WINDSOR NURSING AND REHABILITATION CENTER OF RAYMO

Based on interview and record review the facility failed to document that testing was completed and the results of each staff test for 3 of 4 outbreaks reviewed for COVID-19 testing. <BR/>The facility did not maintain complete and accurate documentation of staff COVID-19 testing when outbreak testing was initiated after a positive COVID-19 case was identified at the facility on 08/31/22, 12/14/22, and 03/06/23. <BR/>This deficient practice could place residents at-risk for exposure to the COVID-19 virus which could result in serious illness or hospitalization.<BR/>The findings included: <BR/>Record review of TULIP (HHSC online incident reporting application) on 03/31/23 at 10:00 a.m., revealed the facility made a self-reported for a new COVID-19 case on 09/01/22 with initial positive result identified on 08/31/22. <BR/>Record review of TULIP (HHSC online incident reporting application) on 03/31/23 at 10:10 a.m., revealed the facility made a self-reported for a new COVID-19 case on 12/15/22 with initial positive result identified on 12/14/22. <BR/>Record review of TULIP (HHSC online incident reporting application) on 03/31/23 at 10:30 a.m., revealed the facility made a self-reported for a new COVID-19 case on 03/06/23 with initial positive result identified on 03/06/23. <BR/>The facility was unable to produce staff testing logs for the facility's COVID-19 outbreak first reported to HHSC on 09/01/22.<BR/>The facility was unable to produce staff testing logs for the facility's COVID-19 outbreak first reported to HHSC on 12/15/22.<BR/>Record review on 04/04/23 at 4:00pm revealed incomplete March 2023 and April 2023 staff testing logs for the facility's COVID-19 outbreak first reported on 03/06/23 with initial positive result identified on 03/06/23. Testing logs did not document results for all staff and only identified those who were positive. <BR/>During an interview with the DON on 04/04/23 at 4:45pm she stated she was the infection preventionist and responsible for maintaining complete and accurate COVID-19 testing records for both staff and residents. The DON stated information regarding individuals name, their test results, date of test, lot number and expiration date of test should be included on testing documentation. The DON stated for outbreaks reported to HHSC on 09/01/22 and 12/15/22 the facility cleared 14 days without any positive COVID-19 cases. The DON was asked to provide COVID-19 testing logs from facility reported outbreaks reported on 09/01/22 and 12/15/22. The DON stated she did not have access to testing logs from September 2022 and was still looking for December 2022 logs. The DON was unable produce any testing documentation by time of exit on 04/04/23 at 7:35pm. The DON stated she did not have testing logs for these outbreaks because she had not compiled them. The DON stated COVID-19 testing should be documented and logged for all staff and stated she could not verify if testing of staff had been documented and logged. The DON was asked for COVID-19 testing logs for most recent reported outbreak to HHSC from 03/06/23. The DON stated mass testing of both residents and staff was still being completed. The DON provided testing logs from 03/06/23 that included staff name, and date they were tested. Testing logs beginning on 03/06/23 did not include test results for all staff tested. Testing logs starting 03/06/23 only identified staff who were positive but did not have results for staff who had tested negative. The DON stated, test results are there for positive ones, when asked if all staff should have a result documented she stated, yes, it should have a result on there. The DON stated she had received CDC training over documentation and maintenance of COVID-19 testing logs. The DON stated she monitored all testing was documented and logs were maintained appropriately by going through a staff list and resident census and confirming with staff members if they have tested and asking for results to initiate if they are positive or negative. The DON stated not documenting and maintaining testing logs can negatively impact the residents because there could be a potential outbreak. <BR/>The DON stated they did not have a policy regarding testing or testing documentation.<BR/>The facility was unable to produce completed testing logs for 3 of 4 outbreaks at time of exit on 04/04/23 at 7:35pm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting alleged allegation of abuse. CNA A failed to report an allegation of abuse to the Administrator involving Resident #1 being tucked into bed with a blanket tucked behind her shoulders sometime in March of 2025. This failure could place residents at risk for undetected abuse and neglect, and a decline in feelings of safety and well-being. The findings included: 1. Record review of Resident #1's face sheet, dated 08/22/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (progressive brain disorder that gradually destroys memory and thinking skills) unspecified dementia (a group of thinking an social symptoms that interferes with daily functioning), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and need for assistance with personal care (ADLs) Record review of Resident #1's annual MDS assessment, dated 06/05/25, revealed Resident #1 had a BIMS score of 00, indicating her cognition was severely impaired. Resident #1's MDS reflected she had unclear speech, was rarely/never understood, and rarely/never understood others. Resident #1's MDS reflected she required supervision or touching assistance to roll left or right in bed, to go from lying to sitting on the side of the bed, to sit to stand and to complete chair/bed to chair transfers. Record review of Resident #1's care plan with an initiation date of 11/21/19 reflected a problems of [Resident #1] has an ADL self -care performance deficit r/t Alzheimer's, impaired balance. Requires a lot of encouragement and guidance to complete a task. With an initiation date of 08/03/23 and intervention of, BED MOBILITY: The resident requires assistance by 1 staff to monitor for safety in bed as necessary. and TRANSFER: The resident requires assistance by 1 staff to move between surfaces necessary. with an initiation date of 08/03/23. During an attempted interview with Resident #1 on 08/06/25 at 2:35pm, she would not respond to any introduction or question. Record review of Resident #1's medical chart from March to May did not reveal any verbiage related to the allegation of Resident #1 being tucked in except for a note written by the DON on 06/18/25 when the facility received a compliance call that mentioned the incident with Resident #1. The note written by the DON stated, A head to toe assessment was performed with no open areas noted. Resident was noted to have red scratch marked to right buttock and right upper thigh with no broken skin. During n interview with CNA A on 08/08/25 at 3:31pm, he said he was no longer employed at the facility as of July, 2025. CNA A stated that sometime in March of 2025 around 3:00am or 4:00am, he was completing his rounds and noticed that Resident #1 was asleep and had 3 or 4 blankets in use and was restrained with some type of blanket. CNA A initially stated it was a blanket with a knot and then stated it was not a knot, but two ends of the blanket were tied, and the blanket was on top of Resident #1's shoulders with the corners crossed in back of her on her back but not in a knot just crossed. CNA A stated the blanket was tucked behind her shoulder blades. CNA A stated, at the time he found Resident #1, he removed the blanket. CNA A stated he did not know who placed the blanket like that and did not know if there was anyone else working with Resident #1 at that time. CNA A stated he never showed a photo of Resident #1 and never had a photo of Resident #1. CNA A stated he had completed 2 prior rounds on her during his shift and had checked her brief each time and did not see a blanket tucked behind her shoulder blades during those rounds. CNA A stated Resident #1 would not have been able to remove the blanket and stated his initial thought was that Resident #1 looked restrained. CNA A stated he considered restraints as a form of abuse. CNA A stated after he removed the blanket from Resident #1, he reported it to LVN B as a safety precaution. CNA A stated he did not report to the Administrator because he did not have her number. CNA A stated he had previously been trained over immediately reporting allegations of abuse to the abuse coordinator who was the Administrator but could not recall who provided him with that training or when. CNA A stated the facility policy stated he needed to report allegations like this one to the administrator immediately, and stated he felt he did not follow the facility policy. CNA A stated not reporting allegations of abuse or restraints to the Administrator could negatively impact residents mentally and could be considered neglect. Record review of a written statement dated 08/08/25 by the DON revealed, This statement is regarding a concern voiced in March. The resident in question was assessed by a licensed nurse who based on their professional experience, voiced that after his thorough assessment, the resident did not have any indication of abuse or neglect as defined by THHS. According to the Licensed Nurse, the resident was not in any immediate danger, her safety was in no way at risk, and the resident was noted to freely move all extremities along with being noted to get out of bed without any form of resistance or signs of distress. During an interview with LVN B on 08/11/25 at 12:43pm, he stated he didn't remember when, but thought maybe in April or May 2025 at around 5:00am in the morning, he was called over by CNA A and LVN C and was shown an undated photo without timestamp that CNA A had of Resident #1. LVN B stated Resident #1 appeared to be tucked in but was not tied. LVN B stated with the way Resident #1 was tucked in she would have been able to break out of and remove. LVN B stated CNA A did not say anything about Resident #1 being restrained or tucked in, and stated he told CNA for them to go look at Resident #1. LVN B stated he went back to see Resident #1 and found her sitting in bed with a smile with blankets at her feet. LVN B stated Resident #1 did not have any markings or signs of abuse or anything. LVN B stated he did not know if CNA A had removed the blankets from Resident #1 prior to him seeing her. LVN B stated Resident #1 had problems with mobility and would have been able to get the blanket off of her without any problems and stated when he saw the photo of Resident #1, she was smiling and had the blanket up to her chest and it was tied or wrapped it was lightly pushed in on the sides. LVN B stated he did not see any abuse or neglect, did not see anything wrong with Resident #1. LVN B stated he had nothing to report, and he did not document anything because there was nothing to document. LVN B stated he had called the DON about an hour after he was shown the photo of Resident #1, and stated she did not call him back until a little later but was not sure what time. LVN B stated at that time, he let the DON know that he was shown an undated, photo without a timestamp of Resident #1, but when he went to check her, he found her with her blankets at her feet and stated she was smiling and was unable to tell him what happened. LVN B stated he didn't think he needed to tell the Administrator because there was nothing there, he did not know when the photo was taken, and he did not see anything or suspect any abuse or neglect . LVN B stated he thought telling the DON was good. LVN B stated he had been trained over abuse and reporting requirements on their annual trainings and monthly trainings, and stated if he suspected or witnessed abuse, he had to report to the abuse coordinator, who was the Administrator, immediately. LVN B stated the Administration was responsible for reporting any allegation of abuse to HHSC and they only had 2 hours to report. LVN B stated he did not consider tucking in a resident as abuse, but if they were wrapped like a burrito, then yes, he would. LVN B stated the facility policy stated they had to report allegation of abuse to their abuse coordinator, and he did not suspect abuse from the photo he saw of Resident #1. LVN B stated he followed the facility's policy and felt like he did what needed to be done at that time. LVN B stated not reporting allegation of abuse to the Administrator, and not reporting to HHSC within the appropriate time frame, could negatively impact the residents because whatever type of abuse could be happening, could also be happening to other residents. During an interview with the DON on 08/11/25 at 3:08pm, she stated the Administrator was the abuse coordinator and responsible for reporting allegation of abuse to HHSC. The DON stated the Administrator provided monthly in-services to staff over abuse which included examples of abuse and what was considered abuse. The DON stated staff were educated on reporting to the Administrator, herself, and the ADON, if they suspected or witnessed any abuse. The DON stated, sometime in March, LVN B had gotten word from CNA A that Resident #1 was tucked in bed, but according to his assessment, she was freely able to move around and get out of bed and he did see anything impeding her from getting out of bed. The DON stated LVN B stated Resident #1 was not scared or afraid, and had no signs that would warn him that something had occurred. The DON stated she was not made aware until a couple days later, when LVN B called her at 7:00am or 8:00am a couple days after to notify her of what he had been told by CNA A. She stated she told LVN B to notify staff of doing things how they should be done with residents, and they completed an In-service with whatever staff was available at that time. The DON stated they did not document or do any investigation at that time, but did complete an in-service. The DON stated they did not do an investigation, because based on LVN B's clinical judgment ,Resident #1 was fine, and LVN B stated there was nothing to report because Resident #1 was free to move around and was safe with no signs or symptoms of abuse. The DON stated if a resident was tucked in tightly to where they could not move or get themselves out, then it would be considered restraints, and restraints would be consider abuse. The DON stated after LVN B reported to her, she called the Administrator who had also just been made aware, and after they spoke about it, there was nothing to report because LVN B said there were no signs or symptoms of abuse that was noted. The DON stated CNA A and LVN B should have reported these allegations to the Administrator at the time they occurred. The DON stated they had a 2-hour time frame to report to HHSC, but did not report anything until they received a compliance call in June 2025 that mentioned the incident. The DON stated the facility's policy stated they had to make a report to the state within 2 hours if they were told of any abuse. The DON stated herself and staff followed the facility's policy and they went by the information they received from the nurses, what they saw, and the findings on their assessments. The DON stated not reporting allegations of abuse to the Administrator, or HHSC within 2 hours, could negatively impact residents with harm if there was actual abuse. The DON stated, in this case, there was nothing. During an interview with the Administrator on 08/11/25 at 4:37pm, she stated she was not aware of the exact date or time that CNA A notified LVN B of Resident #1 being tucked in, but stated CNA A asked LVN B if he could go look at Resident #1 and see how she was tucked in. The Administrator stated LVN B went to assess Resident #1, did not see any signs or symptoms of abuse or anything, and as per his clinical judgement, felt it was nothing to be concerned about. The Administrator stated the DON notified her, she did not remember at what date or time she was notified ,but it was later that same morning. The Administrator stated they did not do anything else in response and did not report it because based on the information provided to them from LVN B, Resident was stable, there was nothing to report, and had not been reported as abuse. The Administrator stated CNA A could have reported to her, but he felt safe with LVN B so he reported to him, the Administrator stated LVN B did not report to her and could have so that she could have been aware as to what was going on. The Administrator stated If LVN B had found something then he should have reported to it to her. The Administrator stated she was the abuse coordinator and was responsible for reporting any allegation of abuse to HHSC. The Administrator stated herself and staff had been trained over reporting abuse at least monthly, and staff should report to her as soon as possible because she only had 2 hours to report. The Administrator stated she considered restraints as abuse, but with being tucked in, it depended. The Administrator stated their facility's policy stated if staff saw, suspected, or even if they were not sure of it, they had to report any abuse to her. She stated, in this situation, she felt her and the staff followed that policy. The Administrator stated they monitored facility incidents to ensure they identified reportables and their appropriate time frame by reviewing documentation, rounding, and providing in-services to staff on what should be reported. The Administrator stated not reporting allegations of abuse to the Administrator and HHSC within a 2-hour time frame could negatively impact the residents because they would not be investigating or following protocols, and if they were not aware, then they were not doing interventions. Record review of the facility's in-service dated 02/13/25 that was provided by the Administrator covered abuse and neglect, and the 3 R's (recognize, remove, report) revealed CNA A, LVN B and the DON had received the training. Record review of the facility's policy with an implemented date of 07/11/25 and titled, Abuse, Neglect and Exploitation included a section titled, V. Investigation of Alleged Abuse, Neglect, and Exploitation that included verbiage stating, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. VII. Reporting/Response.1.Reporting of all alleged violation to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hour after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 7 Residents (Resident #5 and Resident #12) who were observed for ADL care.<BR/>1. CNA D stood while feeding Resident #5 her lunch meal on 12/2/24.<BR/>2. CNA D stood while feeding Resident #12 her lunch meal on 12/2/24. <BR/>These deficient practices could affect dependent residents and contribute to feelings of shame or feeling uncomfortable and could place residents at risk of embarrassment, lack of privacy, and loss of dignity.<BR/>The findings were:<BR/>Review of Resident #5's face sheet, dated 12/3/24, revealed she was initially admitted to the facility on [DATE] with diagnosis including Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions), Chronic Obstructive Pulmonary Disease (A group of lung diseases that block airflow and make it difficult to breathe), Chronic Kidney Disease (a condition where the kidneys are damaged and can't filter blood properly, which can lead to a buildup of waste and fluid in the body), Need for assistance with personal care, all dated 8/11/2021.<BR/>Review of Resident #5's quarterly MDS assessment, dated 11/13/24, revealed her BIMS was 3 meaning she was unable to complete the Brief Interview for Mental Status. Further review revealed she had a diagnosis of Alzheimer's Disease and required assistance with eating.<BR/>Review of Resident #5's Care Plan, initiated on 11/12/23, revealed she had an ADL self-care performance deficit r/t General Weakness, Decreased Mobility, ALZHEIMER's, and the resident requires assistance by 1 staff to eat.<BR/>Observation on 12/2/24 at 12:30PM to 1:00 PM revealed CNA D standing while feeding Resident #5. Resident #5 was eating all of her food while periodically looking up at CNA D.<BR/>2. Review of Resident #12's face sheet, dated 12/3/24, revealed she was admitted to the facility on [DATE] with diagnoses including Dementia (a general term for a range of neurological conditions that cause a decline in mental ability and interfere with daily life) and Cerebral infraction (a general term for a range of neurological conditions that cause a decline in mental ability and interfere with daily life).<BR/>Review of Resident #12's quarterly MDS assessment, dated 09/7/24, revealed her BIMS was 2 meaning she was unable to complete the Brief Interview for Mental Status.<BR/>Review of Resident #12's Care Plan, initiated on 12/29/2017, revealed she had has an ADL self-care performance deficit r/t Activity Intolerance, Dementia, Limited Mobility and the resident requires assistance by 1 staff to eat.<BR/>Observation on 12/2/24 at 12:30PM to 1:00 PM revealed CNA D standing while feeding Resident #12. Resident #12 was eating all of her food while periodically looking up at CNA D.<BR/>Interview on 12/2/24 at 1:00 PM with CNA D revealed that he knew that he had to be sitting down, and he said that today his back was hurting and that was why he was standing up while feeding the residents. He said that he had training but was not able to recall when the training took place.<BR/>Interview on 12/2/24 at 4:10PM with ADON said that feeding the residents standing up is not respectful to the residents. He said that by sitting down while feeding residents shows dignity and respect to the residents.<BR/>Interview on 12/4/24 at 12:00 PM with the DON revealed staff should be sitting down while feeding residents because it shows respect and to prevent violating the resident's dignity. DON said that managers on duty are responsible to make sure staff is sitting down when feeding the residents.<BR/>Review of a facility policy, Promoting/Maintaining Resident Dignity During Mealtimes, implemented on 1/13/23 read: It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protect the rights of each resident. All staff will be seated, if possible, while feeding a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 8 residents (Resident #157 and Resident #27), staff, and the public in that:<BR/>The facility failed to ensure bathroom sinks hot water temperatures were below 110 degrees Fahrenheit in occupied room for Resident #157 and Resident #27.<BR/>This failure could affect residents by placing them at risk for diminished quality of life and at risk for burn injuries.<BR/>Findings Included:<BR/>Record review of Resident #157's , electronic face sheet dated 12/04/2024 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Unspecified Dementia, Mixed Receptive Expressive Language Disorder (problems with speaking), Muscle wasting and Atrophy (loss of muscle tissue), Hyperlipidemia (high cholesterol), and Polyosteoarthritis (arthritis that affects five or more joints at the same time).<BR/>Record review of Resident #157's comprehensive MDS assessment, dated 11/20/2024 revealed a BIMS score of 05, indicating Resident #157 was severely cognitive impaired. Minimal assistance for mobility.<BR/>Record review of Resident #157's care plan revised dated 11/29/24 revealed she had Dementia. Intervention included the resident was able to ambulate with supervision. <BR/>Record review of Resident #27's, electronic face sheet dated 12/04/2024 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE], with original admission date 04/14/2021. Her diagnoses included Alzheimer's Disease, Type 2 Diabetes Mellitus, Muscle wasting and Atrophy (loss of muscle tissue), Anxiety Disorder, Bipolar Disorder, and schizoaffective disorder, and Dysphasia (communication disorder). <BR/>Record review of Resident #27's comprehensive MDS assessment, dated 11/14/2024 revealed a BIMS score of 00, indicating Resident #27 was severely cognitive impaired. Supervision for mobility.<BR/>Record review of Resident #27's care plan revised dated 08/07/24 revealed she had Alzheimer's and ambulates in hallway most of the day. <BR/>Observation on 12/02/24 at 4:15pm with the Maintenance Director and using the maintenance director's digital thermometer revealed the bathroom sink hot water temperature on 12/02/24 at 4:15 PM were:<BR/>room [ROOM NUMBER]- bathroom sink was 114 degrees Fahrenheit for Resident #157 and Resident #27.<BR/>In an interview on 12/02/24 at 4:20pm the Maintenance Director at time of observation stated he did rounds every day in the morning. The Maintenance Director stated he checks at least one room in each hall every day and the last time he checked them was this morning (12/02/24) but he checked the rooms furthest in the hall. The Maintenance Director stated that he documented the temperature readings in the logbook. The Maintenance Director stated the temperature should be between 100-110 degrees Fahrenheit. He stated that he moved the water heater temperature this morning to make sure the temperature was good. The Maintenance Director stated the negative outcome of the water temperature being too hot in the resident's restroom was that the residents can burn themselves. <BR/>In an interview on 12/04/24 at 11:40a.m. with the Administrator, stated that she was not sure on what the procedure was for how often the maintenance director checks water temperatures. She stated that it might be done daily but maybe one room from each hall. She stated they have a system in place called TELS (a platform designed to help maintenance teams' efficiency). The administrator stated she usually gets an alert if something was not completed on time. She stated the hot water temperature should be at 110 degrees Fahrenheit. She stated if the hot water was too hot then it can be dangerous for the residents when they wash their hands and/or their face.<BR/>Record Review of the Logbook documentation dated 12/02/24 revealed room [ROOM NUMBER] was 119 degrees F. Further review of Logbook for month of November revealed minimal variation of temperature between 106 to 108 degrees F.<BR/>Review of facility's incident and accidents logs dated 10/2024, 11/2024, and 12/2024 did not reveal any injuries to residents due to hot water.<BR/>Review of the facility's Grievance logs dated 10/2024, 11/2024, and 12/2024 did not reveal any complaints of water temperature being too hot.<BR/>Review of the facility's Instructions Direct Supply TELS provided the following information:<BR/>1. Ensure patient room water temperatures are between 100 degrees and 110 degrees Fahrenheit.<BR/>Record results in the water temperature log.<BR/>2. Adjust water heater setting as required.<BR/>3. Retest as necessary

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature control, and permit only authorized personnel to have access to keys for the facility's one medication disposal cabinet, observed during survey medication storage task, in the medication storage room observed in that:<BR/>The facility's medication disposal cabinet was found unlocked, not lockable, and unable to latch closed.<BR/>This deficient practice could result in missing or misuse of drugs by unauthorized personnel.<BR/>The findings were:<BR/>Observation on 07/06/22 at 04:12 p.m., revealed the medication disposal cabinet in the medication storage room was found by the surveyor unlocked and unable to be latched closed. Per the inventory sheet in the cabinet, 126 medications, some in bags and some loose, were in the cabinet awaiting disposal. <BR/>In an interview and observation on 07/06/22 at 04:12 p.m. of the medication storage room with LVN C. LVN C, was trying to unlock the medication disposal cabinet for surveyor to check, when she found it unlocked and the cabinet would not close and latch. LVN C stated, That's not good. Let me tell [NAME] to fix it again. The cabinet (medication disposal) is always supposed to be locked and this won't even latch let alone lock. LVN B, who was standing in the doorway, stated, Oh wow. That is not good, then LVN B walked away to notify DON. The medication disposal cabinet was not locked, could not lock, and could not latch closed. <BR/>In an interview 07/06/22 at 04:24 p.m., when DON was notified of the medication disposal cabinet not being locked, unable to lock or unable to latch closed. DON stated she would have [NAME] fix it immediately. DON stated, Sheesh, the easiest thing and it didn't go right (regarding the citation. DON stated the disposal cabinet was always supposed to be locked and everyone knew that.<BR/>On 7/06/22 at 04:30 p.m., Maintenance Supervisor H was observed going into the medication storage room with a power drill as surveyor was exiting building.<BR/>In an interview 07/07/22 at 03:11 p.m., LVN C stated, The medication disposal cabinet is supposed to be locked at all times. Yesterday was my first day back from my two days off and it was locked when I worked last. Yesterday I was very surprised that it was not locked. It isn't good for the cabinet to be unlocked. The main door is locked so only certain people can get in the door. There is a risk of drug diversion or if the main door isn't shut properly, a resident could go in and take something they don't know what it is. <BR/>In an interview on 07/07/22 at 03:28 p.m., LVN G stated, If cabinet were not locked, I'd get my supervisor and let her know. If the (medication disposal) cabinet and (or) door were not locked, that would not be good. Medications could be taken by anyone if the room were not being watched. I personally, make sure the (medication storage room) door is locked at all times when I have to come in here. I have worked here for about 10 months and never had to put any medications in the cabinet for disposal. <BR/>In an interview 07/07/22 at 03:49 p.m., the DON stated the medication disposal cabinet is supposed to be locked at all times. The medication can disappear if left unlocked. Medication can be diverted. <BR/>Record review of inventory sheets for the medications in the unlocked medication disposal cabinet revealed 126 different medications including gabapentin 300mg capsules, metoprolol 50mg tablets, carbidopa-levo 10mg - 100mg tablets, Escitalopram 10mg tablets, clonidine HCl 0.1mg tablets, Metformin HCl F/C 500mg tablets, Trazodone HCl 50mg tablets, Insulin Aspart pen 100unit/1mL insulin pens, Lantus Solostar 100unit/1mL insulin pens, Novolog Flexipen 100/mL insulin pens, ipratropium/sol albuterol, mirtazapine 15mg tablets, Prednisone 20mg tablets, Diphenhydramine HcCl 50mg/1mL solution, levetiracetam 100mg/1mL solution, among the medications in the unlocked medication disposal cabinet.<BR/>Review of the facility policy and procedure titled Omnicare, a CVS Health company dated April 2022, revealed:<BR/>Procedure<BR/>1.Facility staff should destroy and dispose of medications in accordance with Facility policy and Applicable Law, and applicable environmental regulations<BR/>4.Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction.<BR/>11.2 An authorized Facility staff member should place medication containers in a container or box. Facility staff member should then seal the box with strong tape and label the box as MEDICATION FOR DESTRUCTION. The container or box should be secured in a locked cabinet or room until it is disposed or picked up by a licensed waste disposal company.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (CNA) observation for infection control.<BR/>The facility failed to ensure CNA E performed proper peri-care (incontinent care) for Resident #14.<BR/>This deficient practice could place resident in the facility at risk for infections due to improper incontinent care.<BR/>Findings included:<BR/>Observation on 09/19/2023 at 1:28 PM, CNA E performed incontinent care for Resident #14, did not clean the buttocks/anal area. <BR/>An interview on 09/19/2023 with CNA E at 1:56 PM, stated she has not done catheter care in a while. Surveyor asked why she did not clean buttocks/anal area. She said she completely forgot because she was probably concentrating on doing catheter care correctly. Stated she normally does clean the buttocks/anal area. She stated the negative outcome could be that resident can have skin breakdown from bacteria and a lot of different things can come from not cleaning properly. Especially since resident does not get up. <BR/>An interview on 09/21/2023 at 4:00 PM with DON, stated that all CNAs have access to [NAME], point of care. [NAME] is a desktop file system that gives a brief overview of each resident and is updated every shift. DON stated annual skill check offs are done around February or April. She stated she does spot checks as needed. She goes around and observes peri care, g tubes (gastrostomy tube is a tube inserted through the belly that brings nutrition directly to the stomach), wound care, and transfers. DON stated if she sees something incorrectly done, she will follow up and request return demonstration. DON also can do a one-to-one training, if needed. [NAME] stated when doing peri care, they are to ALWAYS included the buttocks/anal area. She has not had any issues or complaints against CNA E.<BR/>An interview on 09/21/2023 at 4:05 PM with Regional Nurse Consultant stated, DON monitors and provides oversight by having IDT meetings in the morning, daily. Nurses come during this meeting and if any questions arise or revisions are needed, then they talk to DON and other head personnel. Regional Nurse Consultant stated the negative outcome depends on the situation. He stated they would do retraining and spot checks. If it continues, then staff would be dismissed.<BR/>Record review of the policy titled Perineal Care dated implemented 10/24/2022 <BR/>revealed the following: It is the practice of this facility to provide perineal care to all <BR/>incontinent residents during routine bath or a needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and prevent and assess for skin breakdown.<BR/>Definition: Perineal care refers to the care of the external and the anal area. <BR/>Policy Explanation and Compliance Guidelines: #12. (k) Clean and dry the bottom of the scrotum and the anal area.

Based on observation, interview and record review, the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure sanitary practices were maintained in the kitchen as dishes, glasses and coffee cups were piled up, more than a single layer, in the same rack then passed through the dish washing machine. <BR/>This failure could place residents who ate from the kitchen at risk for cross-contamination and food-borne illness.<BR/>Findings included:<BR/>In an observation on 07/05/22 at 10:38 a.m., inside the ware washing area, Aide A open clean door of the dish wash machine to take out a rack that had a pile of dishes, plastic cups, and coffee cups. It was observed that the rack had more than a single layer of dishes, plastic cups and coffee cups. It was observed that there were two plastic cups that were filled with water and what appeared to be white foam. Aide proceeded to remove dishes from the rack and placed them with clean dishes, Aide A proceeded to place coffee cups from the rack with other clean coffee cups. <BR/>In an interview on 07/05/22 at 10:40 a.m., Aide A said that she was trained not load dish racks with different types of utensils or to pile them up. She said she forgot not to do it. She said there could be a risk for contamination. <BR/>In an interview on 07/05/22 at 10:42 a.m., the Dietary Manager said she had trained her staff not to mix different types of food utensils or to pile them up due to the possibility of dishes not been cleaned properly. <BR/>In an interview on 07/06/22 at 10:50 a.m., Dietary Manager said dishes could not be stacked in several piles. She also could not mix in the same rack, plates, and cups. She said trained staff verbally and then with return demonstration on how to use the dish machine and how to place similar dishes.<BR/>In an interview on 07/07/22 at 09:59 a.m., Administrator said kitchen staff were contracted. However, he went inside the kitchen, at least once or twice a week, to observe how staff worked and followed procedures to keep a sanitary kitchen. He said if one of his observations indicated that staff had not followed procedure, he would talk to the Dietary Manager about his observation. He said the Dietary Manager then would in-service the kitchen staff. <BR/>In an interview on 07/07/22 at 0:09 a.m., DON said she did rounds inside the kitchen at least once a month. She said would document findings and would relate concerns to the Dietary Manager and she would expect the concerns to be addressed by her. She said not having dishes properly sanitized could lead to the spread of infection. <BR/>In an interview on 07/07/22 at 01:06 p.m., District Food Manager said once a month she would monitor the facility and spend time in each station, including the ware washing area. She said would observe if staff followed the proper procedure to clean dishes, including loading dished in the rack. She said the procedure was to have only one pile of similar dishes per rack. She said having different types of dishes in the same rack could prevent from dishes to be cleaned properly. She said dishes were not supposed to be piled up for the same reason and it could be a risk for spreading an infection. <BR/>Record review of Facility's policy on Ware washing dated 09/2017 revealed:<BR/>- All dishware, service ware, and utensils will be cleaned and sanitized after each use<BR/>- The dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware.<BR/>Record review of Facility's Warewashing procedures for- ES2000/4000 dated 2009 revealed:<BR/>- [Washing; picture No 6: Load rack to capacity. Fill with similar dishes and glasses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting alleged allegation of abuse. CNA A failed to report an allegation of abuse to the Administrator involving Resident #1 being tucked into bed with a blanket tucked behind her shoulders sometime in March of 2025. This failure could place residents at risk for undetected abuse and neglect, and a decline in feelings of safety and well-being. The findings included: 1. Record review of Resident #1's face sheet, dated 08/22/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (progressive brain disorder that gradually destroys memory and thinking skills) unspecified dementia (a group of thinking an social symptoms that interferes with daily functioning), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and need for assistance with personal care (ADLs) Record review of Resident #1's annual MDS assessment, dated 06/05/25, revealed Resident #1 had a BIMS score of 00, indicating her cognition was severely impaired. Resident #1's MDS reflected she had unclear speech, was rarely/never understood, and rarely/never understood others. Resident #1's MDS reflected she required supervision or touching assistance to roll left or right in bed, to go from lying to sitting on the side of the bed, to sit to stand and to complete chair/bed to chair transfers. Record review of Resident #1's care plan with an initiation date of 11/21/19 reflected a problems of [Resident #1] has an ADL self -care performance deficit r/t Alzheimer's, impaired balance. Requires a lot of encouragement and guidance to complete a task. With an initiation date of 08/03/23 and intervention of, BED MOBILITY: The resident requires assistance by 1 staff to monitor for safety in bed as necessary. and TRANSFER: The resident requires assistance by 1 staff to move between surfaces necessary. with an initiation date of 08/03/23. During an attempted interview with Resident #1 on 08/06/25 at 2:35pm, she would not respond to any introduction or question. Record review of Resident #1's medical chart from March to May did not reveal any verbiage related to the allegation of Resident #1 being tucked in except for a note written by the DON on 06/18/25 when the facility received a compliance call that mentioned the incident with Resident #1. The note written by the DON stated, A head to toe assessment was performed with no open areas noted. Resident was noted to have red scratch marked to right buttock and right upper thigh with no broken skin. During n interview with CNA A on 08/08/25 at 3:31pm, he said he was no longer employed at the facility as of July, 2025. CNA A stated that sometime in March of 2025 around 3:00am or 4:00am, he was completing his rounds and noticed that Resident #1 was asleep and had 3 or 4 blankets in use and was restrained with some type of blanket. CNA A initially stated it was a blanket with a knot and then stated it was not a knot, but two ends of the blanket were tied, and the blanket was on top of Resident #1's shoulders with the corners crossed in back of her on her back but not in a knot just crossed. CNA A stated the blanket was tucked behind her shoulder blades. CNA A stated, at the time he found Resident #1, he removed the blanket. CNA A stated he did not know who placed the blanket like that and did not know if there was anyone else working with Resident #1 at that time. CNA A stated he never showed a photo of Resident #1 and never had a photo of Resident #1. CNA A stated he had completed 2 prior rounds on her during his shift and had checked her brief each time and did not see a blanket tucked behind her shoulder blades during those rounds. CNA A stated Resident #1 would not have been able to remove the blanket and stated his initial thought was that Resident #1 looked restrained. CNA A stated he considered restraints as a form of abuse. CNA A stated after he removed the blanket from Resident #1, he reported it to LVN B as a safety precaution. CNA A stated he did not report to the Administrator because he did not have her number. CNA A stated he had previously been trained over immediately reporting allegations of abuse to the abuse coordinator who was the Administrator but could not recall who provided him with that training or when. CNA A stated the facility policy stated he needed to report allegations like this one to the administrator immediately, and stated he felt he did not follow the facility policy. CNA A stated not reporting allegations of abuse or restraints to the Administrator could negatively impact residents mentally and could be considered neglect. Record review of a written statement dated 08/08/25 by the DON revealed, This statement is regarding a concern voiced in March. The resident in question was assessed by a licensed nurse who based on their professional experience, voiced that after his thorough assessment, the resident did not have any indication of abuse or neglect as defined by THHS. According to the Licensed Nurse, the resident was not in any immediate danger, her safety was in no way at risk, and the resident was noted to freely move all extremities along with being noted to get out of bed without any form of resistance or signs of distress. During an interview with LVN B on 08/11/25 at 12:43pm, he stated he didn't remember when, but thought maybe in April or May 2025 at around 5:00am in the morning, he was called over by CNA A and LVN C and was shown an undated photo without timestamp that CNA A had of Resident #1. LVN B stated Resident #1 appeared to be tucked in but was not tied. LVN B stated with the way Resident #1 was tucked in she would have been able to break out of and remove. LVN B stated CNA A did not say anything about Resident #1 being restrained or tucked in, and stated he told CNA for them to go look at Resident #1. LVN B stated he went back to see Resident #1 and found her sitting in bed with a smile with blankets at her feet. LVN B stated Resident #1 did not have any markings or signs of abuse or anything. LVN B stated he did not know if CNA A had removed the blankets from Resident #1 prior to him seeing her. LVN B stated Resident #1 had problems with mobility and would have been able to get the blanket off of her without any problems and stated when he saw the photo of Resident #1, she was smiling and had the blanket up to her chest and it was tied or wrapped it was lightly pushed in on the sides. LVN B stated he did not see any abuse or neglect, did not see anything wrong with Resident #1. LVN B stated he had nothing to report, and he did not document anything because there was nothing to document. LVN B stated he had called the DON about an hour after he was shown the photo of Resident #1, and stated she did not call him back until a little later but was not sure what time. LVN B stated at that time, he let the DON know that he was shown an undated, photo without a timestamp of Resident #1, but when he went to check her, he found her with her blankets at her feet and stated she was smiling and was unable to tell him what happened. LVN B stated he didn't think he needed to tell the Administrator because there was nothing there, he did not know when the photo was taken, and he did not see anything or suspect any abuse or neglect . LVN B stated he thought telling the DON was good. LVN B stated he had been trained over abuse and reporting requirements on their annual trainings and monthly trainings, and stated if he suspected or witnessed abuse, he had to report to the abuse coordinator, who was the Administrator, immediately. LVN B stated the Administration was responsible for reporting any allegation of abuse to HHSC and they only had 2 hours to report. LVN B stated he did not consider tucking in a resident as abuse, but if they were wrapped like a burrito, then yes, he would. LVN B stated the facility policy stated they had to report allegation of abuse to their abuse coordinator, and he did not suspect abuse from the photo he saw of Resident #1. LVN B stated he followed the facility's policy and felt like he did what needed to be done at that time. LVN B stated not reporting allegation of abuse to the Administrator, and not reporting to HHSC within the appropriate time frame, could negatively impact the residents because whatever type of abuse could be happening, could also be happening to other residents. During an interview with the DON on 08/11/25 at 3:08pm, she stated the Administrator was the abuse coordinator and responsible for reporting allegation of abuse to HHSC. The DON stated the Administrator provided monthly in-services to staff over abuse which included examples of abuse and what was considered abuse. The DON stated staff were educated on reporting to the Administrator, herself, and the ADON, if they suspected or witnessed any abuse. The DON stated, sometime in March, LVN B had gotten word from CNA A that Resident #1 was tucked in bed, but according to his assessment, she was freely able to move around and get out of bed and he did see anything impeding her from getting out of bed. The DON stated LVN B stated Resident #1 was not scared or afraid, and had no signs that would warn him that something had occurred. The DON stated she was not made aware until a couple days later, when LVN B called her at 7:00am or 8:00am a couple days after to notify her of what he had been told by CNA A. She stated she told LVN B to notify staff of doing things how they should be done with residents, and they completed an In-service with whatever staff was available at that time. The DON stated they did not document or do any investigation at that time, but did complete an in-service. The DON stated they did not do an investigation, because based on LVN B's clinical judgment ,Resident #1 was fine, and LVN B stated there was nothing to report because Resident #1 was free to move around and was safe with no signs or symptoms of abuse. The DON stated if a resident was tucked in tightly to where they could not move or get themselves out, then it would be considered restraints, and restraints would be consider abuse. The DON stated after LVN B reported to her, she called the Administrator who had also just been made aware, and after they spoke about it, there was nothing to report because LVN B said there were no signs or symptoms of abuse that was noted. The DON stated CNA A and LVN B should have reported these allegations to the Administrator at the time they occurred. The DON stated they had a 2-hour time frame to report to HHSC, but did not report anything until they received a compliance call in June 2025 that mentioned the incident. The DON stated the facility's policy stated they had to make a report to the state within 2 hours if they were told of any abuse. The DON stated herself and staff followed the facility's policy and they went by the information they received from the nurses, what they saw, and the findings on their assessments. The DON stated not reporting allegations of abuse to the Administrator, or HHSC within 2 hours, could negatively impact residents with harm if there was actual abuse. The DON stated, in this case, there was nothing. During an interview with the Administrator on 08/11/25 at 4:37pm, she stated she was not aware of the exact date or time that CNA A notified LVN B of Resident #1 being tucked in, but stated CNA A asked LVN B if he could go look at Resident #1 and see how she was tucked in. The Administrator stated LVN B went to assess Resident #1, did not see any signs or symptoms of abuse or anything, and as per his clinical judgement, felt it was nothing to be concerned about. The Administrator stated the DON notified her, she did not remember at what date or time she was notified ,but it was later that same morning. The Administrator stated they did not do anything else in response and did not report it because based on the information provided to them from LVN B, Resident was stable, there was nothing to report, and had not been reported as abuse. The Administrator stated CNA A could have reported to her, but he felt safe with LVN B so he reported to him, the Administrator stated LVN B did not report to her and could have so that she could have been aware as to what was going on. The Administrator stated If LVN B had found something then he should have reported to it to her. The Administrator stated she was the abuse coordinator and was responsible for reporting any allegation of abuse to HHSC. The Administrator stated herself and staff had been trained over reporting abuse at least monthly, and staff should report to her as soon as possible because she only had 2 hours to report. The Administrator stated she considered restraints as abuse, but with being tucked in, it depended. The Administrator stated their facility's policy stated if staff saw, suspected, or even if they were not sure of it, they had to report any abuse to her. She stated, in this situation, she felt her and the staff followed that policy. The Administrator stated they monitored facility incidents to ensure they identified reportables and their appropriate time frame by reviewing documentation, rounding, and providing in-services to staff on what should be reported. The Administrator stated not reporting allegations of abuse to the Administrator and HHSC within a 2-hour time frame could negatively impact the residents because they would not be investigating or following protocols, and if they were not aware, then they were not doing interventions. Record review of the facility's in-service dated 02/13/25 that was provided by the Administrator covered abuse and neglect, and the 3 R's (recognize, remove, report) revealed CNA A, LVN B and the DON had received the training. Record review of the facility's policy with an implemented date of 07/11/25 and titled, Abuse, Neglect and Exploitation included a section titled, V. Investigation of Alleged Abuse, Neglect, and Exploitation that included verbiage stating, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. VII. Reporting/Response.1.Reporting of all alleged violation to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hour after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident and/or resident representative written notice which specified the duration of the bed-hold policy at the time of transfer of a resident for hospitalization for 1 of 3 residents (Resident #1) reviewed for transfers, in that:<BR/>The facility did not ensure Resident #1's RP was provided with a written bed-hold policy on 11-06-2023 when Resident #1 was transferred to the hospital. <BR/>This failure could place residents at risk of being improperly discharged and placed in unsafe conditions. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated 11/12/2024 reflected Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), seizers (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain), hyperlipidemia (High levels of blood lipids (fats and waxes such as cholesterol), and hypertension (high blood pressure).<BR/>Record review of Resident #1's quarterly MDS assessment, dated 09/04/204 reflected a BIMS score of 04 which indicated her cognition was severely impaired. <BR/>Record review of facility Bed Hold Agreement dated 11/07/2023 reflected it did not include any information such as the duration of bed hold, or the daily rate beyond the allowable days that the state plan would cover. The Bed Hold Agreement only included Resident #1's name and Resident #1's responsible party's name. Resident #1's RP signature was not on form titled Bed Hold Agreement, instead Verbal Authorization given by: over the phone Family Member was noted. The word no was written over the Resident and Family Member/Legal Representative lines. Facility BOM signed the document tiled Bed Hold Agreement.<BR/>Record review of Resident #1's Progress Notes authored by LVN A dated 11/06/2023 reflected: <BR/>Resident found laying on floor supine with legs in flexed position and left hand behind head, crying and moaning reporting pain .Resident was log rolled to left side and red drainage was noted to back of head in center of purple discoloration. Back of head inspected. Swelling noted induration of 6.5cm x 5.5cm with purple discoloration measuring 1.5cm x 1.0cm in center draining serosanguinous drainage coming from an open area. Posterior torso and buttocks noted no acute visible injuries, but resident nodded when asked if she was hurt to areas as nurse palpated . 10:24 Received orders to sent out to ER via EMS .<BR/>In an interview on 11/14/2024 at 11:50 p.m., LVN A said Resident #1 sustained a fall on 11/06/2024 and received orders from her NP to be transferred out to the emergency room. She said Resident #1 was admitted to the hospital. LVN A said when a resident was transferred to the hospital the charge nurse would call the RP and provide information via phone. LVN A said The BOM was responsible for initiating the bed hold agreement. <BR/>A phone interview on 11/15/2024 at 12:09 p.m., The BOM said when a resident was transferred to the hospital and admitted , she would contact their RP to see if they were interested in a bed hold request. She said if their RP requested a bed hold, she would obtain verbal consent and file the form in her office. The BOM said she did not know she had to obtain the resident's or RP's signature, she said she had only been obtaining verbal consent. The BOM said each morning, she would check the Admission/Discharge To/From Report to determine which residents required a bed hold agreement. The BOM said there were no negative outcome for not having the resident or their RP sign the bed hold agreement form because the facility had plenty of room available. <BR/>A phone interview on 11/15/2024 at 12:45 p.m., Resident #1's RP said she remembered a facility's nurse called her on 11/06/2023 to let her know Resident #1 had fallen and was being transferred out to the hospital. Resident #1's RP said the facility did not provide her with any written document regarding their bed hold policy nor was it explained to her. <BR/>An interview on 11/15/2024 at 3:06 p.m., The DON said the bed hold agreement forms were completed by the BOM. The DON said there were no negative outcome to Resident #1 not having a signed bed hold agreement form for when she was sent to the hospital on [DATE] because the facility had plenty of rooms available. <BR/>Record review of the facility's Bed Hold Notice Upon Transfer policy dated October 24, 2022, reflected:<BR/>Policy:<BR/>At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed .<BR/>Bed Hold Notice Upon Transfer:<BR/>2. In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies, as stipulated in the State's plan.<BR/>5. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting alleged allegation of abuse. CNA A failed to report an allegation of abuse to the Administrator involving Resident #1 being tucked into bed with a blanket tucked behind her shoulders sometime in March of 2025. This failure could place residents at risk for undetected abuse and neglect, and a decline in feelings of safety and well-being. The findings included: 1. Record review of Resident #1's face sheet, dated 08/22/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (progressive brain disorder that gradually destroys memory and thinking skills) unspecified dementia (a group of thinking an social symptoms that interferes with daily functioning), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and need for assistance with personal care (ADLs) Record review of Resident #1's annual MDS assessment, dated 06/05/25, revealed Resident #1 had a BIMS score of 00, indicating her cognition was severely impaired. Resident #1's MDS reflected she had unclear speech, was rarely/never understood, and rarely/never understood others. Resident #1's MDS reflected she required supervision or touching assistance to roll left or right in bed, to go from lying to sitting on the side of the bed, to sit to stand and to complete chair/bed to chair transfers. Record review of Resident #1's care plan with an initiation date of 11/21/19 reflected a problems of [Resident #1] has an ADL self -care performance deficit r/t Alzheimer's, impaired balance. Requires a lot of encouragement and guidance to complete a task. With an initiation date of 08/03/23 and intervention of, BED MOBILITY: The resident requires assistance by 1 staff to monitor for safety in bed as necessary. and TRANSFER: The resident requires assistance by 1 staff to move between surfaces necessary. with an initiation date of 08/03/23. During an attempted interview with Resident #1 on 08/06/25 at 2:35pm, she would not respond to any introduction or question. Record review of Resident #1's medical chart from March to May did not reveal any verbiage related to the allegation of Resident #1 being tucked in except for a note written by the DON on 06/18/25 when the facility received a compliance call that mentioned the incident with Resident #1. The note written by the DON stated, A head to toe assessment was performed with no open areas noted. Resident was noted to have red scratch marked to right buttock and right upper thigh with no broken skin. During n interview with CNA A on 08/08/25 at 3:31pm, he said he was no longer employed at the facility as of July, 2025. CNA A stated that sometime in March of 2025 around 3:00am or 4:00am, he was completing his rounds and noticed that Resident #1 was asleep and had 3 or 4 blankets in use and was restrained with some type of blanket. CNA A initially stated it was a blanket with a knot and then stated it was not a knot, but two ends of the blanket were tied, and the blanket was on top of Resident #1's shoulders with the corners crossed in back of her on her back but not in a knot just crossed. CNA A stated the blanket was tucked behind her shoulder blades. CNA A stated, at the time he found Resident #1, he removed the blanket. CNA A stated he did not know who placed the blanket like that and did not know if there was anyone else working with Resident #1 at that time. CNA A stated he never showed a photo of Resident #1 and never had a photo of Resident #1. CNA A stated he had completed 2 prior rounds on her during his shift and had checked her brief each time and did not see a blanket tucked behind her shoulder blades during those rounds. CNA A stated Resident #1 would not have been able to remove the blanket and stated his initial thought was that Resident #1 looked restrained. CNA A stated he considered restraints as a form of abuse. CNA A stated after he removed the blanket from Resident #1, he reported it to LVN B as a safety precaution. CNA A stated he did not report to the Administrator because he did not have her number. CNA A stated he had previously been trained over immediately reporting allegations of abuse to the abuse coordinator who was the Administrator but could not recall who provided him with that training or when. CNA A stated the facility policy stated he needed to report allegations like this one to the administrator immediately, and stated he felt he did not follow the facility policy. CNA A stated not reporting allegations of abuse or restraints to the Administrator could negatively impact residents mentally and could be considered neglect. Record review of a written statement dated 08/08/25 by the DON revealed, This statement is regarding a concern voiced in March. The resident in question was assessed by a licensed nurse who based on their professional experience, voiced that after his thorough assessment, the resident did not have any indication of abuse or neglect as defined by THHS. According to the Licensed Nurse, the resident was not in any immediate danger, her safety was in no way at risk, and the resident was noted to freely move all extremities along with being noted to get out of bed without any form of resistance or signs of distress. During an interview with LVN B on 08/11/25 at 12:43pm, he stated he didn't remember when, but thought maybe in April or May 2025 at around 5:00am in the morning, he was called over by CNA A and LVN C and was shown an undated photo without timestamp that CNA A had of Resident #1. LVN B stated Resident #1 appeared to be tucked in but was not tied. LVN B stated with the way Resident #1 was tucked in she would have been able to break out of and remove. LVN B stated CNA A did not say anything about Resident #1 being restrained or tucked in, and stated he told CNA for them to go look at Resident #1. LVN B stated he went back to see Resident #1 and found her sitting in bed with a smile with blankets at her feet. LVN B stated Resident #1 did not have any markings or signs of abuse or anything. LVN B stated he did not know if CNA A had removed the blankets from Resident #1 prior to him seeing her. LVN B stated Resident #1 had problems with mobility and would have been able to get the blanket off of her without any problems and stated when he saw the photo of Resident #1, she was smiling and had the blanket up to her chest and it was tied or wrapped it was lightly pushed in on the sides. LVN B stated he did not see any abuse or neglect, did not see anything wrong with Resident #1. LVN B stated he had nothing to report, and he did not document anything because there was nothing to document. LVN B stated he had called the DON about an hour after he was shown the photo of Resident #1, and stated she did not call him back until a little later but was not sure what time. LVN B stated at that time, he let the DON know that he was shown an undated, photo without a timestamp of Resident #1, but when he went to check her, he found her with her blankets at her feet and stated she was smiling and was unable to tell him what happened. LVN B stated he didn't think he needed to tell the Administrator because there was nothing there, he did not know when the photo was taken, and he did not see anything or suspect any abuse or neglect . LVN B stated he thought telling the DON was good. LVN B stated he had been trained over abuse and reporting requirements on their annual trainings and monthly trainings, and stated if he suspected or witnessed abuse, he had to report to the abuse coordinator, who was the Administrator, immediately. LVN B stated the Administration was responsible for reporting any allegation of abuse to HHSC and they only had 2 hours to report. LVN B stated he did not consider tucking in a resident as abuse, but if they were wrapped like a burrito, then yes, he would. LVN B stated the facility policy stated they had to report allegation of abuse to their abuse coordinator, and he did not suspect abuse from the photo he saw of Resident #1. LVN B stated he followed the facility's policy and felt like he did what needed to be done at that time. LVN B stated not reporting allegation of abuse to the Administrator, and not reporting to HHSC within the appropriate time frame, could negatively impact the residents because whatever type of abuse could be happening, could also be happening to other residents. During an interview with the DON on 08/11/25 at 3:08pm, she stated the Administrator was the abuse coordinator and responsible for reporting allegation of abuse to HHSC. The DON stated the Administrator provided monthly in-services to staff over abuse which included examples of abuse and what was considered abuse. The DON stated staff were educated on reporting to the Administrator, herself, and the ADON, if they suspected or witnessed any abuse. The DON stated, sometime in March, LVN B had gotten word from CNA A that Resident #1 was tucked in bed, but according to his assessment, she was freely able to move around and get out of bed and he did see anything impeding her from getting out of bed. The DON stated LVN B stated Resident #1 was not scared or afraid, and had no signs that would warn him that something had occurred. The DON stated she was not made aware until a couple days later, when LVN B called her at 7:00am or 8:00am a couple days after to notify her of what he had been told by CNA A. She stated she told LVN B to notify staff of doing things how they should be done with residents, and they completed an In-service with whatever staff was available at that time. The DON stated they did not document or do any investigation at that time, but did complete an in-service. The DON stated they did not do an investigation, because based on LVN B's clinical judgment ,Resident #1 was fine, and LVN B stated there was nothing to report because Resident #1 was free to move around and was safe with no signs or symptoms of abuse. The DON stated if a resident was tucked in tightly to where they could not move or get themselves out, then it would be considered restraints, and restraints would be consider abuse. The DON stated after LVN B reported to her, she called the Administrator who had also just been made aware, and after they spoke about it, there was nothing to report because LVN B said there were no signs or symptoms of abuse that was noted. The DON stated CNA A and LVN B should have reported these allegations to the Administrator at the time they occurred. The DON stated they had a 2-hour time frame to report to HHSC, but did not report anything until they received a compliance call in June 2025 that mentioned the incident. The DON stated the facility's policy stated they had to make a report to the state within 2 hours if they were told of any abuse. The DON stated herself and staff followed the facility's policy and they went by the information they received from the nurses, what they saw, and the findings on their assessments. The DON stated not reporting allegations of abuse to the Administrator, or HHSC within 2 hours, could negatively impact residents with harm if there was actual abuse. The DON stated, in this case, there was nothing. During an interview with the Administrator on 08/11/25 at 4:37pm, she stated she was not aware of the exact date or time that CNA A notified LVN B of Resident #1 being tucked in, but stated CNA A asked LVN B if he could go look at Resident #1 and see how she was tucked in. The Administrator stated LVN B went to assess Resident #1, did not see any signs or symptoms of abuse or anything, and as per his clinical judgement, felt it was nothing to be concerned about. The Administrator stated the DON notified her, she did not remember at what date or time she was notified ,but it was later that same morning. The Administrator stated they did not do anything else in response and did not report it because based on the information provided to them from LVN B, Resident was stable, there was nothing to report, and had not been reported as abuse. The Administrator stated CNA A could have reported to her, but he felt safe with LVN B so he reported to him, the Administrator stated LVN B did not report to her and could have so that she could have been aware as to what was going on. The Administrator stated If LVN B had found something then he should have reported to it to her. The Administrator stated she was the abuse coordinator and was responsible for reporting any allegation of abuse to HHSC. The Administrator stated herself and staff had been trained over reporting abuse at least monthly, and staff should report to her as soon as possible because she only had 2 hours to report. The Administrator stated she considered restraints as abuse, but with being tucked in, it depended. The Administrator stated their facility's policy stated if staff saw, suspected, or even if they were not sure of it, they had to report any abuse to her. She stated, in this situation, she felt her and the staff followed that policy. The Administrator stated they monitored facility incidents to ensure they identified reportables and their appropriate time frame by reviewing documentation, rounding, and providing in-services to staff on what should be reported. The Administrator stated not reporting allegations of abuse to the Administrator and HHSC within a 2-hour time frame could negatively impact the residents because they would not be investigating or following protocols, and if they were not aware, then they were not doing interventions. Record review of the facility's in-service dated 02/13/25 that was provided by the Administrator covered abuse and neglect, and the 3 R's (recognize, remove, report) revealed CNA A, LVN B and the DON had received the training. Record review of the facility's policy with an implemented date of 07/11/25 and titled, Abuse, Neglect and Exploitation included a section titled, V. Investigation of Alleged Abuse, Neglect, and Exploitation that included verbiage stating, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. VII. Reporting/Response.1.Reporting of all alleged violation to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hour after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting alleged allegation of abuse. CNA A failed to report an allegation of abuse to the Administrator involving Resident #1 being tucked into bed with a blanket tucked behind her shoulders sometime in March of 2025. This failure could place residents at risk for undetected abuse and neglect, and a decline in feelings of safety and well-being. The findings included: 1. Record review of Resident #1's face sheet, dated 08/22/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (progressive brain disorder that gradually destroys memory and thinking skills) unspecified dementia (a group of thinking an social symptoms that interferes with daily functioning), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and need for assistance with personal care (ADLs) Record review of Resident #1's annual MDS assessment, dated 06/05/25, revealed Resident #1 had a BIMS score of 00, indicating her cognition was severely impaired. Resident #1's MDS reflected she had unclear speech, was rarely/never understood, and rarely/never understood others. Resident #1's MDS reflected she required supervision or touching assistance to roll left or right in bed, to go from lying to sitting on the side of the bed, to sit to stand and to complete chair/bed to chair transfers. Record review of Resident #1's care plan with an initiation date of 11/21/19 reflected a problems of [Resident #1] has an ADL self -care performance deficit r/t Alzheimer's, impaired balance. Requires a lot of encouragement and guidance to complete a task. With an initiation date of 08/03/23 and intervention of, BED MOBILITY: The resident requires assistance by 1 staff to monitor for safety in bed as necessary. and TRANSFER: The resident requires assistance by 1 staff to move between surfaces necessary. with an initiation date of 08/03/23. During an attempted interview with Resident #1 on 08/06/25 at 2:35pm, she would not respond to any introduction or question. Record review of Resident #1's medical chart from March to May did not reveal any verbiage related to the allegation of Resident #1 being tucked in except for a note written by the DON on 06/18/25 when the facility received a compliance call that mentioned the incident with Resident #1. The note written by the DON stated, A head to toe assessment was performed with no open areas noted. Resident was noted to have red scratch marked to right buttock and right upper thigh with no broken skin. During n interview with CNA A on 08/08/25 at 3:31pm, he said he was no longer employed at the facility as of July, 2025. CNA A stated that sometime in March of 2025 around 3:00am or 4:00am, he was completing his rounds and noticed that Resident #1 was asleep and had 3 or 4 blankets in use and was restrained with some type of blanket. CNA A initially stated it was a blanket with a knot and then stated it was not a knot, but two ends of the blanket were tied, and the blanket was on top of Resident #1's shoulders with the corners crossed in back of her on her back but not in a knot just crossed. CNA A stated the blanket was tucked behind her shoulder blades. CNA A stated, at the time he found Resident #1, he removed the blanket. CNA A stated he did not know who placed the blanket like that and did not know if there was anyone else working with Resident #1 at that time. CNA A stated he never showed a photo of Resident #1 and never had a photo of Resident #1. CNA A stated he had completed 2 prior rounds on her during his shift and had checked her brief each time and did not see a blanket tucked behind her shoulder blades during those rounds. CNA A stated Resident #1 would not have been able to remove the blanket and stated his initial thought was that Resident #1 looked restrained. CNA A stated he considered restraints as a form of abuse. CNA A stated after he removed the blanket from Resident #1, he reported it to LVN B as a safety precaution. CNA A stated he did not report to the Administrator because he did not have her number. CNA A stated he had previously been trained over immediately reporting allegations of abuse to the abuse coordinator who was the Administrator but could not recall who provided him with that training or when. CNA A stated the facility policy stated he needed to report allegations like this one to the administrator immediately, and stated he felt he did not follow the facility policy. CNA A stated not reporting allegations of abuse or restraints to the Administrator could negatively impact residents mentally and could be considered neglect. Record review of a written statement dated 08/08/25 by the DON revealed, This statement is regarding a concern voiced in March. The resident in question was assessed by a licensed nurse who based on their professional experience, voiced that after his thorough assessment, the resident did not have any indication of abuse or neglect as defined by THHS. According to the Licensed Nurse, the resident was not in any immediate danger, her safety was in no way at risk, and the resident was noted to freely move all extremities along with being noted to get out of bed without any form of resistance or signs of distress. During an interview with LVN B on 08/11/25 at 12:43pm, he stated he didn't remember when, but thought maybe in April or May 2025 at around 5:00am in the morning, he was called over by CNA A and LVN C and was shown an undated photo without timestamp that CNA A had of Resident #1. LVN B stated Resident #1 appeared to be tucked in but was not tied. LVN B stated with the way Resident #1 was tucked in she would have been able to break out of and remove. LVN B stated CNA A did not say anything about Resident #1 being restrained or tucked in, and stated he told CNA for them to go look at Resident #1. LVN B stated he went back to see Resident #1 and found her sitting in bed with a smile with blankets at her feet. LVN B stated Resident #1 did not have any markings or signs of abuse or anything. LVN B stated he did not know if CNA A had removed the blankets from Resident #1 prior to him seeing her. LVN B stated Resident #1 had problems with mobility and would have been able to get the blanket off of her without any problems and stated when he saw the photo of Resident #1, she was smiling and had the blanket up to her chest and it was tied or wrapped it was lightly pushed in on the sides. LVN B stated he did not see any abuse or neglect, did not see anything wrong with Resident #1. LVN B stated he had nothing to report, and he did not document anything because there was nothing to document. LVN B stated he had called the DON about an hour after he was shown the photo of Resident #1, and stated she did not call him back until a little later but was not sure what time. LVN B stated at that time, he let the DON know that he was shown an undated, photo without a timestamp of Resident #1, but when he went to check her, he found her with her blankets at her feet and stated she was smiling and was unable to tell him what happened. LVN B stated he didn't think he needed to tell the Administrator because there was nothing there, he did not know when the photo was taken, and he did not see anything or suspect any abuse or neglect . LVN B stated he thought telling the DON was good. LVN B stated he had been trained over abuse and reporting requirements on their annual trainings and monthly trainings, and stated if he suspected or witnessed abuse, he had to report to the abuse coordinator, who was the Administrator, immediately. LVN B stated the Administration was responsible for reporting any allegation of abuse to HHSC and they only had 2 hours to report. LVN B stated he did not consider tucking in a resident as abuse, but if they were wrapped like a burrito, then yes, he would. LVN B stated the facility policy stated they had to report allegation of abuse to their abuse coordinator, and he did not suspect abuse from the photo he saw of Resident #1. LVN B stated he followed the facility's policy and felt like he did what needed to be done at that time. LVN B stated not reporting allegation of abuse to the Administrator, and not reporting to HHSC within the appropriate time frame, could negatively impact the residents because whatever type of abuse could be happening, could also be happening to other residents. During an interview with the DON on 08/11/25 at 3:08pm, she stated the Administrator was the abuse coordinator and responsible for reporting allegation of abuse to HHSC. The DON stated the Administrator provided monthly in-services to staff over abuse which included examples of abuse and what was considered abuse. The DON stated staff were educated on reporting to the Administrator, herself, and the ADON, if they suspected or witnessed any abuse. The DON stated, sometime in March, LVN B had gotten word from CNA A that Resident #1 was tucked in bed, but according to his assessment, she was freely able to move around and get out of bed and he did see anything impeding her from getting out of bed. The DON stated LVN B stated Resident #1 was not scared or afraid, and had no signs that would warn him that something had occurred. The DON stated she was not made aware until a couple days later, when LVN B called her at 7:00am or 8:00am a couple days after to notify her of what he had been told by CNA A. She stated she told LVN B to notify staff of doing things how they should be done with residents, and they completed an In-service with whatever staff was available at that time. The DON stated they did not document or do any investigation at that time, but did complete an in-service. The DON stated they did not do an investigation, because based on LVN B's clinical judgment ,Resident #1 was fine, and LVN B stated there was nothing to report because Resident #1 was free to move around and was safe with no signs or symptoms of abuse. The DON stated if a resident was tucked in tightly to where they could not move or get themselves out, then it would be considered restraints, and restraints would be consider abuse. The DON stated after LVN B reported to her, she called the Administrator who had also just been made aware, and after they spoke about it, there was nothing to report because LVN B said there were no signs or symptoms of abuse that was noted. The DON stated CNA A and LVN B should have reported these allegations to the Administrator at the time they occurred. The DON stated they had a 2-hour time frame to report to HHSC, but did not report anything until they received a compliance call in June 2025 that mentioned the incident. The DON stated the facility's policy stated they had to make a report to the state within 2 hours if they were told of any abuse. The DON stated herself and staff followed the facility's policy and they went by the information they received from the nurses, what they saw, and the findings on their assessments. The DON stated not reporting allegations of abuse to the Administrator, or HHSC within 2 hours, could negatively impact residents with harm if there was actual abuse. The DON stated, in this case, there was nothing. During an interview with the Administrator on 08/11/25 at 4:37pm, she stated she was not aware of the exact date or time that CNA A notified LVN B of Resident #1 being tucked in, but stated CNA A asked LVN B if he could go look at Resident #1 and see how she was tucked in. The Administrator stated LVN B went to assess Resident #1, did not see any signs or symptoms of abuse or anything, and as per his clinical judgement, felt it was nothing to be concerned about. The Administrator stated the DON notified her, she did not remember at what date or time she was notified ,but it was later that same morning. The Administrator stated they did not do anything else in response and did not report it because based on the information provided to them from LVN B, Resident was stable, there was nothing to report, and had not been reported as abuse. The Administrator stated CNA A could have reported to her, but he felt safe with LVN B so he reported to him, the Administrator stated LVN B did not report to her and could have so that she could have been aware as to what was going on. The Administrator stated If LVN B had found something then he should have reported to it to her. The Administrator stated she was the abuse coordinator and was responsible for reporting any allegation of abuse to HHSC. The Administrator stated herself and staff had been trained over reporting abuse at least monthly, and staff should report to her as soon as possible because she only had 2 hours to report. The Administrator stated she considered restraints as abuse, but with being tucked in, it depended. The Administrator stated their facility's policy stated if staff saw, suspected, or even if they were not sure of it, they had to report any abuse to her. She stated, in this situation, she felt her and the staff followed that policy. The Administrator stated they monitored facility incidents to ensure they identified reportables and their appropriate time frame by reviewing documentation, rounding, and providing in-services to staff on what should be reported. The Administrator stated not reporting allegations of abuse to the Administrator and HHSC within a 2-hour time frame could negatively impact the residents because they would not be investigating or following protocols, and if they were not aware, then they were not doing interventions. Record review of the facility's in-service dated 02/13/25 that was provided by the Administrator covered abuse and neglect, and the 3 R's (recognize, remove, report) revealed CNA A, LVN B and the DON had received the training. Record review of the facility's policy with an implemented date of 07/11/25 and titled, Abuse, Neglect and Exploitation included a section titled, V. Investigation of Alleged Abuse, Neglect, and Exploitation that included verbiage stating, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. VII. Reporting/Response.1.Reporting of all alleged violation to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hour after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to have physician orders for the residents immediate care at time of admission for 1 of 4 residents (Resident #3) reviewed for physician admission orders.<BR/>The facility failed to have physician orders in place for care/treatment/monitoring of Resident #3's colostomy.<BR/>This deficient practice could place residents with a colostomy at risk in delay in treatment/care.<BR/>The findings were:<BR/>Record review of Resident #3's face sheet, dated 08/05/24, revealed a [AGE] year old male with an initial admission date of 10/13/2023 with diagnoses which included: encounter for surgical aftercare following surgery of the digestive system (organs that are important for digesting food and liquids), acquired absence of other specified parts of digestive tract (made up of organs that food/liquid travel through when they are swallowed, digested, absorbed and leave the body as feces), colostomy (surgery to create an opening for the colon through the belly) status, hemiplegia (paralysis of one side of body) and hemiparesis (one sided muscle weakness) following unspecified cerebrovascular disease (group of conditions that affect blood flow and the blood vessels in the brain) affecting left non-dominant side.<BR/>Record review of Resident #3's optional state assessment minimum data set assessment (MDS), dated [DATE], revealed Resident #3 had a BIMS score of 10, indicating a moderate cognitive impairment. The MDS assessment reflected Resident #3 was total dependent with 1 person physical assist for toilet use (manages ostomy). <BR/>Record review of Resident #3's care plan with an initiated date of 06/14/18 revealed a problem of, [Resident #3] was re-admitted back to the facility with alteration in gastro-intestinal status r/t (related to) colostomy with an initiated date of 7/24/24. Resident #3's care plan had a goal of, The resident will remain free from discomfort, complications or s/sx (signs and symptoms) related to gastro-intestinal alterations through review date. with an initiated date of 7/24/24 and an intervention to Perform treatment/change in colostomy bag as ordered. Monitor/document BMs (bowel movements) with an initiated date of 7/30/24. <BR/>Record review of Resident #3's hospital progress notes dated 07/22/24 revealed Resident #3 had an open sigmoid colectomy with end colostomy on 7/14/24. <BR/>Record review of Resident #3's hospital discharge documents dated 07/24/24 included a section titled, Medication Instructions and did not include any verbiage regarding colostomy care/treatment or monitoring. Resident #3's hospital discharge documents did include a general education on colostomy care in Spanish and when translated stated the following:<BR/>Summary<BR/>o Routinely measure the stoma opening and record the size. Be alert to changes.<BR/>o Empty the bag before sleeping, before physical activity or sexual intercourse, and always when it has been filled one third or up to half of its capacity. Do not let the bag become more than half full of feces or gas.<BR/>o Replace the bag every 3 or 4 days or as often as directed by your doctor.<BR/>Record review of Resident #3's initial nursing evaluation completed by LVN A and dated 07/24/24 revealed Resident #3 had a left side colostomy site located on the front left iliac crest.<BR/>Record review of Resident #3's physician's orders dated 07/01/24 through 08/05/24, revealed no physician's orders for colostomy care/treatment/monitoring.<BR/>Record review of Resident #3's July 2024 progress notes dated 7/24/24 to 07/31/24 revealed no documentation of colostomy care/treatment/monitoring provided.<BR/>Record review of Resident #3's progress notes dated 07/24/24 at 21:55 (9:55pm) written by RN B stated [MD E] was made aware of medication orders from hospital. as per [MD E], continue medications as listed on [medical chart software].<BR/>During an observation and interview with the DON on 08/06/24 at 12:10 p.m. she confirmed Resident #3 had a colostomy in place. Observation of Resident #3 revealed a colostomy bag on his left lower abdomen that appeared intact with no redness noted, colostomy site and bag were clean and was not full, puffed or leaking any fecal matter or bodily fluids. <BR/>During an interview with RN B on 08/05/24 at 9:43pm he stated he was not the admitting nurse and stated the admitting nurse was LVN A. RN B stated they helped each other out as far as admissions coming in and stated that was why his note was in Resident #3's chart. RN B stated LVN A did the full admission and stated to look at the initial nursing evaluation to see that it was completed by LVN A. <BR/>During an interview on 08/06/24 at 11:55 a.m., Resident #3 stated he had a bag on his stomach that was being checked and cleaned in the morning and during the day by staff. Resident #3 stated the bag on his stomach was changed once a day and had not leaked. <BR/>During a telephone interview on 08/06/24 at 1:38pm with LVN A he stated he was the admitting nurse when Resident #3 returned to the facility on 7/24/24 and stated Resident #3 was admitted with a colostomy in place which was new for him. LVN A stated the nurse was responsible for getting an order and confirming the order with the MD and inputting the order. LVN A stated he notified the MD about Resident #3's colostomy and information he received from hospital but was unable to recall what the MD had said. LVN A stated he and the team working with him that day had split up the orders and stated he would do the assessments and someone else would input orders, however he did not recall who was assisting him with inputting orders and stated he did not recall inputting any orders for colostomy care/treatment/monitoring and had not put them in because he thought someone else had already put them in. LVN A stated orders for Resident #3's colostomy care/treatment/monitoring should have been input. LVN A stated 7/24/24 was the only day he worked with Resident #3 and was unable to detail how often Resident #3 received colostomy care/treatment/monitoring. LVN A stated he was unsure how staff would know how often to complete colostomy care/treatment/monitoring or change out Resident #3's colostomy bag without orders in his chart and stated it would be completed if saturated, dirty or if fecal matter was present. LVN A stated orders needed to be in place prior to providing a resident with care/treatment/services. LVN A was unsure if he followed the facility policy regarding needing physician orders in place to provide care/treatment/services to residents and was unsure what the facility policy stated. LVN A stated he had previously had hands on training with assistance from the nursing leadership and other nurses over inputting orders when residents were admitted to the facility. LVN A stated to ensure physician's orders had been appropriately documented the RNs, ADON and DON would go in and see what was on the order list. LVN A stated providing colostomy care/treatment/monitoring without physician's orders appropriately documented could negatively impact the resident because they might not get the most appropriate care. <BR/>During an interview with the DON on 08/06/24 at 3:00pm. The DON stated she began working at the facility on 07/29/24 and was not present when Resident #3 was readmitted to the facility on [DATE]. The DON stated Resident #3 returned to the facility on 7/24/24 with a colostomy that was new to him. The DON had recently been hired and stated from what she learned the staff had been splitting their admissions by one nurse inputting the medication and the floor nurse doing the assessment and including any extra information such as wounds/colostomy. The DON stated at the end of the night LVN A was responsible for doing the assessment and inputting the colostomy order. The DON confirmed there were not any colostomy care/treatment/monitoring orders in place and had not been put in place until 08/06/24 when she reviewed the record after Surveyor F notified her. The DON stated the orders for colostomy care/treatment/monitoring should have been input and needed to be in place prior to providing a resident with care/treatment services related to a colostomy. The DON stated she did not know why they were not inputted and stated she thought it was due to oversight from the nurse. The DON stated Resident #3's colostomy was being monitored, checked, cleaned and cared for with bag changes and could tell because when it was a new bag it looked clean and stated the bag was being emptied every time he ate because it would get full of air. The DON stated Resident #3 was receiving colostomy care at least every shift and stated the bag was being changed weekly and as needed if it came undone. The DON stated that although there weren't orders in Resident #3's chart the nurses on the floor were veteran nurses and knew when to change and how to follow through with the colostomy. She stated every time Resident #3 got a brief change, they would check the colostomy and would make sure his bag was secure and checked for leaks when he was bathed. The DON stated LVN A and nursing staff in general were oriented upon hire over inputting orders. The DON stated they did not have a general or specific policy for inputting physician orders for colostomy care/treatment/monitoring. The DON stated the ADON and DON would complete an audit to ensure that orders were in place and would try to review the orders as soon as a patient came in and if they arrived at night then they would review orders and pending orders the next day. The DON stated Resident #3 had been receiving his colostomy care but stated providing colostomy care/treatment/monitoring without physician's orders appropriately documented could negatively impact the resident because they could miss their colostomy care. <BR/>Record review of LVN A's annual check off revealed he had been checked off for inputting order information in software on 04/09/24 by the previous director of nursing, DON D. <BR/>During an interview with the DON on 08/06/24 at 4:58pm she stated they did not have a general or specific policy for physician's orders needed to provide care/treatment/services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 Residents (Resident #2) reviewed for medical records accuracy, in that:<BR/>Resident #2's April and May 2024 Treatment Administration Records documentation was incomplete. Staff did not document or sign off on the administration of physician ordered wound care.<BR/>This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.<BR/>The findings included: <BR/>1. Record review of Resident #2's face sheet, dated 06/13/24, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: pressure ulcer of sacral region, stage 4 (sores that extend below the subcutaneous fat into deep tissue, including muscle, tendons and ligaments), Alzheimer's disease, unspecified (progressive disease that destroys memory and other important mental functions), chronic kidney disease, unspecified (longstanding disease of the kidneys leading to renal failure), chronic diastolic (congestive) heart failure (when heart cant pump blood well enough to give your body normal supply and your left ventricle becomes stiffer than normal).<BR/>Record review of Resident #2's state optional Minimum Data Set assessment, dated 04/05/24, revealed Resident #2 had a BIMS score of 03, indicating she was severely cognitively impaired.<BR/>Record review of Resident #2's care plan, retrieved on 06/13/24 revealed Resident #2 had a focus of, [Resident #2] [has] a stage IV to sacrum r/t immobility with an initiation date of 01/05/24 and an intervention of Administer treatments as ordered and monitor for effectiveness. and Administer medications as ordered. Monitor/document for side effects and effectiveness. Both with an initiation date of 04/25/23.<BR/>Record review of Resident #2's physician's orders, retrieved on 06/13/24, revealed orders for <BR/>1. <BR/>SilvaSorb External Gel (Silver) with directions to apply to sacrum topically every shift for wound care. Cleanse with NS, pat dry, apply silvasorb to wound bed, then pack with calcium alginate and cover with bordered dry dressing per NP wound care specialist. with a start date of 03/23/24 and end date of 04/22/24<BR/>2. <BR/>SilvaSorb External Gel (Silver) with directions to apply to sacrum topically every shift for wound care. Cleanse with NS, pat dry, apply silvasorb to wound bed, then pack with calcium alginate and cover with bordered dry dressing per NP wound care specialist. with a start date of 04/22/24 and end date of 05/10/24<BR/>Record review of Resident #2's Treatment Administration Record for April and May 2024 revealed 3 unsigned sections on 04/04/24, 04/25/24 and 05/06/24 for the following physician orders: <BR/>1. <BR/>SilvaSorb External Gel (Silver) with directions to apply to sacrum topically every shift for wound care. Cleanse with NS, pat dry, apply silvasorb to wound bed, then pack with calcium alginate and cover with bordered dry dressing per NP wound care specialist, with a start date of 03/23/24 and end date of 04/22/24. <BR/>2. <BR/>SilvaSorb External Gel (Silver) with directions to apply to sacrum topically every shift for wound care. Cleanse with NS, pat dry, apply silvasorb to wound bed, then pack with calcium alginate and cover with bordered dry dressing per NP wound care specialist, with a start date of 04/22/24 and end date of 05/10/24.<BR/>During a telephone interview with LVN A on 06/13/24 at 4:35pm she stated she worked with Resident #2 on 04/04/24 and 04/25/24 and stated she was responsible for signing her TAR on those days. She stated a blank on the TAR signified it was not done. LVN A stated she completed Resident #2's wound care on 04/04/23 and 04/25/24 and stated it should have been documented on the TAR and she did not know what to respond as to why she did not. LVN A stated treatment provided should be documented because it could look like it was not done. LVN A stated she had recently been trained over documentation of treatment provided by her DON and ADON. LVN A stated the facility policy stated if it was not documented it was not done and to document treatment provided. LVN A stated in this specific situation she had not followed the facility policy. LVN A was unable to answer how the resident charts were monitored to ensure accurate documentation and stated that would be a DON question because they monitored it. LVN A stated not completing documentation for treatment provided could negatively impact a resident because it showed that its not being done and if its actually was not being done then it could harm a resident. <BR/>During a telephone interview with RN B on 06/13/24 at 5:15pm he stated he worked with Resident #2 on 05/06/24 and stated he was responsible for signing her TAR on 05/06/24. RN B stated a blank on the TAR signified that he had not checked it off. RN B stated he had done Resident #2's wound care on 05/06/24 and could not answer why it was not documented. RN B stated he should have documented on the TAR because it would show it was completed. RN B stated he was trained over documentation of treatment provided within the last 3 months by the DON and the ADON. RN B stated the facility policy stated to document anything that was completed. RN B stated the DON would review the resident charts to ensure accurate documentation was completed but did not know how often or when. RN B stated not completing documentation of treatment provided could negatively impact a resident because it might be duplicated if someone else were to do it. <BR/>During an interview and record review with the DON on 06/13/24 at 6:54pm she stated LVN A worked on 04/04/24 and 04/25/24 with Resident #2 and RN B worked with Resident #2 on 05/06/24. The DON stated LVN A and RN B were responsible for signing off on the TAR on the days they worked on 04/04/24, 04/25/24 and 05/06/24. The DON reviewed Resident #2's April and May TAR and confirmed blanks for Resident #2's physician ordered wound care on 04/04/24, 04/25/24 and 05/06/24. The DON stated a blank on the TAR meant it was not completed or was forgotten to be signed. The DON stated the TAR should have been documented. The DON stated treatment provided should be documented because it showed it was done. The DON stated LVN A and RN B told her they had completed the physician ordered wound care on the days they worked but did not document because they got carried away or forgot to press save. The DON stated LVN A and RN B had been trained and completed their annual skills competency over documentation of treatment provided. The DON stated the facility policy for treatment provided was to document to make sure its updated. The DON stated LVN A and RN B had not followed the facility's policy in this situation. <BR/>The DON stated to ensure accurate documentation she used their online medical records software that would flag any documentation that was not completed and stated they had started to review the resident charts in the morning for any missed documented. The DON stated they were not doing this back in April or May (2024). The DON stated she could not say that not completing documentation of treatment provided would be detrimental because she did not know if it would have such impact. <BR/>Record review of facility in-service dated 11/07/23 revealed the training covered documentation and was presented by the DON to staff, which included LVN A and RN B<BR/>Record review of staff competency skills for RN B revealed a section titled, medication administration that included a sub section titled, documentation of administration that was evaluated on 01/08/24 and signed off by the DON. <BR/>Record review of staff competency skills for LVN A revealed a section titled, medication administration that included a sub section titled, documentation of administration that was evaluated on 02/12/24 and signed off by the DON. <BR/>Record review of facility policy titled, Documentation in Medical Record with an implementation date of 10/24/22 included verbiage that reflected, 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred and f. Sign each entry with name and credentials of the person making the entry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 Residents (Resident #2) reviewed for medical records accuracy, in that:<BR/>Resident #2's April and May 2024 Treatment Administration Records documentation was incomplete. Staff did not document or sign off on the administration of physician ordered wound care.<BR/>This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.<BR/>The findings included: <BR/>1. Record review of Resident #2's face sheet, dated 06/13/24, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: pressure ulcer of sacral region, stage 4 (sores that extend below the subcutaneous fat into deep tissue, including muscle, tendons and ligaments), Alzheimer's disease, unspecified (progressive disease that destroys memory and other important mental functions), chronic kidney disease, unspecified (longstanding disease of the kidneys leading to renal failure), chronic diastolic (congestive) heart failure (when heart cant pump blood well enough to give your body normal supply and your left ventricle becomes stiffer than normal).<BR/>Record review of Resident #2's state optional Minimum Data Set assessment, dated 04/05/24, revealed Resident #2 had a BIMS score of 03, indicating she was severely cognitively impaired.<BR/>Record review of Resident #2's care plan, retrieved on 06/13/24 revealed Resident #2 had a focus of, [Resident #2] [has] a stage IV to sacrum r/t immobility with an initiation date of 01/05/24 and an intervention of Administer treatments as ordered and monitor for effectiveness. and Administer medications as ordered. Monitor/document for side effects and effectiveness. Both with an initiation date of 04/25/23.<BR/>Record review of Resident #2's physician's orders, retrieved on 06/13/24, revealed orders for <BR/>1. <BR/>SilvaSorb External Gel (Silver) with directions to apply to sacrum topically every shift for wound care. Cleanse with NS, pat dry, apply silvasorb to wound bed, then pack with calcium alginate and cover with bordered dry dressing per NP wound care specialist. with a start date of 03/23/24 and end date of 04/22/24<BR/>2. <BR/>SilvaSorb External Gel (Silver) with directions to apply to sacrum topically every shift for wound care. Cleanse with NS, pat dry, apply silvasorb to wound bed, then pack with calcium alginate and cover with bordered dry dressing per NP wound care specialist. with a start date of 04/22/24 and end date of 05/10/24<BR/>Record review of Resident #2's Treatment Administration Record for April and May 2024 revealed 3 unsigned sections on 04/04/24, 04/25/24 and 05/06/24 for the following physician orders: <BR/>1. <BR/>SilvaSorb External Gel (Silver) with directions to apply to sacrum topically every shift for wound care. Cleanse with NS, pat dry, apply silvasorb to wound bed, then pack with calcium alginate and cover with bordered dry dressing per NP wound care specialist, with a start date of 03/23/24 and end date of 04/22/24. <BR/>2. <BR/>SilvaSorb External Gel (Silver) with directions to apply to sacrum topically every shift for wound care. Cleanse with NS, pat dry, apply silvasorb to wound bed, then pack with calcium alginate and cover with bordered dry dressing per NP wound care specialist, with a start date of 04/22/24 and end date of 05/10/24.<BR/>During a telephone interview with LVN A on 06/13/24 at 4:35pm she stated she worked with Resident #2 on 04/04/24 and 04/25/24 and stated she was responsible for signing her TAR on those days. She stated a blank on the TAR signified it was not done. LVN A stated she completed Resident #2's wound care on 04/04/23 and 04/25/24 and stated it should have been documented on the TAR and she did not know what to respond as to why she did not. LVN A stated treatment provided should be documented because it could look like it was not done. LVN A stated she had recently been trained over documentation of treatment provided by her DON and ADON. LVN A stated the facility policy stated if it was not documented it was not done and to document treatment provided. LVN A stated in this specific situation she had not followed the facility policy. LVN A was unable to answer how the resident charts were monitored to ensure accurate documentation and stated that would be a DON question because they monitored it. LVN A stated not completing documentation for treatment provided could negatively impact a resident because it showed that its not being done and if its actually was not being done then it could harm a resident. <BR/>During a telephone interview with RN B on 06/13/24 at 5:15pm he stated he worked with Resident #2 on 05/06/24 and stated he was responsible for signing her TAR on 05/06/24. RN B stated a blank on the TAR signified that he had not checked it off. RN B stated he had done Resident #2's wound care on 05/06/24 and could not answer why it was not documented. RN B stated he should have documented on the TAR because it would show it was completed. RN B stated he was trained over documentation of treatment provided within the last 3 months by the DON and the ADON. RN B stated the facility policy stated to document anything that was completed. RN B stated the DON would review the resident charts to ensure accurate documentation was completed but did not know how often or when. RN B stated not completing documentation of treatment provided could negatively impact a resident because it might be duplicated if someone else were to do it. <BR/>During an interview and record review with the DON on 06/13/24 at 6:54pm she stated LVN A worked on 04/04/24 and 04/25/24 with Resident #2 and RN B worked with Resident #2 on 05/06/24. The DON stated LVN A and RN B were responsible for signing off on the TAR on the days they worked on 04/04/24, 04/25/24 and 05/06/24. The DON reviewed Resident #2's April and May TAR and confirmed blanks for Resident #2's physician ordered wound care on 04/04/24, 04/25/24 and 05/06/24. The DON stated a blank on the TAR meant it was not completed or was forgotten to be signed. The DON stated the TAR should have been documented. The DON stated treatment provided should be documented because it showed it was done. The DON stated LVN A and RN B told her they had completed the physician ordered wound care on the days they worked but did not document because they got carried away or forgot to press save. The DON stated LVN A and RN B had been trained and completed their annual skills competency over documentation of treatment provided. The DON stated the facility policy for treatment provided was to document to make sure its updated. The DON stated LVN A and RN B had not followed the facility's policy in this situation. <BR/>The DON stated to ensure accurate documentation she used their online medical records software that would flag any documentation that was not completed and stated they had started to review the resident charts in the morning for any missed documented. The DON stated they were not doing this back in April or May (2024). The DON stated she could not say that not completing documentation of treatment provided would be detrimental because she did not know if it would have such impact. <BR/>Record review of facility in-service dated 11/07/23 revealed the training covered documentation and was presented by the DON to staff, which included LVN A and RN B<BR/>Record review of staff competency skills for RN B revealed a section titled, medication administration that included a sub section titled, documentation of administration that was evaluated on 01/08/24 and signed off by the DON. <BR/>Record review of staff competency skills for LVN A revealed a section titled, medication administration that included a sub section titled, documentation of administration that was evaluated on 02/12/24 and signed off by the DON. <BR/>Record review of facility policy titled, Documentation in Medical Record with an implementation date of 10/24/22 included verbiage that reflected, 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred and f. Sign each entry with name and credentials of the person making the entry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop the resident's comprehensive care plan for two (Resident #40, Resident #44) of 14 residents reviewed for care plans that describe the services to be provided to attain the resident's highest practicable physical, mental, and psychological well-being in that:<BR/>1. <BR/>The facility failed to develop a care plan to address Resident #40's choice of Do not Resuscitate code status. <BR/>2. <BR/>The facility failed to implement a comprehensive person-centered care plan for Resident #44 addressing 1/4 side rails to bed. <BR/>This failure could affect the 18 residents in the facility who chose to formulate advance directives of OOH-DNR at risk of having CPR performed against their wishes and could place resident in the facility at risk for decrease level of function with ADLs, falls and not having personalized plans developed to address their needs.<BR/>The findings included: <BR/>1.Record review of Resident #40's Face Sheet dated [DATE] indicated Resident #40 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of dementia (progressive or persistent loss of intellectual functioning), hypertensive heart disease with heart failure (condition that can occur when high blood pressure is unmanaged), chronic kidney disease (kidneys do not work to filter waste and extra fluid out of the blood). <BR/>Record review of Resident#40's Significant Change of Condition MDS assessment dated [DATE] revealed Resident #40 had a BIMS of 02 which indicated Resident #40 had severe cognitive impairment.<BR/>Record review of Resident #40's [DATE] Physician's Orders revealed an order dated [DATE] for DNR.<BR/>Record review of Resident #40's electronic medical record revealed an OOH-DNR form dated [DATE]<BR/>Record review of Resident #40's Care plan dated [DATE] did not reveal a care plan for advance directive of DNR. <BR/>Observation on [DATE] at 8:55 AM revealed Resident #40 was in bed on her back, head resting on the pillow. Resident #40 had her knees flexed and crossed. Resident was asleep and breathing through her mouth.<BR/>In an interview on [DATE] at 11:44 AM LVN A said when a resident comes from the hospital, the hospital would send the orders and it would have the code status or the admission Coordinator would ask the family what code status the resident should be. The nurse would ask the resident's physician to give the order for the code status and the nurse will input the order into the computer and if the resident was DNR then the nurse would input the code status in the computer.<BR/>In an interview on [DATE] at 01:36 PM RN J said the code status was on the electronic medication administration record. The code status was also on the face sheet in the binder in case the power went out. The RN said if the binder had DNR and the computer had full code they would look for the latest date. RN said Resident #40 had a code status of DNR.<BR/>In an interview on [DATE] at 2:31 PM The DON said the SW and the MDS Case Managers were responsible for initiating the care plan for the code status. The DON said Resident #40 came in as full code on admission and then the family decided to change the code status after Resident #40 had a change in condition. The care plan for full code was discontinued and the care plan should have been initiated then on [DATE], but it was not. The DON said the negative outcome of not developing a care plan for the correct code status depended on the wishes of the resident or family. If the facility staff perform CPR and the resident was DNR then the Resident was brought back against her or the family's wishes. If the staff do not perform CPR and she was full code, then the resident would die. <BR/>In an interview on [DATE] at 5:38 PM MDS/LVN C said they look at the orders from the hospital when a resident was admitted to the facility. The RN would initiate the baseline care plan. The MDS Case Managers would follow the physician's orders and the baseline care plan to determine the code status for the resident. MDS/LVN C said they got training through computer training regarding the code status. The MDS/LVN said Resident #40 came in on the second of the month and the order for DNR came in later. MDS/LVN C was not sure exactly what happened and why she did not care plan the DNR code status.<BR/>Review of the facility's Comprehensive Care Plans policy dated [DATE], revealed It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. <BR/>3. <BR/>The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 2.Record review of facility face sheet dated [DATE], indicated Resident #44 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Left side Hemiplegia (paralysis of the left side of the body), Dementia, Cerebral Infarction (stroke), unspecified convulsions. <BR/>Record review of Comprehensive Care Plan dated [DATE], indicated Resident #44 had Left side Hemiparesis affecting left non dominant side, gait/balance problems, limited ROM and required 1/4 side rails to bed. On [DATE] the care plan was updated to include the need for 1/4 side rails for resident to be free of falls. <BR/>Record review of Minimum Data Set, dated [DATE], indicated Resident #44 had a BIMS score of 02 out of 15, indicating severe cognitive impairment. Resident #44 is a one person assist. <BR/>Record review of physician order for Resident#44 dated [DATE], indicated order for quarter bilateral side rails to bed.<BR/>During an observation on [DATE] at 1:50 PM Resident #44 was on her left unattended on her left side with the bed high and there were no side rails in place. The bed was high at working level while CNA E stepped away to wash her hands in the bathroom. <BR/>An interview on [DATE] with CNA E at 1:56 PM. stated she does peri care on her own with Resident#44. She stated she normally does not have assistance when she does peri care. Most of the time she changes residents on her own. CNA E stated negative outcome of leaving resident unattended on her side with bed high and no side rails, was that the resident could fall. She was not aware of resident needing side rails. <BR/>During an observation on [DATE] at 3:50 PM, no side rails on Residents #44 bed. Resident was sitting in wheelchair. <BR/>An interview on [DATE] with CNA F at 4:00 PM, stated Resident#44 bed does not have side rails. <BR/>An interview on [DATE] at 4:02 PM with MDS /LVN C, stated that care plans are linked to Kardex. Kardex is a desktop file system that gives a brief overview of each resident and is updated every shift. She stated all CNAs have access to the Kardex. She pulled up Residents#44 information on her laptop and stated Resident#44 has a doctor's order for 1/4 side rail dated [DATE]. MDS LVN C, stated DON monitors that care plans are implemented.<BR/>An interview on [DATE] at 4:04 PM with MDS/LVN D, stated that care plans are linked to Kardex. She stated all CNAs have access to the Kardex. MDS LVN D pulled up Residents#44 information on her laptop and stated Resident#44 has a doctor's order for 1/4 side rail dated [DATE]. MDS LVN D, stated DON monitors that care plans are implemented.<BR/>An interview on [DATE] with DON at 4:10 PM, stated that care plans are updated and completed by following doctors' orders. We proceeded to walked to Residents#44 room, resident was not in the room at this time. DON observed residents' bed and confirmed that Resident#44 bed had no side rails. DON was then informed that Resident has an order for 1/4 side rails, and 1/4 side bed rails were care planned. DON stated that CNAs have access to Kardex and this is where residents care planned information is located for quick reference. Stated resident was moved from 200 hall and she remembers resident having side rails in that room. DON cannot remember when resident was moved to 100 hall. She stated CNAs are expected to follow Kardex. DON stated again, residents' bed does not have any side rails.<BR/>Record review of Care Plan Policy implemented dated on [DATE], revealed the following: <BR/>It is this facility is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a residents medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. <BR/>Policy Explanation and Compliance Guidelines: #3 (a) The services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. #6 . Alternative interventions will be documented, as well.

Based on observation, interview, and record review; the facility failed to provide pharmaceutical services that included the accurate acquiring and receiving of all drugs and biologicals to meet the needs of each resident noted in 3 of 6 medication carts (Medication cart A) reviewed.<BR/>Medication cart A contained 1 prescription medication card containing Hydralazine 10mg for Resident #15 that was expired 08/31/2023. <BR/>The deficient practice could result in a resident receiving a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes.<BR/>Findings include:<BR/>During medication pass observation on 09/19/2023 at 03:11PM MA A, was not going to administer Hydralazine 10mg to Resident#15 due to blood pressure reading being out of parameters. Noted Hydralazine 10mg medication card had an expiration date of 8/31/2023. MA G proceeded to take it and show it to RN J who stated that it was probably a pharmacy error. RN J then notified DON and she instructed him to call pharmacy. MA G stated the last time it was administered was on Sunday. She stated she does not work on the weekends, only Monday thru Friday. There were two pills missing out of the medication card. MA G stated she checks her medication cart daily. She's not sure how often the pharmacist comes and checks medication carts. Stated the negative outcome is that the resident would probably have an upset stomach.<BR/>Record Review of Medication Administration Record for Resident #15, indicated that Hydralazine 10mg was administered in the morning on 9/19/23 and the day before, 9/18/23. <BR/>An interview on 09/21/2023 at 8:50 AM with MA H, stated she has been working at this facility for 9 years, shift 6am-2pm. Stated she gets medications to include medication cards from the medication rooms. She stated she checks expiration dates in her medication cart to include over the counter medications, once a month. She also cleans cart once a day but deep cleans it once a week. Over the counter medications are kept for 3 months then discarded. Stated she takes the expired medications to the medication room where they have a box. Stated LVN B, checks expirations on carts and in medication storage. States she had in service on keeping carts clean and organized about 1.5 months ago.<BR/>An interview on 09/21/2023 at 8:58 AM with LVN B Medical Records, stated she has been working at the facility for 10 years. Stated she checks medication carts every now and then but not on a regular basis. She stated Pharmacy Consultant is the pharmacist who comes and checks once a month.<BR/>An interview on 09/21/2023 at 9:50 AM via phone with Pharmacy Consultant, others present in the call were DON and Administrator. Pharmacy Consultant stated she comes once a month to spot check one medication cart out of three and medication room. Facility only has one medication room. She does not do a thorough check. Stated she was here on 9/19/23 in the afternoon and checked MA medication cart A.<BR/>An interview on 09/21/2023 at 10:05 AM with DON, also present in the interview was the Administrator. DON stated the pharmacy driver delivers medications. Medications are then put in the medication storage room. When sorting medications in the medication storage room, drug and name are the only thing that was checked. Once medication was put into medication cart, that was when drug, name and expiration dates get checked.<BR/>Record review of the facility provided policy titled Storage of Medications revised July 2015, revealed the following:<BR/>Policy General Guidelines:<BR/>#3. No discontinued, outdated, or deteriorated medications are available for use in this facility. All such medications are destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (CNA) observation for infection control.<BR/>The facility failed to ensure CNA E performed proper peri-care (incontinent care) for Resident #14.<BR/>This deficient practice could place resident in the facility at risk for infections due to improper incontinent care.<BR/>Findings included:<BR/>Observation on 09/19/2023 at 1:28 PM, CNA E performed incontinent care for Resident #14, did not clean the buttocks/anal area. <BR/>An interview on 09/19/2023 with CNA E at 1:56 PM, stated she has not done catheter care in a while. Surveyor asked why she did not clean buttocks/anal area. She said she completely forgot because she was probably concentrating on doing catheter care correctly. Stated she normally does clean the buttocks/anal area. She stated the negative outcome could be that resident can have skin breakdown from bacteria and a lot of different things can come from not cleaning properly. Especially since resident does not get up. <BR/>An interview on 09/21/2023 at 4:00 PM with DON, stated that all CNAs have access to [NAME], point of care. [NAME] is a desktop file system that gives a brief overview of each resident and is updated every shift. DON stated annual skill check offs are done around February or April. She stated she does spot checks as needed. She goes around and observes peri care, g tubes (gastrostomy tube is a tube inserted through the belly that brings nutrition directly to the stomach), wound care, and transfers. DON stated if she sees something incorrectly done, she will follow up and request return demonstration. DON also can do a one-to-one training, if needed. [NAME] stated when doing peri care, they are to ALWAYS included the buttocks/anal area. She has not had any issues or complaints against CNA E.<BR/>An interview on 09/21/2023 at 4:05 PM with Regional Nurse Consultant stated, DON monitors and provides oversight by having IDT meetings in the morning, daily. Nurses come during this meeting and if any questions arise or revisions are needed, then they talk to DON and other head personnel. Regional Nurse Consultant stated the negative outcome depends on the situation. He stated they would do retraining and spot checks. If it continues, then staff would be dismissed.<BR/>Record review of the policy titled Perineal Care dated implemented 10/24/2022 <BR/>revealed the following: It is the practice of this facility to provide perineal care to all <BR/>incontinent residents during routine bath or a needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and prevent and assess for skin breakdown.<BR/>Definition: Perineal care refers to the care of the external and the anal area. <BR/>Policy Explanation and Compliance Guidelines: #12. (k) Clean and dry the bottom of the scrotum and the anal area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures to investigate any such allegations, for 1 of 3 residents (R #1) reviewed for incidents/accidents.<BR/>The facility failed to follow the incidents/accidents policy for an incident on 07/30/23 for R #1. <BR/>This failure could place residents at risk of further incidents. <BR/>The findings included:<BR/>Record review of the Policy:<BR/>Incidents and Accidents Policy (date implemented: 08/15/22)<BR/>Compliance Guidelines:<BR/>2. Licensed staff will utilize PCC Risk Management to report incidents/accidents and assist with completion of any investigative information to identify root causes.<BR/>12. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications, and orders obtained or follow-up interventions.<BR/>Record review of R #1's file reflected an [AGE] year-old female, with an original admission date of 10/11/19. Her diagnoses included: Dementia, Osteoarthritis, muscle wasting and atrophy, Congestive Heart failure, Chronic Kidney Disease, Hypertension, Bipolar Disorder, Anxiety Disorder, and Brief Psychotic Disorder .<BR/>Record review of R #1's SBAR Change of condition communication form dated 07/30/23 at 1:24 PM reflected nurse was notified by RP that resident has discoloration to left forearm. Upon assessing the resident two discoloration marks were noted to left forearm. Documented by LVN H.<BR/>Record review of R #1's skin evaluation dated 07/30/23 at 9:31 PM reflected discoloration to left forearm. Documented by: LVN H.<BR/>Record review of R #1's progress notes reflected:<BR/>On 07/30/23 at 2:32 PM, written by LVN H. As per 6-2 SN discoloration to left forearm, residents family wants an investigation to be made in place. <BR/>On 08/02/23 at 11:12 AM, written by DON. Spoke with RP and discussed resident's skin. Understood resident can get combative at time while providing care. <BR/>In an interview with LVN H on 09/20/23 at 3:04 PM. LVN H said if there was an injury of unknown origin brought to her attention, LVN H would begin an investigation or tell the DON and follow chain of command. LVN H said the purpose for investigating is so that the facility can do what they can to avoid that situation again. LVN H said she does not recall dealing with R #1 having bruising to R #1's arm. LVN H said if LVN H was told that R #1 had bruising to her arm, LVN H would have notified the DON. LVN H said she must have notified the DON and documented regarding the injury. LVN H said when there is an injury reported, nursing investigates and then notifies the DON. LVN H said the DON takes it from there. LVN H said she does not recall seeing the bruises on R #1. LVN H said if LVN H assessed R #1, it would be documented in the nurse's notes. LVN H said she must have called the doctor and notified the RP, which would also be in the notes. <BR/>In an interview with DON on 09/20/23 at 3:25 PM. DON said if there is an injury of unknown origin, some of the residents can say what happened. DON said if the resident cannot say what happened, then DON completes an investigation. DON said the nurse completes a skin assessment, the family is notified, the doctor is notified, and orders are obtained depending on what it is. DON said depending on what she discovers, she will inform the Administrator of any concerns that need to be reported to the state. DON said R #1 had 2 bruises to R #1's left forearm at the end of July. DON said she spoke to staff that worked with R #1 and questioned them to see how R #1 may have obtained the bruises. DON said she spoke to CNA A who indicated CNA A assisted R #1. DON said R #1 can be combative at times when R #1 is being assisted. DON said CNA A told her that R #1 was going to strike CNA A during a brief change, so CNA A put her hand up to protect herself from getting hit, and CNA A moved R #1's arm away. DON said it was not in an abusive manner but rather to protect herself. DON said she spoke to R #1's daughters on 08/02/23 and advised them that R #1 could become combative, and how she likely got the bruising. DON said R #1 does refuse assistance and she will grab and kick staff sometimes. DON said R #1 had labs done which showed R #1 had a UTI. DON said a UTI could cause R #1 to be confused, withdrawn, and have behavior changes. DON said she only spoke to CNA A because she explained what happened and DON identified the root cause. DON said she would provide a copy of the investigation documentation (risk assessment).<BR/>In an interview with Administrator on 09/20/23 at 3:45 PM. Administrator said injuries of unknown origin would be a reportable event if the team cannot explain what happened. Administrator said an unknown injury would be investigated as an incident. Administrator said the DON gathers the facts, talks to staff, and does an internal investigation of the incident. Administrator said he waits for the DON to see if there is something truly of unknown origin and if it is something that needs to be reported. Administrator said he does not recall being told about an injury of unknown origin for R #1. Administrator said if the DON did not bring it to his attention, then there were no concerns with R #1 regarding bruising. Administrator said perhaps it was ascertained how it occurred. Administrator said maybe staff saw or explained how it happened or the resident was able to say how it happened. Administrator said if the facility cannot explain how it happened, then it would be reportable. Administrator said the purpose of reporting would be to prevent further incidents to that resident or other residents. Administrator said the purpose of investigating incidents is to protect the resident and take corrective actions, as needed.<BR/>In an interview with DON on 09/21/2023 11:00 AM. DON said the nurse notified the family and the doctor about the change of condition which would be the bruising to R #1's arm. DON said DON completed her investigation by interviewing CNA A. DON said there was no concerns of abuse or neglect. DON said the nurse did assess R #1 and filled out a skin evaluation and completed the SBAR. DON said DON did not do the risk assessment in the system so she cannot provide that report. DON said DON did document in the resident's chart how she spoke to R #1's daughters after, but she did not document her investigation because that would normally be documented in the risk assessment. DON said DON forgot to complete the risk assessment. DON said that is part of the policy regarding incidents or unwitnessed injuries. DON said if the policy is not followed, then the facility cannot rule out harm or prevent future incidents for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 1 (Resident #34) of 24 residents reviewed for PASRR:<BR/>The facility did not correctly identify Resident #34 on the PASRR Level One Screening Form as having mental illness and did not submit a request to correct their negative screening. <BR/>This failure could affect residents with a diagnosis of mental illness and could result in these residents not receiving needed PASRR services.<BR/>The findings included: <BR/>Record review of Resident #34's Physician's Orders revealed a [AGE] year-old male was admitted to facility on 05/09/22 with diagnoses of Cirrhosis of liver (late-stage liver disease in which healthy liver tissue is replaced with scar tissue), Type 2 Diabetes Mellitus (chronic condition that affect the way the body processes blood sugar), Anxiety Disorder, Schizophrenia (chronic brain disorder that affect a person's ability to think, feel and behave clearly). <BR/>Record review of Resident 34's admission MDS assessment dated [DATE] reflected the following: <BR/>-Section A1500: Is the resident considered by the state level II PASRR process to have serious mental illness and/or intellectual disability? <BR/>-The response was No.<BR/>-is sometimes understood,<BR/>-sometimes understands others,<BR/>- was not able to complete the BIMS,<BR/>-is totally dependent on staff for bed mobility and toileting,<BR/>-requires extensive assistance of one person for dressing, eating, personal hygiene, and,<BR/>-had diagnoses of Anxiety Disorder and Schizophrenia. <BR/>Record review of Resident #34's PASRR Level I assessment, dated 05/18/22, indicated Resident #34 was negative for mental illness, intellectual disability, and developmental disability. <BR/>On 07/05/22 at 12:10 PM, Surveyor observed Resident #34 in a low bed with HOB raised 35 degrees, and his mattress on the floor. There was a customized high-back wheelchair at the end of the bed. Resident #34 had his eyes closed and had a family member sitting by his bedside.<BR/>In an interview on 07/06/22 at 9:00 AM, Resident #34 said he had been at the facility about 8 weeks. Resident #34 said he did not know what medications he was taking, what care he was receiving or how long he would be at the facility. Resident #34 said he was not able to walk and wanted to get physical therapy so he could walk again. Resident #34 said he was not getting therapy and would like to ask someone about getting the therapy. <BR/>In an interview on 07/07/22 at 02:25 PM, MDS/LVN I said Resident #34 came from another facility and his PASRR was negative for mental illness and IDD/DD. MDS/LVN I said Resident #34 did not have a diagnosis of mental illness. MDS/ LVN I checked the PCC in the computer and found that he did have a diagnosis of Schizophrenia. MDS/LVN I said Resident #34 did not have any behaviors. MDS/LVN I said she would call the local mental health authority and ask if Resident #34 had services with them and if he did then they will revise the PASRR Level I so Resident #34 can receive the needed services. <BR/>In an interview on 07/07/22 03:58 PM, MDS/LVN J said Resident #34 came from another facility. MDS/LVN J said they look at the diagnoses and will have care plan meeting after 72 hours with the responsible party. They had a meeting with the family, and they gave a copy of the care plan and a list of medications to them. The MDS nurses will also do observations and if they notice anything new, they will revise the care plan. The MDS will then do interventions for the changes. MDS/LVN J said the PASRR negative can be reviewed at the next assessment such as a quarterly assessment and if they need to, they will reassess the resident and revise the PASRR Level I. MDS/LVN J said if Resident #34 requires services they will address it then. <BR/>. <BR/>In an interview on 07/08/22 at 10:20 AM, the DON said the MDS case manager will review the PASRR when they have a new admission and then the department heads will discuss the PASRR in the morning meeting. The DON said if there was a question about the PASRR assessment, the MDS case manager would call the state-designated mental health or ID authority to conduct the PASRR evaluation. <BR/>In an interview on 07/08/22 at 11:45 AM, the Administrator said they did not have anyone to review the PASRR Level I's accuracy. The administrator said they took if for granted that the assessments were accurate but going forward, he will assign someone to review the assessments for accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature control, and permit only authorized personnel to have access to keys for the facility's one medication disposal cabinet, observed during survey medication storage task, in the medication storage room observed in that:<BR/>The facility's medication disposal cabinet was found unlocked, not lockable, and unable to latch closed.<BR/>This deficient practice could result in missing or misuse of drugs by unauthorized personnel.<BR/>The findings were:<BR/>Observation on 07/06/22 at 04:12 p.m., revealed the medication disposal cabinet in the medication storage room was found by the surveyor unlocked and unable to be latched closed. Per the inventory sheet in the cabinet, 126 medications, some in bags and some loose, were in the cabinet awaiting disposal. <BR/>In an interview and observation on 07/06/22 at 04:12 p.m. of the medication storage room with LVN C. LVN C, was trying to unlock the medication disposal cabinet for surveyor to check, when she found it unlocked and the cabinet would not close and latch. LVN C stated, That's not good. Let me tell [NAME] to fix it again. The cabinet (medication disposal) is always supposed to be locked and this won't even latch let alone lock. LVN B, who was standing in the doorway, stated, Oh wow. That is not good, then LVN B walked away to notify DON. The medication disposal cabinet was not locked, could not lock, and could not latch closed. <BR/>In an interview 07/06/22 at 04:24 p.m., when DON was notified of the medication disposal cabinet not being locked, unable to lock or unable to latch closed. DON stated she would have [NAME] fix it immediately. DON stated, Sheesh, the easiest thing and it didn't go right (regarding the citation. DON stated the disposal cabinet was always supposed to be locked and everyone knew that.<BR/>On 7/06/22 at 04:30 p.m., Maintenance Supervisor H was observed going into the medication storage room with a power drill as surveyor was exiting building.<BR/>In an interview 07/07/22 at 03:11 p.m., LVN C stated, The medication disposal cabinet is supposed to be locked at all times. Yesterday was my first day back from my two days off and it was locked when I worked last. Yesterday I was very surprised that it was not locked. It isn't good for the cabinet to be unlocked. The main door is locked so only certain people can get in the door. There is a risk of drug diversion or if the main door isn't shut properly, a resident could go in and take something they don't know what it is. <BR/>In an interview on 07/07/22 at 03:28 p.m., LVN G stated, If cabinet were not locked, I'd get my supervisor and let her know. If the (medication disposal) cabinet and (or) door were not locked, that would not be good. Medications could be taken by anyone if the room were not being watched. I personally, make sure the (medication storage room) door is locked at all times when I have to come in here. I have worked here for about 10 months and never had to put any medications in the cabinet for disposal. <BR/>In an interview 07/07/22 at 03:49 p.m., the DON stated the medication disposal cabinet is supposed to be locked at all times. The medication can disappear if left unlocked. Medication can be diverted. <BR/>Record review of inventory sheets for the medications in the unlocked medication disposal cabinet revealed 126 different medications including gabapentin 300mg capsules, metoprolol 50mg tablets, carbidopa-levo 10mg - 100mg tablets, Escitalopram 10mg tablets, clonidine HCl 0.1mg tablets, Metformin HCl F/C 500mg tablets, Trazodone HCl 50mg tablets, Insulin Aspart pen 100unit/1mL insulin pens, Lantus Solostar 100unit/1mL insulin pens, Novolog Flexipen 100/mL insulin pens, ipratropium/sol albuterol, mirtazapine 15mg tablets, Prednisone 20mg tablets, Diphenhydramine HcCl 50mg/1mL solution, levetiracetam 100mg/1mL solution, among the medications in the unlocked medication disposal cabinet.<BR/>Review of the facility policy and procedure titled Omnicare, a CVS Health company dated April 2022, revealed:<BR/>Procedure<BR/>1.Facility staff should destroy and dispose of medications in accordance with Facility policy and Applicable Law, and applicable environmental regulations<BR/>4.Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction.<BR/>11.2 An authorized Facility staff member should place medication containers in a container or box. Facility staff member should then seal the box with strong tape and label the box as MEDICATION FOR DESTRUCTION. The container or box should be secured in a locked cabinet or room until it is disposed or picked up by a licensed waste disposal company.

Based on observation, interview and record review, the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>The facility failed to ensure sanitary practices were maintained in the kitchen as dishes, glasses and coffee cups were piled up, more than a single layer, in the same rack then passed through the dish washing machine. <BR/>This failure could place residents who ate from the kitchen at risk for cross-contamination and food-borne illness.<BR/>Findings included:<BR/>In an observation on 07/05/22 at 10:38 a.m., inside the ware washing area, Aide A open clean door of the dish wash machine to take out a rack that had a pile of dishes, plastic cups, and coffee cups. It was observed that the rack had more than a single layer of dishes, plastic cups and coffee cups. It was observed that there were two plastic cups that were filled with water and what appeared to be white foam. Aide proceeded to remove dishes from the rack and placed them with clean dishes, Aide A proceeded to place coffee cups from the rack with other clean coffee cups. <BR/>In an interview on 07/05/22 at 10:40 a.m., Aide A said that she was trained not load dish racks with different types of utensils or to pile them up. She said she forgot not to do it. She said there could be a risk for contamination. <BR/>In an interview on 07/05/22 at 10:42 a.m., the Dietary Manager said she had trained her staff not to mix different types of food utensils or to pile them up due to the possibility of dishes not been cleaned properly. <BR/>In an interview on 07/06/22 at 10:50 a.m., Dietary Manager said dishes could not be stacked in several piles. She also could not mix in the same rack, plates, and cups. She said trained staff verbally and then with return demonstration on how to use the dish machine and how to place similar dishes.<BR/>In an interview on 07/07/22 at 09:59 a.m., Administrator said kitchen staff were contracted. However, he went inside the kitchen, at least once or twice a week, to observe how staff worked and followed procedures to keep a sanitary kitchen. He said if one of his observations indicated that staff had not followed procedure, he would talk to the Dietary Manager about his observation. He said the Dietary Manager then would in-service the kitchen staff. <BR/>In an interview on 07/07/22 at 0:09 a.m., DON said she did rounds inside the kitchen at least once a month. She said would document findings and would relate concerns to the Dietary Manager and she would expect the concerns to be addressed by her. She said not having dishes properly sanitized could lead to the spread of infection. <BR/>In an interview on 07/07/22 at 01:06 p.m., District Food Manager said once a month she would monitor the facility and spend time in each station, including the ware washing area. She said would observe if staff followed the proper procedure to clean dishes, including loading dished in the rack. She said the procedure was to have only one pile of similar dishes per rack. She said having different types of dishes in the same rack could prevent from dishes to be cleaned properly. She said dishes were not supposed to be piled up for the same reason and it could be a risk for spreading an infection. <BR/>Record review of Facility's policy on Ware washing dated 09/2017 revealed:<BR/>- All dishware, service ware, and utensils will be cleaned and sanitized after each use<BR/>- The dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware.<BR/>Record review of Facility's Warewashing procedures for- ES2000/4000 dated 2009 revealed:<BR/>- [Washing; picture No 6: Load rack to capacity. Fill with similar dishes and glasses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received adequate supervision for one Resident (Resident #4) of three Residents reviewed for supervision.<BR/>The facility failed to ensure Resident #4 received two-person assist when providing incontinent care. <BR/>This failure could place residents at risk for accidents and injury. <BR/>The findings were: <BR/>Record review of Resident #4's face sheet dated 5/7/23 revealed an [AGE] year-old female with an admission date of 5/27/22 and diagnoses which included: Alzheimer's disease with early onset (a progressive disease that destroys memory and other mental functions), Muscle wasting and atrophy (thinning of muscle mass), not elsewhere classified, Need for assistance with personal care, other frontotemporal neurocognitive disorder (damage to neurons in the frontal and temporal lobes of the brain), Paranoid schizophrenia (delusions and hallucinations).<BR/>Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed she had a BIM Score of 2 which indicated severe cognitive impairment. Resident requires extensive assistance / two person physical assistance in toilet use. <BR/>Record review of Resident #4's care plan with a review date of 5/1/23 revealed problem of ADL self-care performance deficit r/t Dementia, I need assistance for all my adl care needs. <BR/>Interventions were: Toilet use: the resident is incontinent of bladder and bowel and requires total assist. Toilet Use: The resident requires (moderate assistance by (2) staff for toileting. <BR/>Record Review of Incidents by Incident Type dated 5/7/23 revealed Resident #4 experienced an un-witnessed fall on 5/5/23. Resident #4 was not in facility at the time of investigation. <BR/>Record Review of the X-Ray Radiology Interpretation dated 5/5/23 revealed no evidence of skull fracture present. <BR/>Record review of the nursing progress note dated 5/5/23 at 5:50 pm revealed LVN F was notified by CNA B that resident was found laying on the side of the bed on the floor. Resident was found with a laceration to left side of head. No redness noted to hip, legs, or arms and resident denied any pain when asked that day after the fall. <BR/>In an interview with LVN F on 5/7/23 at 3:11 pm he said CNA B was providing incontinent care on Resident #4 when he called him and said Resident #4 had fallen off the bed. LVN F said he assessed her for injuries and pain. She called the physician to inform of the fall. Resident #4 denied pain and had steri-strips placed on the laceration. LVN F said he believed Resident #4 was a one person transfer and assist with ADL's. He said CNA B was the only person providing care for Resident #4 at the time of incident. <BR/>In an interview on 5/7/23 at 4:05 pm CNA B said he was changing, providing incontinent care for Resident #4. He said he walked towards the doorway of Resident #4's room to call LVN F so he could provide wound care and turned to see Resident #4 overreaching with her hand and fell off the bed. He said he was the only person in the room providing care at the time. CNA B said that he provided care for her by himself with no assistance because he's a pretty big guy and was able to do it on his own. He said he does not look at the care plan to see how much help Resident #4 needed because he has been working at the facility for 2 years and knew how to help Resident #4 and she has never had a fall in the time he's worked with her. CNA B said that if a resident was not helped properly with providing incontinent care, falls like the one she experienced with him would happen. He also said he was in serviced on falls after the incident. <BR/>In an interview on 5/7/23 at 5:19 pm the ADON said that she was investigating the fall that happened on 5/5/23. She said CNA's had access to a system, [NAME] where each resident had instruction/information on transfers and bed mobility. ADON replied there is a potential for injury to resident if instructions are not followed on resident's care. <BR/>In an interview on 5/7/23 at 5:49 pm Administrator said they were investigating the incident on the fall. CNA B was providing care to Resident #4 when she had the fall. He said he had only gotten statements from staff and was still investigating. Administrator said he could not tell surveyor specifically as to what could happen if resident care instructions were not followed because each situation is different, he wouldn't be able to render an opinion. Especially when it's the clinical aspect. He said he could not answer. <BR/>Unable to interview DON, as she was not present at the time of investigation or time of incident. <BR/>Facility Policy for Accidents was reviewed, however, it stated the process and definitions of reporting incidents and accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 (Resident #161) of 8 residents reviewed for care plan completion.<BR/>The facility failed to complete a baseline care plan that addressed enhanced barrier precautions for Resident #161 within the required 48-hour timeframe of admission.<BR/>This deficient practice could place newly admitted residents at risk of not being provided with the necessary care and having personalized plans developed to address their specific needs.<BR/>Findings included:<BR/>Record review of Resident #161's face sheet dated 12/02/2024 revealed the resident was an [AGE] year-old male admitted on [DATE] with the following diagnoses: Urinary tract infection- ESBL(bacteria resistant to most antibiotics), Metabolic Encephalopathy (a disorder that affects brain function), Type 2 Diabetes Mellitus, Transient Cerebral Ischemic Attack (mini stroke), Chronic Kidney Disease, Stage 4, and Cystitis (infection in the urinary bladder). <BR/>Record review of Resident #161's BIMS dated 11/30/2024 revealed he scored of 08, which indicated he had moderately cognitive impairment. <BR/>Record review of Resident #161's medical record on 12/02/2024 revealed no evidence of the completion of a baseline care plan for enhanced barrier precautions.<BR/>In an interview on 12/04/2024 at 11:09 a.m. with the ADON, stated there should be a baseline care plan in place for the enhanced barrier precautions. He stated the care plan was in place because it was the picture of what the nurses are doing for the resident. It was what the nurses follow to adequately care for their residents. He stated that he can add to the care plan, but the DON was the one who completes the baseline care plan. ADON stated that Resident #161 was admitted over a holiday weekend and maybe that was why it got overlooked. <BR/>In an interview on 12/4/24 at 11:20 a.m. with the DON stated that she was responsible for completing the baseline care plan for the enhanced barrier precautions as well as the admitting nurses. She stated when they do the baseline care plan, it was a quick assessment, and they did not look at the ESBL and E. coli information. The DON stated that Resident #161 was admitted over the weekend, and it got overlooked. She stated that it was important to have the enhanced barrier precaution care planned because that was how they know how they will work with the resident. The care plan was what they follow for what care they are providing for the resident.<BR/>Record review of facility policy titled, Baseline Care Plan date reviewed/revised 10/05/2023, revealed Policy: The facility will level and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. <BR/>Policy Explanation and Compliance Guidelines: <BR/>a. Be developed within 48 hours of a resident's admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 14 residents ( Resident #58), reviewed for comprehensive care plans in that: <BR/>Advanced directive code status was not updated for Resident #58 care plan. <BR/>These deficient practices could affect residents with comprehensive care plans and could result in missed or delayed continuity of care.<BR/>The findings included:<BR/>Record review of Resident # 58's face sheet dated [DATE] revealed resident was admitted on [DATE] with diagnosis that included osteoarthritis, right knee, history of falling, type 2 diabetes mellitus, chronic kidney disease, hypertension, dementia, psychotic disturbance, atrial fibrillation, moderate protein-calorie malnutrition, transient ischemic attack (TIA), cognitive communication deficit.<BR/>Record review of Resident #58's MDS dated [DATE] revealed a BIMS score of 08 which indicated moderate cognitive impairment for daily decision-making skills.<BR/>Record review of Resident #58's comprehensive care plan revealed she was a full code, date initiated [DATE].<BR/>Record review of Resident #58's face sheet, dated [DATE] revealed she was a DNR.<BR/>Record review of Resident # 58's physician's order dated [DATE] revealed resident was a DNR.<BR/>Record review of Resident #58's OOHDNR (Out of Hospital Do Not Resuscitate) form dated [DATE] (dated by resident only) revealed resident's signature, two witness's signatures and 1 physician's signature with no date.<BR/>Observation on [DATE] @ 9:57a.m., Resident #58 was observed outside in the patio socializing with residents. She was wearing personal clothing and well groomed.<BR/>Interview on [DATE] at 2:31 p.m., The DON said The Social Worker was responsible to assist resident and/or POA (power of attorney) in completing OOHDN form if they wish to be a DNR. She said after form was completed/dated by resident or POA and witnesses The Social Worker will place form in a designated area by the nurse's station for the corresponding physician to sign. Once the physician signs and dates the form, it wasis given to the Medical Records LVN to be uploaded to resident's record. She said it was the responsibility of the Medical Records LVN to ensure OOHDNR form is completed correctly before uploading. DON said if the Medical Records LVN finds any discrepancies, she will return form to The Social Worker for him to correct. The DON said OOHDNR form requires the physician to sign in two different places for the form to be considered complete. She said if the OOHDNR form does not have the physician's signature in the two required places then the form may be considered invalid. The DON said the only place licensed nursing staff are trained to check for a resident's code status is was on PCC's face sheet and physician's order. The DON said licensed nursing staff are not trained to use the code binder which is in the nurse's station or OOHDNR form which can be found on PCC under miscellaneous to check code status. She said she should have removed the binder from the nurse's station but forgot it was there. She said the binder contained outdated face sheets and is in the process of being phased out. She said in case of a power outage, the facility has a designated printer in which staff can use to obtain information found in PCC. She said PCC information is updated every 4 hours. She said printer is plugged into a red outlet and will be powered by the facility's generator in case of a power outage. The DON said Resident #58 and Resident #20 must have changed their code status after being admitted that is why the OOHDNR form had a more recent date. DON said if the resident's face sheet, comprehensive care plan, physician's orders do not coincide with each other the resident and/or their family may be caused unnecessary distress if they receive CPR, and they are a DNR or are DNR and CPR was performed.<BR/>Interview on [DATE] at 11:45 a.m., LVN A said when a resident was coding, she will immediately check PCC under their face sheet for their code status. She said she has never had a resident code during her shift but has been trained on how to proceed in those situations. She said making sure what the resident's code status is important and if the resident's or family members wishes are not honored I would be in a lot of trouble. LVN A said she knows there was a binder in the nurse's station (not sure what information it contains) but said the only place she would check wasis on PCC.<BR/>Interviews (via telephone and in person) on [DATE] between 4:00 p.m. and 6:00 p.m., the survey team interviewed 11 licensed nursing staff, all revealed the only place they would check for a resident's code status was on PCC (face sheet and under orders).<BR/>Interview on [DATE] at 11:30 a.m., The Administrator said The Social Worker and The Medical Records LVN work together to ensure the OOHDNR forms are completed correctly and ensure resident's or family wishes are correctly entered in PCC. <BR/>Interview on [DATE] at 4:00 p.m., Case Management Specialist LVN said she was not sure why Resident #58's care plan had her as a full code when it should have been updated to reflect her DNR status. She said it must have been a miscommunication between her and Medical Records LVN.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents have the right to request, refuse, and or discontinue treatment, to particpate or in experimental research, and to formulate an advance directive for 4 (Resident #37, Resident #40, Resident #20, Resident #58) of 14 residents whose records were reviewed for Out-of-Hospital Do-Not-Resuscitate Order forms in that:<BR/>1. <BR/>The facility did not ensure Resident #40's OOH-DNR form was completed fully and correctly.<BR/>2. <BR/>The facility did not ensure Resident #37's OOH-DNR form was completed fully and correctly. <BR/>3. <BR/>Resident #20 had missing information on the front of their OOHDNR ((Out of Hospital Do Not Resuscitate) form.<BR/>4. <BR/>Resident #58 had missing information on the front of their OOHDNR (Out of Hospital Do Not Resuscitate) form.<BR/>These failures could affect the 18 residents in the facility with OOHDNR orders at risk of CPR performed against their wishes. <BR/>The findings included:<BR/>1.Record review of Resident #37's Face Sheet dated [DATE] indicated Resident #37 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Parkinson's Disease ( a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves)., Type 2 Diabetes Mellitus (Type 2 diabetes is a condition that affects how your body uses glucose, the main source of energy for your cells)., and Cerebral Ischemia (a stroke caused by low blood flow to the brain, depriving it of oxygen and nutrients).<BR/>Record Review of Resident #37's Quarterly MDS assessment dated [DATE] indicated Resident #37 has a BIMS of 08 which indicated Resident #37 had moderate cognitive impairment. <BR/>Record review of Resident #37's [DATE] Physician's Orders revealed an active order dated [DATE] for code status of DNR.<BR/>Record review of Resident #37's OOH-DNR form dated [DATE] revealed the physician signed on section E - Declaration on behalf of the minor person. The second physician's signature was on the section F - Directive by two physicians on behalf of the adult person who was incompetent or unable to communicate. The bottom section that indicated all who signed above must sign below did not have a physician's signature. <BR/>2.Record review of Resident #40's Face Sheet dated [DATE] indicated Resident #40 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of dementia (progressive or persistent loss of intellectual functioning), hypertensive heart disease with heart failure (condition that can occur when high blood pressure is unmanaged), chronic kidney disease (kidneys do not work to filter waste and extra fluid out of the blood). <BR/>Record review of Resident#40's Significant Change of Condition MDS assessment dated [DATE] revealed Resident #40 had a BIMS of 02 which indicated Resident #40 had severe cognitive impairment.<BR/>Record review of Resident #40's [DATE] Physician's Orders revealed an active order dated [DATE] for code status of DNR.<BR/>Record review of Resident #40's OOH-DNR form dated [DATE] revealed the section for Physician's Statement was missing the date the form was signed and the physician's signature. The bottom section that indicated all who signed above must sign below did not have the physician's signature. <BR/>In an interview on [DATE] at 11:44 AM LVN A said when a resident came from the hospital, the hospital would send the orders and it would have the code status or the admission Coordinator would ask the family what code status the resident should be. The nurse would ask the resident's physician for the order for the code status and the nurse would input the order into the computer and if the resident was DNR then the nurse would input the code status in the computer.<BR/>In an interview on [DATE] at 01:36 PM RN J said the code status was on the electronic medication administration record. The code status was also on the face sheet in the binder in case the power goes out. The RN said if the binder had a DNR code status and the computer had full code they would look for the latest date. RN said Resident #40 had a code status of DNR.<BR/>Interview on [DATE] at 2:31 p.m., The DON said The Social Worker was responsible to assist resident and/or POA (power of attorney) in completing OOH-DN form if they wish to be a DNR. She said after form was completed/dated by resident or POA and witnesses the Social Worker would place the form in a designated area by the nurse's station for the corresponding physician to sign. Once the physician signed and dated the form, it was given to the Medical Records LVN to be uploaded to the resident's record. The DON said it was the responsibility of the Medical Records LVN to ensure the OOH-DNR form is completed correctly before uploading it. The DON said if the Medical Records LVN finds any discrepancies, she will return the form to The Social Worker for him to correct. The DON said OOH-DNR form requires the physician to sign in two different places for the form to be considered complete. She said if the OOH-DNR form does not have the physician's signature in the two required places then the form may be considered invalid. The DON said the only place licensed nursing staff are trained to check for a resident's code status was on PCC's face sheet and physician's order. The DON said licensed nursing staff are not trained to use the code binder which was in the nurse's station or OOH-DNR form which can be found on PCC under miscellaneous to check code status. She said she should have removed the binder from the nurse's station but forgot it was there. She said the binder contained outdated face sheets and was in the process of being phased out. The DON said the negative outcome depends on the wishes of the resident or family. If facility staff performs CPR and the resident was DNR then the Resident was brought back against her wishes or if staff do not perform CPR and she was full code, then the resident dies.<BR/>In an interview on [DATE] at 2:43 Medical Records LVN B said she just glances at the DNR forms before she scans and uploads to the forms. LVN B said she looks to make sure the physician signs the form on the third section. LVN B said she did not know that the physician needed to sign below also. If it was missing a signature, she will take it back to the SW and have him fix it. LVN B said she did have training ten years ago, but she only thought the form needed one signature from the physician. The Medical Records LVN B said the DON told her the nurses will look in PCC to check a resident's code status. <BR/>In an interview on [DATE] at 10:32 AM the SW said he assists the resident or the responsible party to complete the form. The SW said he ensured the resident, or the responsible party to sign the form and he would get two witnesses to sign the form. The SW said he did not always get the completed form to review. Once the doctor gets the form and signs it, the Medical Records Clerk will take the form and scan it and upload it to PCC. The SW said if something was not signed correctly then he would redo the form and have the witnesses sign the form again. However, he would not get the physician to sign the form; that was the responsibility of the Medical Records Clerk. SW said he did audits of the DNR forms at times. The last audit he conducted was done six months ago. SW said they get the orders for DNR when there is a change in condition, the family wants to change code status or the resident states they want to be DNR.<BR/>Review of the facility's Advance Directives Policy dated 07/2015 revealed:<BR/>An Advance Directive is a document that sets forth the resident's decision regarding medical treatment prior to the moment when such a decision is necessary. The term Advance Directive normally, but not always, refers to end-of-life decisions.<BR/>The law also provides for certain requirements for each type of decision-making listed above. It is important that Advance Directives and surrogate decision-making documents be executed and implemented properly in order to provide legal protection for the caregivers. However, any wishes the resident has put into writing, whether or not properly executed, should be helpful to those who should make decisions for a resident who is no longer able to do so