Service List, revealed the FSS with a hire date of 05/14/2000.<BR/>In an interview on 03/26/2024 at 11:00 a.m., the FSS revealed he had been hired and worked as a cook at the facility for almost 4 years. When the previous supervisor left somewhat suddenly, 25 days ago, the FSS stated he was offered the position to move into the FSS role. The FSS stated he did not have the certification or degrees as a nursing home dietary manager, so he was enrolled in the course.<BR/>In an interview on 03/26/2024 at 11:23 a.m., the Administrator stated the FSS had recently started when the previous manager left for health reasons. She further stated he was the likely candidate, so the position was offerred and he was enrolled in the course to start in May 2024.<BR/>Record review of the Dietary Manager Registration Form, provided by the facility revealed the FSS was registered on 03/13/2024 and had chosen the semester May-August to begin.<BR/>Record review of the job description for Certified Dietary Manager, provided by the facility revealed a section, Educational/Training Requirements: Graduate of a 2 or 4 year Dietary Manager's Program or is a Registered Dietician. Licensing Requirements: Successful completion of Certified Dietary Manager exam.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain, in accordance with accepted professional standards and practices medical records on each resident that were complete and accurately documented for 1 of 15 residents (Resident #50), reviewed for accuracy of records, in that: <BR/>The facility failed to ensure Resident #50's diagnosis for schizoaffective disorder was listed on face sheet. <BR/>This deficient practice could place residents at risk of having misinformation about the professional care provided.<BR/>Findings include: <BR/>Record review of Resident #50's face sheet, dated 3/27/24, revealed a [AGE] year old male who was admitted to facility on 5/1/21 with diagnoses which included: Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Bell's palsy (is a condition that causes sudden weakness in the muscles on one side of the face), and Epilepsy (brain disorder that causes recurring, unprovoked seizures).<BR/>Record review of Resident 50's Quarterly MDS dated [DATE], reflected a BIMS score of 3, which indicated severe cognitive impairment, and section A.1510 option (A) was selected which indicated severe mental illness. <BR/>Record review of Resident #50's PASRR (Pre admission Screening and Resident Review) dated 8/1/23, reflected Section (C.100) Is there evidence of mental illness, yes was selected which indicated mental illness. <BR/>Record review of [Name of Company] Psychiatric Subsequent Assessment for Resident #50, dated 3/12/24 reflected treating diagnosis, schizoaffective disorder.<BR/>During an interview with the MDS nurse on 3/28/24 at 10:15 a.m., revealed she was responsible for updating face sheets with medical diagnosis. The MDS nurse stated she was unaware why the medical diagnosis for, schizoaffective disorder, was not on face sheet for Resident #50. The MDS nurse stated by the medical diagnosis not being listed on the face sheet, the resident risked not having all care providers on same page regarding medical diagnosis. <BR/>During an interview with the Administrator on 3/28/24 at 10:32 a.m., revealed it was her expectation that documentation was accurate in the medical record as lack of documentation could result in misinformation with in care providers. <BR/>Record review of the facility's policy titled, Documentation in Medical Record, dated 10/24/22, revealed, Documentation shall be accurate, relevant and complete, containing sufficient details about the residents care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had a right to safe, clean, comfortable and homelike environment including but not limited to receiving treatment and supports for daily living for 1 of 1 facility reviewed for resident rights.<BR/>The facility failed to replace bathroom lights in four resident rooms, adequately clean three bathroom ceiling vents in resident rooms, and repair bathroom wall scraps in two resident rooms. <BR/>This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.<BR/>The findings included:<BR/>During an observation on 03/25/24 from 3:25 p.m. to 3:45 p.m. with the Maintenance Director revealed the following the following:<BR/>1. Resident room [ROOM NUMBER] which was occupied had a scrap on the bathroom wall near the sink fixture which measured approximately 18x2 inches.<BR/>2. Resident room [ROOM NUMBER] which was occupied had a bathroom ceiling vent which measured 12x6 inches with rust particles noted on the vent slats.<BR/>3. Resident room [ROOM NUMBER] which was occupied had a bathroom light above the bathroom mirror that was not working.<BR/>4. Resident room [ROOM NUMBER] which was occupied had a bathroom light above the bathroom mirror that was not working.<BR/>5. Resident room [ROOM NUMBER] which was occupied had a bathroom light above the bathroom mirror that was not working.<BR/>6. Resident room [ROOM NUMBER] which was occupied had a bathroom ceiling vent which measured approximately 12x6 inches with dust particles noted on the vent slats.<BR/>7. room [ROOM NUMBER] which was occupied had a scrap on the bathroom wall near the sink fixture which measured approximately 12x6 inches.<BR/>8. Resident room [ROOM NUMBER] which was occupied had a bathroom light above the bathroom mirror that was not working.<BR/>9. Resident room [ROOM NUMBER] which was occupied had a bathroom ceiling vent which measured 12x6 inches with dust particles noted on the vent slats.<BR/>During an interview with the Maintenance Director and Administrator on 03/26/24 at 3:50 p.m. the Administrator stated staff used the TELS work order notification system to alert the Maintenance Director of needed repairs. The Administrator stated staff were in-serviced on the use of the TELS system and she was not aware of any work order requests for the bathroom lights not working or the bathroom wall scrapes needing repair or rust on the bathroom ceiling vent. The Administrator stated Housekeeping was responsible for removal of dust from the bathroom ceiling vents. The Maintenance Director stated bathroom lights not working in resident rooms could reduce visibility for resident's safety, the bathroom wall scrapes could upset the resident family members perception of the bathroom, and not having a clean bathroom ceiling vent would affect air quality in resident rooms.<BR/>Record review of the facility's undated general orientation agenda revealed new employees were in-serviced by the Maintenance Director on the topic of work orders.<BR/>Record review of the facility's in-service training report dated 10/27/23 revealed departmental staff were in-serviced on TELS with the topic-Reporting issues in building immediately through system and not reporting directly to employee due to overlaid of issues daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain, in accordance with accepted professional standards and practices medical records on each resident that were complete and accurately documented for 1 of 15 residents (Resident #50), reviewed for accuracy of records, in that: <BR/>The facility failed to ensure Resident #50's diagnosis for schizoaffective disorder was listed on face sheet. <BR/>This deficient practice could place residents at risk of having misinformation about the professional care provided.<BR/>Findings include: <BR/>Record review of Resident #50's face sheet, dated 3/27/24, revealed a [AGE] year old male who was admitted to facility on 5/1/21 with diagnoses which included: Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Bell's palsy (is a condition that causes sudden weakness in the muscles on one side of the face), and Epilepsy (brain disorder that causes recurring, unprovoked seizures).<BR/>Record review of Resident 50's Quarterly MDS dated [DATE], reflected a BIMS score of 3, which indicated severe cognitive impairment, and section A.1510 option (A) was selected which indicated severe mental illness. <BR/>Record review of Resident #50's PASRR (Pre admission Screening and Resident Review) dated 8/1/23, reflected Section (C.100) Is there evidence of mental illness, yes was selected which indicated mental illness. <BR/>Record review of [Name of Company] Psychiatric Subsequent Assessment for Resident #50, dated 3/12/24 reflected treating diagnosis, schizoaffective disorder.<BR/>During an interview with the MDS nurse on 3/28/24 at 10:15 a.m., revealed she was responsible for updating face sheets with medical diagnosis. The MDS nurse stated she was unaware why the medical diagnosis for, schizoaffective disorder, was not on face sheet for Resident #50. The MDS nurse stated by the medical diagnosis not being listed on the face sheet, the resident risked not having all care providers on same page regarding medical diagnosis. <BR/>During an interview with the Administrator on 3/28/24 at 10:32 a.m., revealed it was her expectation that documentation was accurate in the medical record as lack of documentation could result in misinformation with in care providers. <BR/>Record review of the facility's policy titled, Documentation in Medical Record, dated 10/24/22, revealed, Documentation shall be accurate, relevant and complete, containing sufficient details about the residents care.