WESTWARD TRAILS NURSING AND REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 2 of 20 residents (Resident #11 and Resident #54) reviewed for ADLs, in that:.<BR/>Resident #11 missed 11 scheduled baths in January 2023, 12 scheduled baths in February 2023, and 5 scheduled baths in March 2023.<BR/>Resident #54 missed 12 scheduled baths in January 2023, 12 scheduled baths in February 2023, and 5 scheduled baths in March 2023.<BR/>These failures could cause all residents not to receive daily personal hygiene services and cause the residents to have health, social, and emotional issues.<BR/>Findings included:<BR/>1. <BR/>Record review of a face sheet dated 3/15/23 for Resident #11 indicated she was a [AGE] year-old female with diagnoses including: urinary tract infection, major depressive disorder, abnormalities of gait and mobility, reduced mobility, and heart failure. <BR/>Record review of a 5-day Medicare MDS dated [DATE] for Resident #11 indicated she did not have any impairment in thinking with a BIMS score of 13. She required extensive assist with dressing, toileting, and personal hygiene. According to section G, she had not received a bath or shower in previous 7 days. <BR/>Record review of a Care plan dated 3/15/23 for Resident #11 indicated resident had an ADL Self Care Performance Deficit and required staff x1 for assistance with bathing. <BR/>Record review of task documentation reports for Resident #11 dated 3/15/23 for the month of January, February, and March 2023 indicated that residents scheduled bath days were Monday, Wednesday, and Friday. Bathing task documentation was blank for the following days:<BR/>January: 1/2/23, 1/4/23, 1/6/23, 1/9/23, 1/11/23, 1/13/23, 1/20/23, 1/23/23, 1/25/23, 1/27/23, and 1/30/23.<BR/>February: 2/1/23, 2/3/23, 2/6/23, 2/8/23, 2/10/23, 2/13/23, 2/15/23, 2/17/23, 2/20/23, 2/22/23, 2/24/23, and 2/27/23.<BR/>March: 3/1/23, 3/3/23, 3/6/23, 3/8/23, and 3/13/23.<BR/>2. <BR/>Record review of face sheet dated 3/15/23 for Resident #54 indicated she was a [AGE] year-old female with diagnoses including: Parkinson's disease, major depressive disorder, and abnormalities of gait and mobility.<BR/>Record review of a quarterly MDS dated [DATE] for Resident #54 indicated that she did not have any impairment in thinking with a BIMS score of 15. MDS section G also indicated that Bathing/Showering did not occur in the previous 7-day period. She required limited assist for bed mobility, supervision for dressing and locomotion, and had limited ROM in bilateral lower extremities. <BR/>Record review of a Care Plan dated 3/15/23 for Resident #54 indicated that she had an ADL Self Care Performance Deficit and required staff assist X 1 for bathing. <BR/>Record review of task documentation reports for Resident #54 dated 3/15/23 for the month of January, February, and March 2023 indicated that residents scheduled bath days were Monday, Wednesday, and Friday. Bathing task documentation was blank for the following days:<BR/>January: 1/2/23, 1/4/23, 1/6/23, 1/9/23, 1/11/23, 1/18/23, 1/16/23, 1/18/23, 1/20/23, 1/23/23, 1/25/23, and 1/30/23.<BR/>February: 2/1/23, 2/3/23, 2/6/23, 2/8/23, 2/10/23, 2/13/23, 2/15/23, 2/17/23, 2/20/23, 2/22/23, 2/24/23, and 2/27/23.<BR/>March: 3/1/23, 3/3/23, 3/6/23, 3/8/23, and 3/13/23.<BR/>During an observation and interview with Resident #11 on 03/13/23 at 09:38 AM she indicated that she had not had a bath in about a month, no bodily orders were observed, but hair did appear to be oily and unwashed. She said that it made her feel dirty when she did not receive a bath and she did not like that feeling. <BR/>During an observation and interview with Resident #54 on 3/14/23 at 11:00 AM she said that she did not get a shower. Her hair was noted to be clean, and she said that she washed it herself in the bathroom sink because the aides would never take her to the shower. She said when she asked, they would say they would come back and get her, but they never would. She stated that DON told her not to get in the shower by herself, because she could fall and hurt herself. Resident said that since the aides would never come and help her shower, she would just get in by herself because she felt so grungy. Said that she went 8 weeks one time with no shower and finally just started getting in there when no-one was in there and doing it herself.<BR/>During an interview with hall CNA A on 03/14/23 at 04:15 PM she said they have a shower tech and the aides on the halls would get the residents to the shower tech for the showers as scheduled: B beds on T/Th/Sat, and A beds on M/W/F. She said that the shower tech was supposed to document that the showers were given.<BR/>During an interview with DON on 03/14/23 at 04:20 PM she said that they had had a problem previously with residents getting showers, but they had rehired the shower tech. She said that she knew of no-one on 100 hall that was not receiving their showers. She said that the Charge nurse and Shower tech were responsible for ensuring the showers/baths were documented.<BR/>During an interview with Shower Aide on 03/15/23 at 10:29 AM she said that showers were on a set schedule and A beds were showered on Mondays, Wednesdays, and Fridays, and B Beds were showered Tuesdays, Thursdays, and Saturdays. She said that the CNAs on the halls brought the residents to her for their showers. She said that she would document her showers in the kiosk, but if she got too busy, she would sometimes get the hall CNAs to help her to document. She said that she would tell the CNAs which ones they need to document. She was unable to answer why documentation was missing from Resident #53's record. She said that Resident #11 received a bed bath and was unable to answer why the hall CNA was not documenting her baths.<BR/>During an interview with DON on 03/15/23 at 08:40 AM she said that if the residents do not receive their showers/baths that it could put them at risk for skin breakdown and infection. She said they were now working on improving the shower issue. Said that they were now going to have a shower sheet for aides to document the shower of each resident and monitor it every day to ensure each resident received their showers. Department heads are to ask each ask resident during their Champion rounds if they received their shower so they can monitor better. She said that they will be discussing their findings every morning during the morning meeting. She said that residents could be at risk for skin breakdown and infection by not receiving baths/showers. <BR/>During an interview with the Administrator on 3/15/23 at 12:45pm he said that they were already doing champion rounds, and they have added a section asking about showers and they will review that every morning in the morning meeting. He said that residents could be at risk for skin breakdown and infection by not receiving baths/showers. <BR/>Record review of facility policy titled Bath, Tub/Shower, undated, stated .Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed .10. Assist to stand in the shower or sit on a stool or chair in the shower or tub, inform the resident of the use of the rails for support in getting in and out to prevent falls. 11. Remain with the resident if he is weak or assistance is needed in washing .16. Assist out of the tub or shower, wrap in the bath towel, allow to sit on a chair, and assist to dry if needed, especially in the skin folds. 17. Assist to dress if needed or supply aids for dressing independently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure residents the right to be free from abuse and neglect for 1 of 6 (Resident #4) residents reviewed for abuse and neglect. <BR/>The facility failed to ensure Resident #4 was free from verbal abuse from Resident #3 on 10/31/2024 during a resident to resident verbal altercation.<BR/>These deficient practices could place residents at risk for abuse, neglect, and not having their needs met.<BR/>Findings included:<BR/>1.Record review of Resident #4's electronic face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with most recent admission on [DATE]. Resident #4's diagnoses included: nontraumatic subarachnoid hemorrhage (bleeding in the brain), seizures (disruption of normal brain function), and muscle weakness. <BR/>Record review of Resident #4's Quarterly MDS, dated [DATE] indicated a BIMS of 03 indicating a severe cognitive impairment. The MDS indicated Resident #4 was dependent for all bed mobility.<BR/>Record Review of Resident #4's care plan dated 12/7/2021 and revised on 2/5/2024 indicated: Resident #4 had a communication problem related to cerebrovascular accident causing aphasia, dysphagia and cognitive deficit with interventions that included: Use effective strategies: facial expression, eye contact, gestures, tone of voice, non-threatening posture, short direct phrases, speak slowly, speak in a calm, distinct manner, interpreter, time to communicate, 1 to 1, quiet setting for communicating with resident.<BR/>2.Record review of facility electronic face sheet indicated Resident #3 was a [AGE] year-old female admitted to facility on 5/01/2024 with the most recent admission on [DATE]. Resident #3's diagnosis included: dementia (decline in mental ability), anxiety (excessive worry, fear, and nervousness), and bipolar disorder (extreme shifts in mood, energy, and behavior).<BR/>Record Review of Resident #3's comprehensive care plan dated 1/08/2025 indicated Resident # 3 refused medications at times with intervention of a negotiated risk assessment signed. Resident #3 had impaired cognitive function dementia or impaired thought processes with an intervention to administer medications as ordered. Resident #3 had verbal behaviors threatening to kill roommate and staff with an intervention of assist resident in avoiding resident that may incite outburst. Resident #3 required antipsychotic medications with an intervention to administer medications as ordered, monitor and document for side effects and effectiveness.<BR/>Record review of Resident #3's Quarterly MDS dated [DATE] indicated Resident #3 had a BIMS of 15 indicating no cognitive impairment.<BR/>Record review of nursing progress note dated 10/31/2025 at 4:15 AM written by RN D indicated: I heard resident screaming at nurse aide that if she touches her, she will kill her. I entered the room and resident sitting [Resident #4's] bed and cursing. I called the aide to the side, and she stated that she was trying to get [Resident #3] to get off the bed, as she was threatening her too. I witnessed then [Resident #3] threaten to hit the other resident, and to even kill her if she touched her. I asked [Resident #3] what is wrong, did she need me to send her to the hospital. She said no. Interventions: I talked with [Resident #3] and convinced her to get into her own bed. She started to cry, got up and got into her bed and covered her head .<BR/>During an interview on 3/25/2025 at 1:05 PM LVN E said Resident #3 had a psychotic episode on 10/31/2025 at 4:15 AM. She said RN D went to Resident #3's room and during the psychotic episode found Resident #3 on top of Resident #4 threatening to kill her. She said RN D was able to de-escalate the situation and moved Resident #4 out of the room. <BR/>During an interview on 3/25/2025 at 3:00 PM the DON said on 10/31/2024 Resident #3 was found sitting on Resident #4's bed threatening to kill her. She said Resident #4 was removed from the room and did not have any effects from the incident due to Resident #4's cognition. <BR/>During an interview on 3/26/2025 at 10:49 AM RN D said on 10/31/2025 at about 4:15 AM she went down the hall and heard resident screaming so she went in the room and the aide was in the room and Resident #3 was sitting on Resident #4's bed shaking her fist threatening to kill Resident #4. She said she removed Resident #4 from the room and took her to the dining room. She said she tried to call the DON with no answer, so she notified the on-call nurse of the situation.<BR/>During an interview on 3/26/2025 at 11:21 AM RN G said she was on call the night of 10/31/2024 and received a call from RN D regarding Resident #3 having a psychotic episode. She said she told RN D to make sure that Resident #4 was out of the room and safe.<BR/>During an interview on 3/26/2025 at 1:19 PM CNA H said on the night of 10/31/2025 she remembered Resident #3 was not herself that night. She said Resident #3 was getting up and going over to Resident #4's side of the room. She said Resident #4 was bedbound and Resident #3 was sitting on the edge of Resident #4's bed threatening to kill her. She said she told Resident #3 she couldn't be on Resident #4's bed and that's when she became combative to the CNA. She said RN D entered the room and was finally able to calm Resident #3 down enough to get her off Resident #4's bed and back in her own bed. She said Resident #4 was then removed from the room. <BR/>During an interview on 3/26/2025 at 2:45 PM the DON said the reason it was not reported was because Resident #3 had a psychotic issue but never did anything to Resident #4. She said that Resident #4 did not appear to be upset and she did not feel as though the incident was reportable. She said they did not feel as though it was abuse because it did not harm Resident #4 physically or emotionally. She said she knew they talked about the situation in the morning meeting the next day. So, it was at least by the morning meeting that the Administrator was notified. She said the expectation was that all allegations of alleged abuse be reported to the abuse coordinator immediately.<BR/>During an interview on 3/26/2025 at 2:55 PM the Administrator said they did not report that incident because Resident #4 did not even know what was going on. He said when they separated Resident #3 and Resident #4 there was no injury to Resident #4. He said his expectation was they will follow their policy and guidelines for reporting alleged abuse.<BR/>Record review of facility policy titled Abuse/Neglect dated 3/29/18 indicated: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . 3. Verbal Abuse: Any use of oral , written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability .Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able to see her family again, etc. Abuse as defined in 40 TAC 19.101(1) . E. Reporting .3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 6 residents (Resident #4 and Resident # 3) reviewed for abuse. <BR/>The facility failed to keep Resident #4 safe from verbal abuse from Resident #3. On 10/31/2025 at 4:15 AM Resident #4's roommate was found on Resident #3 's bed threatening to kill her. <BR/>This failure could place residents at risk of further potential abuse. <BR/>Findings included: <BR/>1.Record review of Resident #4's electronic face sheet revealed an [AGE] year-old-female who was admitted to the facility on [DATE] with most recent admission on [DATE]. Resident #4's diagnoses included: nontraumatic subarachnoid hemorrhage (bleeding in the brain), seizures (disruption of normal brain function), and muscle weakness. <BR/>Record review of Resident #4's Quarterly MDS, dated [DATE] indicated a BIMS of 03 indicating a severe cognitive impairment. The MDS indicated Resident #4 was dependent for all bed mobility.<BR/>Record Review of Resident #4's care plan dated 12/7/2021 and revised on 2/5/2024 indicated: Resident #4 had a communication problem related to cerebrovascular accident causing aphasia(affects the ability to communicate), dysphagia (difficulty swallowing) and cognitive deficit with interventions that included: Use effective strategies: facial expression, eye contact, gestures, tone of voice, non-threatening posture, short direct phrases, speak slowly, speak in a calm, distinct manner, interpreter, time to communicate, 1 to 1, quiet setting for communicating with resident.<BR/>2.Record review of facility electronic face sheet indicated Resident #3 was a [AGE] year-old female admitted to facility on 5/01/2024 with the most recent admission on [DATE]. Resident #3's diagnosis included: dementia (decline in mental ability), anxiety (excessive worry, fear, and nervousness), and bipolar disorder (extreme shifts in mood, energy, and behavior).<BR/>Record Review of Resident #3's comprehensive care plan dated 1/08/2025 indicated Resident # 3 refused medications at times with intervention of a negotiated risk assessment signed. Resident #3 had impaired cognitive function dementia or impaired thought processes with a intervention to administer medications as ordered. Resident #3 had verbal behaviors threatening to kill roommate and staff with an intervention of assist resident in avoiding resident that may incite outburst. Resident #3 required antipsychotic medications with an intervention to administer medications as ordered, monitor and document for side effects and effectiveness.<BR/>Record review of Resident #3's Quarterly MDS dated [DATE] indicated Resident #3 had a BIMS of 15 indicating no cognitive impairment.<BR/>Record review of nursing progress note dated 10/31/2025 at 4:15 AM written by RN D indicated: I heard resident screaming at nurse aide that if she touches her she will kill her. I entered the room and resident sitting [Resident #4's] bed and cursing. I called the aide to the side and she stated that she was trying to get [Resident #3] to get off the bed, as she was threatening her too. I witnessed then [Resident #3] threaten to hit the other resident, and to even kill her if she touched her. I asked [Resident #3] what is wrong, did she need me to send her to the hospital. She said no. Interventions: I talked with [Resident #3] and convinced her to get into her own bed. She started to cry, got up and got into her bed and covered her head .<BR/>During an interview on 3/25/2025 at 11:00 AM Resident #4 was not able to answer questions appropriately due to cognition.<BR/>During an interview on 3/25/2025 at 1:05 PM LVN E said Resident #3 had a psychotic episode on 10/31/2025 at 4:15 AM. She said RN D went to Resident #3's room and during the psychotic episode found Resident #3 on top of Resident #4 threatening to kill her. She said RN D was able to de-escalate the situation and moved Resident #4 out of the room. <BR/>During an interview on 3/25/2025 at 3:00 PM the DON said on 10/31/2024 Resident #3 was found sitting on Resident #4's bed threatening to kill her. She said Resident #4 was removed from the room and did not have any effects from the incident due to Resident #4's cognition. Resident #3 was monitored 1 to 1 until she discharged to the hospital. <BR/>During an interview on 3/26/2025 at 10:49 AM RN D said on 10/31/2025 at about 4:15 AM she went down the hall and heard resident screaming so she went in the room and the aide was in the room and Resident #3 was sitting on Resident #4's bed shaking her fist threatening to kill Resident #4. She said she removed Resident #4 from the room and took her to the dining room. She said she tried to call the DON with no answer, so she notified the on-call nurse of the situation.<BR/>During an interview on 3/26/2025 at 11:21 AM RN G said she was on call the night of 10/31/2024 and received a call from RN D regarding Resident #3 having a psychotic episode. She said she told RN D to make sure that Resident #4 was out of the room and safe.<BR/>During an interview on 3/26/2025 at 1:19 PM CNA H said on the night of 10/31/2025 she remembered Resident #3 was not herself that night. She said Resident #3 was getting up and going over to Resident #4's side of the room. She said Resident #4 was bedbound and Resident #3 was sitting on the edge of Resident #4's bed threatening to kill her. She said she told Resident #3 she couldn't be on Resident #4's bed and that's when she became combative to the CNA. She said RN D entered the room and was finally able to calm Resident #3 down enough to get her off Resident #4's bed and back in her own bed. She said Resident #4 was then removed from the room. <BR/>During an interview on 3/26/2025 at 2:45 PM the DON said the reason it was not reported is because Resident #3 had a psychotic issue but never did anything to Resident #4. She said that Resident #4 did not appear to be upset and she did not feel as though the incident was reportable. She said they did not feel as though it was abuse because it did not harm Resident #4 physically or emotionally. She said she knew they talked about the situation in the morning meeting the next day. So, it was at least by the morning meeting that the Administrator was notified. She said the expectation was that all allegations of alleged abuse be reported to the abuse coordinator immediately.<BR/>During an interview on 3/26/2025 at 2:55 PM the Administrator said they did not report that incident because Resident #4 did not even know what was going on. He said when they separated Resident #3 and Resident #4 there was no injury to Resident #4. He said his expectation is they will follow their policy and guidelines for reporting alleged abuse.<BR/>Record review of facility policy titled Abuse/Neglect dated 3/29/18 indicated: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . 3. Verbal Abuse: Any use of oral , written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability .Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able to see her family again, etc. Abuse as defined in 40 TAC 19.101(1) . E. Reporting .3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards and each resident received adequate supervision as is possible for 2 of 6 resident (Resident #1 and Resident #2) reviewed for accidents and hazards.<BR/>1.The facility failed to ensure Resident #1 did not wander outside of the facility and down the road while wearing a wander guard. On 1/04/2025 Resident #1 while wearing a wander guard left the facility through the front door and was seen walking down the road by another resident's family member who notified the facility of Resident #1's whereabouts. <BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 01/04/2025 and ended on 01/08/2025. The facility corrected the non-compliance before surveyor's entrance. <BR/>2.The facility failed to ensure Resident #2 was properly strapped down in the van to prevent Resident #2's wheelchair from flipping over backwards during transport. On 2/21/2025 during transport to dialysis by the contract transport service Resident #2's wheelchair flipped over backwards in the van causing Resident #2 to have head and neck pain.<BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/21/2025 and ended on 02/25/2025. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure could place residents at risk of harm and serious injuries due to lack of supervision and failure to follow protocols.<BR/>Findings included:<BR/>Record review Resident #1's Face sheet dated 3/25/2025 indicated Resident #1 was admitted to the facility on [DATE] with the most recent admission on [DATE]. Resident #1 was a [AGE] year-old female admitted with diagnosis of severe dementia with anxiety (agitation, restlessness, and difficulty concentrating stemming from confusion and disorientation), hypertension (high blood pressure), and muscle weakness.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 04 indicating severe cognitive impairment. The MDS Assessment indicated Resident #1 required supervision or touching assistance with walking 150 feet.<BR/>Record review of Resident#1's care plan dated 11/04/2021 indicated: Resident #1 was at risk for wandering, Resident #1 had a wander guard in place with interventions that included: .3. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. 4. Identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. 5. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. <BR/>Record review of Resident #1's medication administration record dated January 2025 indicated: Monitor for function of wander guard every shift and as needed for preventative and was signed as functioning on 1/3/2025 night shift. <BR/>Record review of Resident #1's weekly skin assessment dated [DATE] indicated Resident #1 did not have any skin issues.<BR/>Record review of Resident #1's elopement risk assessment dated [DATE] indicated a score of 9 which indicated low risk for elopement.<BR/>Record review of incident report dated 01/04/2025 revealed: elopement on 1/04/2025 at 9:10am from the reception/lobby. No injuries were observed at the time of the incident and Resident #1 was not taken to the hospital.<BR/>Record review of the facility's Provider Investigation report dated 01/09/2025 revealed the following: The resident went out the front door and was observed by another family member about 60 yards away from the facility. They notified the facility, and the resident was returned with no injuries.<BR/>During an observation on 3/25/2025 at 3:00 PM the Administrator and DON demonstrated Resident #1's wander guard at the front door and the door did not alarm or lock. The Corporate Maintenance Director provided a new wander guard and when approached at the front door the door locked, when the new wander guard approached the front door when the door was open, and alarm sounded.<BR/>During an interview on 3/25/2025 at 3:00 PM the DON said Resident #1 went out the front door of the facility. She said Resident #1's wander guard did not lock the front door or alarm. The DON said the wander guard had been checked on the night shift prior to the morning of the incident and said it was functioning. She said after the incident and Resident #1 was returned to the facility the malfunctioning wander guard was replaced with a new one and Resident #1 was placed on 1 to 1 supervision. She said Resident #1 was discharged later that day to a facility with a secured unit.<BR/>During an interview on 3/25/2025 at 3:00 PM the Administrator said the Resident #1's wander guard did not lock the front door or alarm. He said sometime between it being checked on the night shift and the incident the wander guard malfunctioned and did not work. He said another resident's family member took a picture of the resident walking down the road and showed it to the facility and the facility went and retrieved Resident #1 without incident. Resident #1 was returned to the facility and a new wander guard was placed on Resident #1. He said a head-to-toe assessment was completed on Resident #1 with no injuries found. He said later that same day the resident was transferred to another facility with a secured unit.<BR/>Record review of QAPI notes dated 01/04/2025 indicated that the meeting was attended by the following members: Administrator, DON, ADON, Medical Director, Social Services, Dietary, MDS Nurse, Activity Director, Therapy, and Medical Records. The interventions and plan for correction included: <BR/>1. <BR/>Self report to HHSC.<BR/>2. <BR/>Interview the resident completed on 1/4/2025. <BR/>3. <BR/>Take statements from everyone involved or with potential knowledge/involvement completed 1/4/2025.<BR/>4. <BR/>Determine if resident will be able to remain in the facility with any new interventions. Resident #1 was transferred to a new facility with a secured unit on 1/4/2025.<BR/>5. <BR/>1 on 1 monitoring for resident involved until evaluated by the IDT and further instructions are provided. Completed on 1/4/2025.<BR/>6. <BR/>Complete risk management entry for elopement and complete elopement event note and elopement risk assessment for the resident involved. Document conclusion in the risk management entry of PCC (records system). Completed on 1/4/2025.<BR/>7. <BR/>Complete an elopement risk assessment for all other residents. Completed 1/4/2025. <BR/>8. <BR/>Complete the QA tool for elopements. Completed 2/4/2025.<BR/>9. <BR/>Update the care plan for the resident who exited with new interventions. Completed 1/4/2025. <BR/>10. <BR/> Review and update the plan of care as needed of any resident who has been assessed to be a high risk for elopement. Completed 1/4/2025. <BR/>11. <BR/> Perform trauma informed PRN assessment on affected resident and initiate/update care plan interventions as needed. Completed 1/4/2025.<BR/>12. <BR/> If known, in-service staff related to findings and ways to prevent residents exiting. In-services on abuse, neglect, and elopement initiated on 1/4/2025.<BR/>13. <BR/> Notification to families to mindful of residents attempting to exit the facility and not to share the door code with the residents. Completed on 1/10/2025. <BR/>14. <BR/> Place signage at visitor exits to be mindful of residents attempting to exit the facility and not to share a door code with the residents. Completed 1/4/2025. <BR/>15. <BR/> The Medical Director was notified of this plan. Completed 1/4/2025. <BR/>Record review of Resident #1's electronic medical record indicated Resident #1 discharged from the facility on 1/4/2025.<BR/>Record review of 1 to 1 monitoring sheets dated 1/4/2025 from 9:30 AM to 3:45 PM. <BR/>Record review of Missing Resident/Elopement Monitoring tool dated 1/4/2025 through 2/4/2025 indicated: 1. The locking mechanism or alarm functioned properly on all exit doors of the facility. 2. Wander guard bracelets were in place every shift.<BR/>Record review of Trauma Informed PRN Assessment dated 1/4/2025 indicated Resident #1 had no trauma from the incident. <BR/>Record review of Elopement Risk Assessment dated 1/4/2025 indicated a score of 28 which indicated high risk for elopement. <BR/>Record review of the care plan for Resident #1 indicated revised on 1/4/2025 indicated a new intervention for 1 to 1 monitoring of Resident #1 until alternate placement could be arranged. <BR/>Record review of in-services dated 1/4/2025-1/5/2025 titled Abuse, Neglect, Elopement, ways to prevent resident exiting, reporting concerns with 135 employee signatures. <BR/>Record review of elopement drills dated 1/7/2025, 1/9/2025, 1/15/2025, 1/17/2025, 1/21/2025, and 1/23/2025 indicated multiple drills across multiple shifts had been conducted. <BR/>Observation of signage on the front door of the facility on 3/25/2025 at 3:00 PM notifying families to be mindful of residents attempting to exit the facility and not to share door code with the residents. <BR/>On 3/25/25 at 10:51 am the Administrator, and DON were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 1/04/2025 and ended on 2/4/2025. The facility had corrected the noncompliance before the investigation began.<BR/>2. Record review of the electronic face sheet dated 3/24/2025 for Resident #2 indicated Resident #2 was admitted to the facility on [DATE] with diagnosis that included: end stage renal disease (kidneys do not function properly), hyperkalemia (excessive amount of potassium in the blood), and muscle weakness. <BR/>Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 had a BIMS score of 11 which indicated mild cognitive impairment. The MDS assessment indicated Resident #2 required supervision or touching assistance for transfers. <BR/>Record review of Resident #2's care plan dated 9/22/2023 and revised on 2/5/2024 indicated Resident #2 had end stage renal disease and was on dialysis on Mondays, Wednesdays, and Fridays with interventions that included: 1. Encourage resident to do for the scheduled dialysis appointments, resident received dialysis on Mondays, Wednesdays, and Fridays. The resident had an ADL self-care performance deficit with interventions that included: 1. the resident uses a wheelchair. The resident was at risk for falls gait/balance problems with interventions that included: 1. Skin assessment, new pain medication, xrays ordered, neuros started, 3rd party transportation on hold for in-servicing their staff on van safety/buckling and monitoring in place.<BR/>Record review of nursing progress note dated 2/21/2025 at 6:00 AM written by LVN C indicated Notified by transport driver, while on the way to drop off resident at dialysis, residents wheelchair tilted backwards resulting in resident falling backwards in chair. Driver states resident stated he was ok to continue to dialysis appointment.<BR/>Record review of nursing progress note dated 2/21/2025 at 10:30 AM written by LVN C indicated Resident returned from dialysis and is complaining of neck pain post fall from this morning. New order received for xray of neck due to neck pain.<BR/>Record review of nursing progress note dated 2/21/2025 at 10:30 AM written by the DON indicated Resident denied any pain medication at this time and stated he would let us know if he needed anything.<BR/>Record review of nursing progress note dated 2/21/2025 at 11:40 AM written by the DON indicated Down to check on resident at this time to see how he is doing; resident is stating that his head/neck is bothering him and asked if he could get something for pain at this time. MD was notified and new order for Tylenol 325mg every 4 hours as needed for pain. (medication was administered at this time to resident) Attempted to notify [family] but no answer at this time.<BR/>Record review of nursing progress note dated 2/21/2025 at 12:03 PM written by the DON indicated Down to follow up with resident and he does state that the Tylenol was effective.<BR/>Record review of nursing progress note dated 2/21/2025 at 1:46 PM written by the DON indicated Went down to check on resident at this time and he stated that he was feeling ok. Inquired again if resident was wanting to go to ER (resident had been asked when incident initially occurred if he would like to go be he did not feel he needed to go at that time and wanted to proceed going to dialysis) to get checked out and he stated well I feel like I guess I should. Explained that xrays had been taken and results were pending when I last looked however if felt he needed to be checked out we could certainly send him. He thought for a minute and stated he felt like he ought to go ahead and go just to be safe. MD notified of request and new orders given to transport to ER for evaluation and treatment.<BR/>Record review of nursing progress noted dated 2/21/2025 at 5:42 PM written by ADON B indicated Resident returned via wheelchair with [facility] van transport from [hospital] ER related to fall, resident cleared from ER and sent back to facility with no changes in medications or orders.<BR/>Record review of facility incident report dated 2/21/2025 at 6:00 AM indicated Resident #2 had a fall with no other information. <BR/>Record review of hospital paperwork dated 2/21/2025 indicated no acute findings and Resident #2 was discharged back to the facility with no new orders.<BR/>During an interview on 3/24/2025 at 10:33 AM Resident #2 said on the day he fell in the van the Contract Van Driver did not strap him down in the van. He said the Contract Van Driver was trying to go up the hill in the driveway and his wheelchair flipped backwards. He said the Contract Van Driver stopped and picked him back up in the van. He said he told the Contract Van Driver he was having pain but the Contract Van Driver continued on to dialysis. He said he told them at dialysis he was in pain also. He said when he got back to the facility the nurse checked him over and he complained of head and neck pain. He said the facility sent him out to the ER to get checked out. He said he no longer is having any pain to his head and neck.<BR/>During an interview on 3/24/2025 at 11:10 AM the Contract Van Driver said on 2/21/2025 at approximately 5:00 AM he got to the facility and put the resident on the van. He said he placed Resident #2 on the ramp and raised the ramp. He said he then pushed Resident #2 forward, he said he usually used 2 front straps, and 2 back straps when securing a resident in the van. He said when he drove off and going up the incline in the facility parking lot Resident #2 flipped back in his wheelchair. He said he stopped the van and got out to check if Resident #2 was ok, and said Resident #2 told him that he was fine and to continue on to dialysis. He said he picked Resident #2 upright in his wheelchair and continued on to dialysis. He said he did not notify anyone of the fall until later on that day. He said he had no idea how the incident happened.<BR/>During an interview on 3/24/2025 at 11:30 AM the Facility Van Driver said she picked up Resident #2 from dialysis on the day he fell on the Contract Van. She said when she picked him up about 10:30am the Dialysis Tech pushed him out to the van that day and said Resident #2 was complaining of severe head and neck pain because he fell backwards in the Contract Van that morning. She said she brought Resident #2 straight back to the facility and said when she got there the Contract Van Driver was at the facility to report the fall that happened that morning. Said she reported to the nurse that Resident #2 was complaining of head and neck pain. She said to properly secure a resident's wheelchair in the van there should be 2 tie down straps at the front of the wheelchair and 2 tie down straps at the back of the wheelchair, she said then there is a seatbelt that goes across the resident to hold the resident in the chair. She said if all straps are applied appropriately there would be no way a resident's wheelchair could flip over backwards.<BR/>During an interview on 3/24/2025 at 12:26 PM the Dialysis Tech said on 2/21/2025 Resident #2 never complained of pain until the end of his treatment and then he told her that he had fallen in the van on his way to dialysis that morning. She said she did not administer anything for pain while he was at dialysis that day. She said the Contract Van Driver did not notify anyone at dialysis that Resident #2 had fallen that morning. <BR/>During an Observation and interview on 3/24/2025 at 12:43 PM the Contract Van Driver demonstrated how to correctly strap down a wheelchair in the van. At the end of the demonstration the surveyor asked the Contract Van Driver if it was plausible that on the day Resident #2 fell in the van that Resident #2 was not secured properly in the van and the Contract Van Driver said yes.<BR/>During an interview on 3/25/2025 at 10:25 AM the Corporate Maintenance Director said to properly secure a resident's wheelchair in the van there should be 2 tie down straps at the front of the wheelchair and 2 tie down straps at the back of the wheelchair, he said then there is a seatbelt that goes across the resident to hold the resident in the wheelchair. He said if all straps are applied appropriately there would be no way a resident's wheelchair could flip over backwards and the wheelchair should not move in the van. <BR/>During an interview on 3/25/2025 at 10:40 AM the DON said on 2/21/2025 at approximately 10:30 AM the Contract Van Driver came to the facility to report to her that Resident #2 had fallen in the van that morning. She said the Contract Van Driver did not report it to the facility that morning when it happened but waited until later in the day. She said the Contract Van Driver told her he asked Resident #2 if he was ok and Resident #2 said he was, so he continued with transporting Resident #2 to dialysis. She said the Contract Van driver said he had not reported the incident to dialysis.<BR/>During an interview on 3/25/2025 at 11:04 AM the Administrator said on 2/21/2025 he received a call from the Contract Van Drivers supervisor stating the Contract Van Driver was going to the facility to let them know about and incident that had happened that morning. He said at approximately 10:30 AM he overheard the Contract Van Driver telling the DON that Resident #2 had fallen in the van that morning. He said the Contract Van Driver said he loaded Resident #2 on the van and when leaving the facility parking lot incline Resident #2 flipped backwards in his wheelchair. He said the Contract Van Driver immediately stopped the vehicle and asked Resident #2 if he was ok and Resident #2 said lets just go on to dialysis. He said Resident #2 denied any pain, so he continued transport to dialysis. <BR/>Record review of Contract Van Drivers successful completion of the Passenger Assistance Safety and Sensitivity 7.0 Two-day Driver Certification Program including sensitivity training, left operating procedures, wheelchair and occupant securement valid January 09, 2025, through January 09, 2027. <BR/>Observation of training video titled Retractable wheelchair tie-downs to secure wheelchair superior van and mobility. Video was accessed at https://youtu.be/mY_GThwGdbI?si=zQH-3ntbRIcPyck0 which indicated there should be 2 tie down straps in the front of the wheel chair and 2 tie down straps at the back of the wheelchair and the seatbelt that goes across the resident. <BR/>Surveyor requested the facility policy and procedure regarding wheelchair tie down procedure and none was provided. <BR/>Record review of QAPI notes dated 02/21/2025 indicated that the meeting was attended by the following members: Administrator, DON, ADON, Medical Director, Social Services, Dietary, MDS Nurse, Activity Director, Therapy, and Medical Records. The interventions and plan for correction included: <BR/>1. <BR/>Self report to HHSC. Completed 2/21/2025.<BR/>2. <BR/>The Contract van services was removed from service for resident transport on 2/21/2025.<BR/>3. <BR/>The Contract Van Services were to educate drivers before services to be reinstated. Completed on 2/25/2025. <BR/>4. <BR/>The Contract Van Driver was not allowed to transport for the facility pending investigation. Completed 2/21/2025.<BR/>5. <BR/>Take statements from everyone involved or with potential knowledge/involvement. Completed 2/21/2025.<BR/>6. <BR/>Begin abuse/neglect in-service for all staff who transport or assist with transporting residents in the van. Started on 2/21/2025.<BR/>7. <BR/>In-service staff who transport or assist with transporting residents in the van on the following (with return demonstration): How to safely load and unload residents in the van using the lift, properly securing a resident in the van, ambulatory resident -securing with a seatbelt, Non-ambulatory resident-securing the wheel chair and the resident. Started 2/21/2025. <BR/>8. <BR/>Maintain a list of staff who have completed training and provided return demonstration regarding transporting a resident in the van. Staff not listed will not transport residents. Completed on 2/24/2025. <BR/>9. <BR/>Complete risk management entry as other in PCC. Attempt to determine the root cause of the incident. Document conclusion in this risk management entry of PCC. Fall Note completed 2/21/2025.<BR/>10. <BR/> Perform trauma informed PRN assessment on affected resident and initiate/update care plan interventions as needed. Completed 2/21/2025. <BR/>11. <BR/> The medical director was notified of this plan. Completed on 2/21/2025. <BR/>Record review of in-service titled Van Training/Proper Tie Down Procedures Dated 2/24/2025 provided by the Corporate Maintenance Director and signed by the Facility Van Driver. <BR/>Record review of Education Sign in Sheet with the topic Wheelchair securement during Transport dated 2/25/2025 signed by the Contract Van Service 6 employees.<BR/>Record review on plan of correction submitted to the facility by the Contract Van Services indicated: 1. All transporters will receive reinforcement education of reasons for following all safety precautions, with visual confirmation. Education for log implementation will be provided also with the date to be completed of 2/26/2025. 2. Log to be implemented to record daily checks that all belts are to be checked daily prior to vehicle use to confirm safe and correct functioning to be completed daily with implementation by 2/26/2025. Supervisor will check logs of all vehicles used weekly to ensure compliance. If a vehicle is not used on a given day, it should be marked as not used on the log for that day. 3. [Contract Van Driver] will show correct use of all safety belts and sign acknowledgement of importance for checking safe functioning and ensuring correct use every time. He will also acknowledge who and how to reach out for support if he is unsure of a procedure or safe functioning completed 2/26/2025. Supervisor will monitor patients for safe travel and follow up with [Contract Van Driver] weekly for 2 months, then as needed, to ensure compliance and provide support for [Contract Van Driver] to be successful in safely transporting patients.<BR/>Record review of Follow up Training Completion Sheet 2025 for the Contract Van Driver indicated his supervisor had signed completion for 4 weeks dated 2/21/2025 through 3/21/2025. <BR/>Record review of Daily Checklist for Securement Device(s) Functionality dated March 2025 for multiple transport vehicles dated 3/3/2025 through 3/23/2025. <BR/>Record review of facility in-services titled Abuse, Neglect, Resident Rights dated 2/21/2025 with 130 facility employee signatures. <BR/>Record review of Trauma informed PRN assessment dated [DATE] at 12:40 PM indicated Resident #2 did not experience any trauma from the incident.<BR/>Record review of employee questionnaires on abuse/neglect completed on 2/21/2025 with no concerns noted.<BR/>Record review of resident safe surveys on abuse/neglect completed on 2/21/2025 with no concerns noted. <BR/>Record review of monitoring of the Facility Van Driver completed 2/21/2025 through 2/27/2025 with no concerns noted. <BR/>On 3/25/25 at 10:51 am the Administrator, and DON were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 2/21/2025 and ended on 2/25/2025. The facility had corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 6 residents (Resident #3) and reviewed for pharmacy services. <BR/>The facility failed to ensure Resident #3 ingested all medications as prescribed and was not able to stash medications in room. On 10/31/2024 Resident #3 had a psychotic episode, and 40 to 50 pills were found on the floor in Resident #3's room. On 1/29/2024 Resident #3 had a psychotic episode, and 10 to 15 pills were found in Resident #3's room. <BR/>These failures could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and not receiving the intended therapeutic benefit of the medications.<BR/>Findings included: <BR/>Record review of facility electronic face sheet indicated Resident #3 was a [AGE] year-old female admitted to facility on 5/01/2024 with the most recent admission on [DATE]. Resident #3's diagnosis included: dementia (decline in mental ability), anxiety (excessive worry, fear, and nervousness), and bipolar disorder (extreme shifts in mood, energy, and behavior).<BR/>Record Review of Resident #3's comprehensive care plan dated 1/08/2025 indicated Resident # 3 refused medications at times with intervention of a negotiated risk assessment signed. Resident #3 had impaired cognitive function dementia or impaired thought processes with an intervention to administer medications as ordered. Resident #3 had verbal behaviors threatening to kill roommate and staff with an intervention of assist resident in avoiding resident that may incite outburst. Resident #3 required antipsychotic medications with an intervention to administer medications as ordered, monitor and document for side effects and effectiveness.<BR/>Record review of Resident #3's Quarterly MDS dated [DATE] indicated Resident #3 had a BIMS of 15 indicating no cognitive impairment.<BR/>Record review of physician orders dated as of 1/29/2025 indicated Resident #3 had an order for acetaminiophen-codeine 300-60mg 1 tablet every 6 hours as needed, alprazolam 0.25mg 1 tablet at bedtime, amantadine 100mg 1 tablet twice daily, baclofen 10mg 1 tablet three times daily, ciprofloxacin 500mg 1 tablet twice daily, dicyclomine 20mg 1 tablet every 8 hours as needed, linzess 72mcg 1 tablet once a day, esomeprazole 40mg 1 tablet once a day, omega-3 capsule 1000mg 1 tablet once a day, oxcarbazepine 300mg give 2 tablets twice daily, probiotic capsule 1 capsule daily, rosuvastatin 5mg 1 tablet once daily, Seroquel 300mg 1 tablet twice daily, Seroquel 25mg 1 tablet twice daily, trazodone 50mg 2 tablets at bedtime, and Wellbutrin xl 150mg 1 tablet once daily. <BR/>Record review of Resident #3's medication administration record dated 10/01/24-10/31/2024 revealed Resident #3 refused to take omega-3 on 10/29/24 and 10/31/24.<BR/>Record review of Resident #3's medication administration record dated 1/01/25-1/31/2025 revealed Resident #3 refused to take omega-3 on 1/1/24, 1/15/24, 1/16/24, 1/17/24, 1/21/24, and 1/23/24. She refused linzess 72mcg on 1/2/25, 1/10/25, 1/20/25, 1/21/25, 1/23/25, 1/27/25, and 1/28/25. She refused probiotic 1/3/25, 1/11/25, and 1/23/25. She refused Wellbutrin xl 150mg on 1/6/25, 1/9/25, and 1/29/25. She refused amantadine 100mg on 1/1/25, 1/6/25, and 1/7/25. She refused baclofen 10mg on 1/4/25, 1/6/25, 1/13/25, 1/14/25, 1/15/25, 1/17/25, 1/20/25, 1/22/25, 1/23/25, 1/24/25, and 1/26/25.<BR/>Record review of nursing progress note dated 10/31/2024 at 4:15 AM written by RN D indicated: .I talked with [Resident #3] and convinced her to get into her own bed. She started to cry, got up and got into her bed and covered her head. I saw multiple pills on the floor. I picked them all up. I called [psych doctor] and spoke with NP. She gave orders to go 1 to 1 with [Resident #3] if it were possible. She also stated that resident needs to go to an inpatient psych facility as soon as possible.<BR/>During an interview on 3/25/2025 at 1:05 PM LVN E said Resident #3 had a psychotic episode on 10/31/2025. She said RN D went to Resident #3's room and during the psychotic episode found approximately 50 pills scattered on the floor. She said RN D picked up the pills and put them in a cup for the DON. She said the next time Resident #3 had a psychotic episode was on 1/29/2025 and said Resident #3's room was searched after she transferred to the inpatient psych hospital and 10 to 15 more pills were found in different places in Resident #3's room. <BR/>During an interview on 3/25/2025 at 3:00 PM the DON said she could not remember which psychotic episode it was but there were about 12 pills found in Resident #3's room. She said she used the computer pill identifier and said the pills mostly consisted of Resident #3's linzess, probiotic, and omega-3. She said Resident #3 had taken her antipsychotic medications and it was mostly her vitamins that were found not taken. She said she did 1 to 1 education with the weekend medication nurse LVN F that consisted of an in-service about not leaving medications at bedside. The DON said her expectation was for all medications to be administered per facility policy and physicians orders. <BR/>Record review of in-service dated 11/1/2024 titled Leaving Medications at Bedside signed by LVN F.<BR/>During an interview on 3/26/2025 at 8:29 AM ADON A said during Resident #3's psychotic episode on 10/31/2025 there were approximately 20 pills found in a basket on Resident #3's bedside table, in Resident #3's purse, and in Resident #3's dresser drawer. She said she recognized some of the pills as a multivitamin and said some of the pills she did not recognize that could have maybe been a stool softener, she said there were not any narcotics and none of the medications were psych medications. She said the episode that happened on 1/29/2025 approximately 5 or 6 pills more pills were found in the basket in Resident #3's beside table. <BR/>During an interview on 3/26/2025 at 10:49 AM RN D said on 10/31/2025 at about 4:00 AM she entered Resident #3's room due to Resident #3 having a psychotic episode. She said she felt something crunching under her feet and there were pills all over the floor. She said there were approximately 50 pills on the floor. She said she picked up all the pills and gave them to the day shift nurse LVN C the next morning to give to the DON. <BR/>During an interview on 3/26/2025 at 11:21 AM RN G said she was on call the night of 10/31/2024 and received a call from RN D regarding Resident #3 having a psychotic episode. She said RN D told her she had found a bunch of pills on the floor in Resident #3's room. She said she did not give RN D any instruction on what to do with the pills. She said on 1/29/2025 Resident #3 had a similar psychotic episode and thought there were pills found in Resident #3's room again.<BR/>During an interview on 3/26/2025 at 1:19 PM CNA H said on the night of 10/31/2025 she remembered Resident #3 having a psychotic episode and remembered seeing approximately 30-50 pills scattered all over the floor and behind her bed. She said RN D picked up all the pills and put them in a cup. She said it looked like Resident #3 had been stashing the pills and had knocked them over scattering them all over the floor. <BR/>During an interview on 3/26/2025 at 2:55 PM the Administrator said it was his expectation for all medications to be administered per the physicians' orders and facility policy. He said no medications should be left at bedside. <BR/>During an interview on 3/31/2025 at 11:37 AM LVN F said there was an incident that she did leave medications at bedside for Resident #3. She said Resident #3 requested her to leave her medications on her bedside table. She said one day she forgot to go back and check to make sure Resident #3 took the medications. She said when she left the medications at bedside, she means she went back to computer right outside the door not that she left the hall. She said Resident #3 was never out of her line of vision when taking her medications. She said she did not know where Resident #3 could have gotten the pills that were found. She said Resident #3 never refused medication and always took all her medications after it was explained to her what they were. She said Resident #3 was the only resident she left pills at bedside for. She said she was not aware of the pills that were found after the psychotic incident on 10/31/2024 or 1/29/2025. She said she had been in serviced upon hire regarding medication administration. She said she was aware she was not supposed leave medications at bedside. She said she had been in-serviced 1 on 1 regarding leaving medications at bedside.<BR/>Record review of facility policy titled Medication Administration Procedures dated 10/25/17 indicated: 5. After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. It is recommended that medication be charted immediately after administration, but if facility policy permits, medication may be charted immediately before administration. Initials are to be used. Check marks are not acceptable. During the medication administration process, the unlocked side of the cart must always be in full view of the nurse . 6. If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes or in the PRN nurses notes section of the medication administration record. In the presence of individual facility policies concerning refused and held documentation, the facility policy supersedes this policy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards and each resident received adequate supervision as is possible for 2 of 6 resident (Resident #1 and Resident #2) reviewed for accidents and hazards.<BR/>1.The facility failed to ensure Resident #1 did not wander outside of the facility and down the road while wearing a wander guard. On 1/04/2025 Resident #1 while wearing a wander guard left the facility through the front door and was seen walking down the road by another resident's family member who notified the facility of Resident #1's whereabouts. <BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 01/04/2025 and ended on 01/08/2025. The facility corrected the non-compliance before surveyor's entrance. <BR/>2.The facility failed to ensure Resident #2 was properly strapped down in the van to prevent Resident #2's wheelchair from flipping over backwards during transport. On 2/21/2025 during transport to dialysis by the contract transport service Resident #2's wheelchair flipped over backwards in the van causing Resident #2 to have head and neck pain.<BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/21/2025 and ended on 02/25/2025. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure could place residents at risk of harm and serious injuries due to lack of supervision and failure to follow protocols.<BR/>Findings included:<BR/>Record review Resident #1's Face sheet dated 3/25/2025 indicated Resident #1 was admitted to the facility on [DATE] with the most recent admission on [DATE]. Resident #1 was a [AGE] year-old female admitted with diagnosis of severe dementia with anxiety (agitation, restlessness, and difficulty concentrating stemming from confusion and disorientation), hypertension (high blood pressure), and muscle weakness.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 04 indicating severe cognitive impairment. The MDS Assessment indicated Resident #1 required supervision or touching assistance with walking 150 feet.<BR/>Record review of Resident#1's care plan dated 11/04/2021 indicated: Resident #1 was at risk for wandering, Resident #1 had a wander guard in place with interventions that included: .3. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. 4. Identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. 5. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. <BR/>Record review of Resident #1's medication administration record dated January 2025 indicated: Monitor for function of wander guard every shift and as needed for preventative and was signed as functioning on 1/3/2025 night shift. <BR/>Record review of Resident #1's weekly skin assessment dated [DATE] indicated Resident #1 did not have any skin issues.<BR/>Record review of Resident #1's elopement risk assessment dated [DATE] indicated a score of 9 which indicated low risk for elopement.<BR/>Record review of incident report dated 01/04/2025 revealed: elopement on 1/04/2025 at 9:10am from the reception/lobby. No injuries were observed at the time of the incident and Resident #1 was not taken to the hospital.<BR/>Record review of the facility's Provider Investigation report dated 01/09/2025 revealed the following: The resident went out the front door and was observed by another family member about 60 yards away from the facility. They notified the facility, and the resident was returned with no injuries.<BR/>During an observation on 3/25/2025 at 3:00 PM the Administrator and DON demonstrated Resident #1's wander guard at the front door and the door did not alarm or lock. The Corporate Maintenance Director provided a new wander guard and when approached at the front door the door locked, when the new wander guard approached the front door when the door was open, and alarm sounded.<BR/>During an interview on 3/25/2025 at 3:00 PM the DON said Resident #1 went out the front door of the facility. She said Resident #1's wander guard did not lock the front door or alarm. The DON said the wander guard had been checked on the night shift prior to the morning of the incident and said it was functioning. She said after the incident and Resident #1 was returned to the facility the malfunctioning wander guard was replaced with a new one and Resident #1 was placed on 1 to 1 supervision. She said Resident #1 was discharged later that day to a facility with a secured unit.<BR/>During an interview on 3/25/2025 at 3:00 PM the Administrator said the Resident #1's wander guard did not lock the front door or alarm. He said sometime between it being checked on the night shift and the incident the wander guard malfunctioned and did not work. He said another resident's family member took a picture of the resident walking down the road and showed it to the facility and the facility went and retrieved Resident #1 without incident. Resident #1 was returned to the facility and a new wander guard was placed on Resident #1. He said a head-to-toe assessment was completed on Resident #1 with no injuries found. He said later that same day the resident was transferred to another facility with a secured unit.<BR/>Record review of QAPI notes dated 01/04/2025 indicated that the meeting was attended by the following members: Administrator, DON, ADON, Medical Director, Social Services, Dietary, MDS Nurse, Activity Director, Therapy, and Medical Records. The interventions and plan for correction included: <BR/>1. <BR/>Self report to HHSC.<BR/>2. <BR/>Interview the resident completed on 1/4/2025. <BR/>3. <BR/>Take statements from everyone involved or with potential knowledge/involvement completed 1/4/2025.<BR/>4. <BR/>Determine if resident will be able to remain in the facility with any new interventions. Resident #1 was transferred to a new facility with a secured unit on 1/4/2025.<BR/>5. <BR/>1 on 1 monitoring for resident involved until evaluated by the IDT and further instructions are provided. Completed on 1/4/2025.<BR/>6. <BR/>Complete risk management entry for elopement and complete elopement event note and elopement risk assessment for the resident involved. Document conclusion in the risk management entry of PCC (records system). Completed on 1/4/2025.<BR/>7. <BR/>Complete an elopement risk assessment for all other residents. Completed 1/4/2025. <BR/>8. <BR/>Complete the QA tool for elopements. Completed 2/4/2025.<BR/>9. <BR/>Update the care plan for the resident who exited with new interventions. Completed 1/4/2025. <BR/>10. <BR/> Review and update the plan of care as needed of any resident who has been assessed to be a high risk for elopement. Completed 1/4/2025. <BR/>11. <BR/> Perform trauma informed PRN assessment on affected resident and initiate/update care plan interventions as needed. Completed 1/4/2025.<BR/>12. <BR/> If known, in-service staff related to findings and ways to prevent residents exiting. In-services on abuse, neglect, and elopement initiated on 1/4/2025.<BR/>13. <BR/> Notification to families to mindful of residents attempting to exit the facility and not to share the door code with the residents. Completed on 1/10/2025. <BR/>14. <BR/> Place signage at visitor exits to be mindful of residents attempting to exit the facility and not to share a door code with the residents. Completed 1/4/2025. <BR/>15. <BR/> The Medical Director was notified of this plan. Completed 1/4/2025. <BR/>Record review of Resident #1's electronic medical record indicated Resident #1 discharged from the facility on 1/4/2025.<BR/>Record review of 1 to 1 monitoring sheets dated 1/4/2025 from 9:30 AM to 3:45 PM. <BR/>Record review of Missing Resident/Elopement Monitoring tool dated 1/4/2025 through 2/4/2025 indicated: 1. The locking mechanism or alarm functioned properly on all exit doors of the facility. 2. Wander guard bracelets were in place every shift.<BR/>Record review of Trauma Informed PRN Assessment dated 1/4/2025 indicated Resident #1 had no trauma from the incident. <BR/>Record review of Elopement Risk Assessment dated 1/4/2025 indicated a score of 28 which indicated high risk for elopement. <BR/>Record review of the care plan for Resident #1 indicated revised on 1/4/2025 indicated a new intervention for 1 to 1 monitoring of Resident #1 until alternate placement could be arranged. <BR/>Record review of in-services dated 1/4/2025-1/5/2025 titled Abuse, Neglect, Elopement, ways to prevent resident exiting, reporting concerns with 135 employee signatures. <BR/>Record review of elopement drills dated 1/7/2025, 1/9/2025, 1/15/2025, 1/17/2025, 1/21/2025, and 1/23/2025 indicated multiple drills across multiple shifts had been conducted. <BR/>Observation of signage on the front door of the facility on 3/25/2025 at 3:00 PM notifying families to be mindful of residents attempting to exit the facility and not to share door code with the residents. <BR/>On 3/25/25 at 10:51 am the Administrator, and DON were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 1/04/2025 and ended on 2/4/2025. The facility had corrected the noncompliance before the investigation began.<BR/>2. Record review of the electronic face sheet dated 3/24/2025 for Resident #2 indicated Resident #2 was admitted to the facility on [DATE] with diagnosis that included: end stage renal disease (kidneys do not function properly), hyperkalemia (excessive amount of potassium in the blood), and muscle weakness. <BR/>Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 had a BIMS score of 11 which indicated mild cognitive impairment. The MDS assessment indicated Resident #2 required supervision or touching assistance for transfers. <BR/>Record review of Resident #2's care plan dated 9/22/2023 and revised on 2/5/2024 indicated Resident #2 had end stage renal disease and was on dialysis on Mondays, Wednesdays, and Fridays with interventions that included: 1. Encourage resident to do for the scheduled dialysis appointments, resident received dialysis on Mondays, Wednesdays, and Fridays. The resident had an ADL self-care performance deficit with interventions that included: 1. the resident uses a wheelchair. The resident was at risk for falls gait/balance problems with interventions that included: 1. Skin assessment, new pain medication, xrays ordered, neuros started, 3rd party transportation on hold for in-servicing their staff on van safety/buckling and monitoring in place.<BR/>Record review of nursing progress note dated 2/21/2025 at 6:00 AM written by LVN C indicated Notified by transport driver, while on the way to drop off resident at dialysis, residents wheelchair tilted backwards resulting in resident falling backwards in chair. Driver states resident stated he was ok to continue to dialysis appointment.<BR/>Record review of nursing progress note dated 2/21/2025 at 10:30 AM written by LVN C indicated Resident returned from dialysis and is complaining of neck pain post fall from this morning. New order received for xray of neck due to neck pain.<BR/>Record review of nursing progress note dated 2/21/2025 at 10:30 AM written by the DON indicated Resident denied any pain medication at this time and stated he would let us know if he needed anything.<BR/>Record review of nursing progress note dated 2/21/2025 at 11:40 AM written by the DON indicated Down to check on resident at this time to see how he is doing; resident is stating that his head/neck is bothering him and asked if he could get something for pain at this time. MD was notified and new order for Tylenol 325mg every 4 hours as needed for pain. (medication was administered at this time to resident) Attempted to notify [family] but no answer at this time.<BR/>Record review of nursing progress note dated 2/21/2025 at 12:03 PM written by the DON indicated Down to follow up with resident and he does state that the Tylenol was effective.<BR/>Record review of nursing progress note dated 2/21/2025 at 1:46 PM written by the DON indicated Went down to check on resident at this time and he stated that he was feeling ok. Inquired again if resident was wanting to go to ER (resident had been asked when incident initially occurred if he would like to go be he did not feel he needed to go at that time and wanted to proceed going to dialysis) to get checked out and he stated well I feel like I guess I should. Explained that xrays had been taken and results were pending when I last looked however if felt he needed to be checked out we could certainly send him. He thought for a minute and stated he felt like he ought to go ahead and go just to be safe. MD notified of request and new orders given to transport to ER for evaluation and treatment.<BR/>Record review of nursing progress noted dated 2/21/2025 at 5:42 PM written by ADON B indicated Resident returned via wheelchair with [facility] van transport from [hospital] ER related to fall, resident cleared from ER and sent back to facility with no changes in medications or orders.<BR/>Record review of facility incident report dated 2/21/2025 at 6:00 AM indicated Resident #2 had a fall with no other information. <BR/>Record review of hospital paperwork dated 2/21/2025 indicated no acute findings and Resident #2 was discharged back to the facility with no new orders.<BR/>During an interview on 3/24/2025 at 10:33 AM Resident #2 said on the day he fell in the van the Contract Van Driver did not strap him down in the van. He said the Contract Van Driver was trying to go up the hill in the driveway and his wheelchair flipped backwards. He said the Contract Van Driver stopped and picked him back up in the van. He said he told the Contract Van Driver he was having pain but the Contract Van Driver continued on to dialysis. He said he told them at dialysis he was in pain also. He said when he got back to the facility the nurse checked him over and he complained of head and neck pain. He said the facility sent him out to the ER to get checked out. He said he no longer is having any pain to his head and neck.<BR/>During an interview on 3/24/2025 at 11:10 AM the Contract Van Driver said on 2/21/2025 at approximately 5:00 AM he got to the facility and put the resident on the van. He said he placed Resident #2 on the ramp and raised the ramp. He said he then pushed Resident #2 forward, he said he usually used 2 front straps, and 2 back straps when securing a resident in the van. He said when he drove off and going up the incline in the facility parking lot Resident #2 flipped back in his wheelchair. He said he stopped the van and got out to check if Resident #2 was ok, and said Resident #2 told him that he was fine and to continue on to dialysis. He said he picked Resident #2 upright in his wheelchair and continued on to dialysis. He said he did not notify anyone of the fall until later on that day. He said he had no idea how the incident happened.<BR/>During an interview on 3/24/2025 at 11:30 AM the Facility Van Driver said she picked up Resident #2 from dialysis on the day he fell on the Contract Van. She said when she picked him up about 10:30am the Dialysis Tech pushed him out to the van that day and said Resident #2 was complaining of severe head and neck pain because he fell backwards in the Contract Van that morning. She said she brought Resident #2 straight back to the facility and said when she got there the Contract Van Driver was at the facility to report the fall that happened that morning. Said she reported to the nurse that Resident #2 was complaining of head and neck pain. She said to properly secure a resident's wheelchair in the van there should be 2 tie down straps at the front of the wheelchair and 2 tie down straps at the back of the wheelchair, she said then there is a seatbelt that goes across the resident to hold the resident in the chair. She said if all straps are applied appropriately there would be no way a resident's wheelchair could flip over backwards.<BR/>During an interview on 3/24/2025 at 12:26 PM the Dialysis Tech said on 2/21/2025 Resident #2 never complained of pain until the end of his treatment and then he told her that he had fallen in the van on his way to dialysis that morning. She said she did not administer anything for pain while he was at dialysis that day. She said the Contract Van Driver did not notify anyone at dialysis that Resident #2 had fallen that morning. <BR/>During an Observation and interview on 3/24/2025 at 12:43 PM the Contract Van Driver demonstrated how to correctly strap down a wheelchair in the van. At the end of the demonstration the surveyor asked the Contract Van Driver if it was plausible that on the day Resident #2 fell in the van that Resident #2 was not secured properly in the van and the Contract Van Driver said yes.<BR/>During an interview on 3/25/2025 at 10:25 AM the Corporate Maintenance Director said to properly secure a resident's wheelchair in the van there should be 2 tie down straps at the front of the wheelchair and 2 tie down straps at the back of the wheelchair, he said then there is a seatbelt that goes across the resident to hold the resident in the wheelchair. He said if all straps are applied appropriately there would be no way a resident's wheelchair could flip over backwards and the wheelchair should not move in the van. <BR/>During an interview on 3/25/2025 at 10:40 AM the DON said on 2/21/2025 at approximately 10:30 AM the Contract Van Driver came to the facility to report to her that Resident #2 had fallen in the van that morning. She said the Contract Van Driver did not report it to the facility that morning when it happened but waited until later in the day. She said the Contract Van Driver told her he asked Resident #2 if he was ok and Resident #2 said he was, so he continued with transporting Resident #2 to dialysis. She said the Contract Van driver said he had not reported the incident to dialysis.<BR/>During an interview on 3/25/2025 at 11:04 AM the Administrator said on 2/21/2025 he received a call from the Contract Van Drivers supervisor stating the Contract Van Driver was going to the facility to let them know about and incident that had happened that morning. He said at approximately 10:30 AM he overheard the Contract Van Driver telling the DON that Resident #2 had fallen in the van that morning. He said the Contract Van Driver said he loaded Resident #2 on the van and when leaving the facility parking lot incline Resident #2 flipped backwards in his wheelchair. He said the Contract Van Driver immediately stopped the vehicle and asked Resident #2 if he was ok and Resident #2 said lets just go on to dialysis. He said Resident #2 denied any pain, so he continued transport to dialysis. <BR/>Record review of Contract Van Drivers successful completion of the Passenger Assistance Safety and Sensitivity 7.0 Two-day Driver Certification Program including sensitivity training, left operating procedures, wheelchair and occupant securement valid January 09, 2025, through January 09, 2027. <BR/>Observation of training video titled Retractable wheelchair tie-downs to secure wheelchair superior van and mobility. Video was accessed at https://youtu.be/mY_GThwGdbI?si=zQH-3ntbRIcPyck0 which indicated there should be 2 tie down straps in the front of the wheel chair and 2 tie down straps at the back of the wheelchair and the seatbelt that goes across the resident. <BR/>Surveyor requested the facility policy and procedure regarding wheelchair tie down procedure and none was provided. <BR/>Record review of QAPI notes dated 02/21/2025 indicated that the meeting was attended by the following members: Administrator, DON, ADON, Medical Director, Social Services, Dietary, MDS Nurse, Activity Director, Therapy, and Medical Records. The interventions and plan for correction included: <BR/>1. <BR/>Self report to HHSC. Completed 2/21/2025.<BR/>2. <BR/>The Contract van services was removed from service for resident transport on 2/21/2025.<BR/>3. <BR/>The Contract Van Services were to educate drivers before services to be reinstated. Completed on 2/25/2025. <BR/>4. <BR/>The Contract Van Driver was not allowed to transport for the facility pending investigation. Completed 2/21/2025.<BR/>5. <BR/>Take statements from everyone involved or with potential knowledge/involvement. Completed 2/21/2025.<BR/>6. <BR/>Begin abuse/neglect in-service for all staff who transport or assist with transporting residents in the van. Started on 2/21/2025.<BR/>7. <BR/>In-service staff who transport or assist with transporting residents in the van on the following (with return demonstration): How to safely load and unload residents in the van using the lift, properly securing a resident in the van, ambulatory resident -securing with a seatbelt, Non-ambulatory resident-securing the wheel chair and the resident. Started 2/21/2025. <BR/>8. <BR/>Maintain a list of staff who have completed training and provided return demonstration regarding transporting a resident in the van. Staff not listed will not transport residents. Completed on 2/24/2025. <BR/>9. <BR/>Complete risk management entry as other in PCC. Attempt to determine the root cause of the incident. Document conclusion in this risk management entry of PCC. Fall Note completed 2/21/2025.<BR/>10. <BR/> Perform trauma informed PRN assessment on affected resident and initiate/update care plan interventions as needed. Completed 2/21/2025. <BR/>11. <BR/> The medical director was notified of this plan. Completed on 2/21/2025. <BR/>Record review of in-service titled Van Training/Proper Tie Down Procedures Dated 2/24/2025 provided by the Corporate Maintenance Director and signed by the Facility Van Driver. <BR/>Record review of Education Sign in Sheet with the topic Wheelchair securement during Transport dated 2/25/2025 signed by the Contract Van Service 6 employees.<BR/>Record review on plan of correction submitted to the facility by the Contract Van Services indicated: 1. All transporters will receive reinforcement education of reasons for following all safety precautions, with visual confirmation. Education for log implementation will be provided also with the date to be completed of 2/26/2025. 2. Log to be implemented to record daily checks that all belts are to be checked daily prior to vehicle use to confirm safe and correct functioning to be completed daily with implementation by 2/26/2025. Supervisor will check logs of all vehicles used weekly to ensure compliance. If a vehicle is not used on a given day, it should be marked as not used on the log for that day. 3. [Contract Van Driver] will show correct use of all safety belts and sign acknowledgement of importance for checking safe functioning and ensuring correct use every time. He will also acknowledge who and how to reach out for support if he is unsure of a procedure or safe functioning completed 2/26/2025. Supervisor will monitor patients for safe travel and follow up with [Contract Van Driver] weekly for 2 months, then as needed, to ensure compliance and provide support for [Contract Van Driver] to be successful in safely transporting patients.<BR/>Record review of Follow up Training Completion Sheet 2025 for the Contract Van Driver indicated his supervisor had signed completion for 4 weeks dated 2/21/2025 through 3/21/2025. <BR/>Record review of Daily Checklist for Securement Device(s) Functionality dated March 2025 for multiple transport vehicles dated 3/3/2025 through 3/23/2025. <BR/>Record review of facility in-services titled Abuse, Neglect, Resident Rights dated 2/21/2025 with 130 facility employee signatures. <BR/>Record review of Trauma informed PRN assessment dated [DATE] at 12:40 PM indicated Resident #2 did not experience any trauma from the incident.<BR/>Record review of employee questionnaires on abuse/neglect completed on 2/21/2025 with no concerns noted.<BR/>Record review of resident safe surveys on abuse/neglect completed on 2/21/2025 with no concerns noted. <BR/>Record review of monitoring of the Facility Van Driver completed 2/21/2025 through 2/27/2025 with no concerns noted. <BR/>On 3/25/25 at 10:51 am the Administrator, and DON were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 2/21/2025 and ended on 2/25/2025. The facility had corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident had a right to privacy during medical care for 1 of 25 residents (Residents #13) observed for privacy.<BR/>The facility failed to ensure full visual privacy during incontinent care for Resident #13 on 04/22/2024. <BR/>This deficient practice placed residents at risk of loss of privacy and dignity.<BR/>The findings were:<BR/>Record review of a facility face sheet dated 04/23/2024 indicated Resident #13 was a [AGE] year-old female and admitted to the facility on [DATE] with a diagnosis of end stage renal disease (inability of the kidneys to filter waste), diabetes (high glucose content in the blood), and morbid obesity.<BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident #13 had a BIMS score of 12 indicating cognition was mildly impaired and was incontinent of urine and bowel requiring total assistance with toileting.<BR/>Record review of the care plan dated 02/12/2024 indicated Resident # 13 had an ADL (activity of daily living) function disorder and to assist with ADLs as needed.<BR/>During an observation of incontinent care on 04/22/2024 at 9:43 am this state surveyor knocked on the door and asked permission to enter. Permission was granted. The privacy curtain was not pulled around Resident #13. Resident #13 was unclothed from the neck down exposing her breasts and her legs spread apart. Resident # 13 was being prepared for incontinent care by CNA A and CNA H. <BR/>During an observation and interview on 04/22/24 at 10:00 am outside of Resident #13's window, a male worker was cutting grass and picking up the lawn. Midway into the care with resident unclothed CNA A saw the workers and said oh I've done it again. She closed the blind and said oh I should have closed it before I started. CNA H then drew the privacy curtain around Resident #13.<BR/>During an interview on 04/22/24 at 1:30 pm Resident #13 said she never realized the blinds were up and the curtain was not pulled. She said not providing privacy could embarrass some residents. Resident #13 said she had been through a lot of things, and it really did not affect her.<BR/>During an interview on 04/22/2024 at 12:00 pm the DON said she was very disappointed that CNA A did not follow the proper procedure for privacy. She said if privacy was not maintained, and a resident was exposed during personal care it could cause embarrassment. <BR/>During an interview on 04/23/2024 at 3:20 pm the Administrator stated he expected everyone in the facility to be trained, follow resident rights, treat all residents with dignity, and maintain privacy . She stated by not doing so could cause resident embarrassment.<BR/>During an interview on 04/24/2024 at 8:33 am the ADON said she was responsible for competency checks for the nurses and aides. She said that CNA A had been trained on resident rights to include providing privacy during personal care by closing the window covering, pulling the curtain, and closing the door to the room. She said if privacy was not maintained, and a resident was exposed during personal care it could cause embarrassment . <BR/>Record review of an undated facility policy titled Resident Rights indicated, The resident has a right to a dignified existence, self-determination .<BR/>Record review of a facility policy titled Personal Care dated 5/11/2022 indicated, .prepare: 7). provide privacy and modesty by closing the door and/or curtain .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's mental and physical condition for 1 of 6 residents (Resident #4) reviewed for assessments. <BR/>The facility failed to reassess Resident #4 following a hospice admission (specific care for the sick or terminally ill) on 12/15/2023.<BR/>This failure could place residents at risk for not having their individual needs met due to inaccurate assessments.<BR/>The findings included:<BR/>Record review of a face sheet for Resident #4 dated 4/23/2024 indicated he admitted to the facility 9/3/2013 and was [AGE] years old with diagnosis of parkinsonism (brain condition that causes slowed movements, stiffness, and tremors), schizoaffective disorder, bipolar type (delusions with mood swings and depression), mild intellectual disabilities (slower in areas of thinking and development of social and daily living skills), and hypertension (high blood pressure).<BR/>Record review of active physician orders dated 4/23/2024 for Resident #4 indicated an order to admit to hospice services with a start date of 12/15/2023.<BR/>Record review of a Quarterly MDS Assessment for Resident #4 dated 1/5/2024 indicated he had significant impairment in thinking with a BIMS score of 3. Special Treatments and Procedures did not indicate he was on hospice services in the 14 days look back period.<BR/>Record review of a care plan dated 10/23/2023 for Resident #4 indicated he had hospice services as evidenced by terminal illness with a diagnosis of senile degeneration of the brain. Interventions included: Assist with ADLS and provide comfort measures as needed.<BR/>During an interview on 4/23/2024 at 12:20 PM, MDS Coordinator D and MDS Coordinator E both said Resident #4 admitted to hospice services on 10/20/2023 and did not know why his orders showed 12/15/2023. MDS Coordinator E said the previous MDS Coordinator would have been responsible for completing a significant change MDS Assessment for Resident #4 but was no longer employed at the facility. They both said the significant change MDS assessment should have been done on the day of admission to hospice services and should have been completed within 7 days. MDS Coordinator E said during the morning meetings they discussed any residents with significant changes such as declines or improvements, admission to hospice, or residents discharging from hospice, and was not aware that Resident #4 did not have a significant change MDS assessment. MDS Coordinator E said residents could be at risk of the state not being aware of changes and it affected everything.<BR/>During an interview on 4/24/2024 at 9:50 AM, the DON and Administrator both said the MDS Coordinators were responsible for the resident assessments. The DON said she only signed the MDS assessments and the MDS Coordinators were responsible for accuracy. Both said they discussed significant changes in the morning meetings and there was a discussion about Resident #4 at the time he was admitted to hospice. Both said they were not sure how his significant change MDS assessment was missed. Going forward, the DON said she would question any significant changes and the residents could be a risk of not getting needed services.<BR/>Record review of a facility policy titled Resident Assessment undated indicated, .1. A comprehensive assessment will be completed within 14 days of admission and annually on each resident. The facility will utilize the Resident Assessment Instrument (RAI). 3. RAI assessments must be conducted within 14 days after the date of admission; promptly after a significant change in the resident's physical or mental condition (as soon as the resident stabilizes at a new functional or cognitive level, or within two weeks, whichever is earlier) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 6 Residents (Resident #32) reviewed for PASSAR (Preadmission Screening and Resident Review Services).<BR/>The facility failed to ensure Resident #32 had a new level 1 PASSAR completed with a new diagnosis of Post-Traumatic Stress Disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations) and major depressive disorder (persistent feeling of sadness and loss of interest that interferes with daily life).<BR/>These failures could place residents at risk of not receiving the needed PASSAR services to meet their individual needs and could result in a decreased quality of life.<BR/>The findings were: <BR/>Record review of a face sheet dated 4/23/2024 for Resident #32 indicated she admitted to the facility on [DATE] and was a [AGE] year old female with diagnoses of Huntington's disease (an inherited condition in which the nerve cells in the brain break down over time), post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations), major depressive disorder with psychotic symptoms (persistent feeling of sadness and loss of interest that interferes with daily life), and heart failure.<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #32 indicated she had moderate impairment in thinking with a BIMS score of 8. She had active diagnoses that included psychiatric/mood disorders of anxiety disorder, depression, and post-traumatic stress disorder (PTSD) during the 7 days look back period. There was no referral made to the local contact agency because the discharge date was more than 3 months away. <BR/>Record review of a PL1 dated 9/27/2021 for Resident #32 indicated she was positive for mental illness.<BR/>Record review of a PE dated 9/28/2021 for Resident #32 indicated she did not meet the definition of mental illness.<BR/>Record review of a care plan dated 7/1/2021 revised on 2/5/2024 for Resident #32 indicated she had depression related to diagnosis of major depressive disorder with interventions to administer medications as ordered, monitor/record/report to MD prn risk for harm to self, pharmacy review monthly or per protocol, and psych services as indicated. PTSD was not care planned for Resident #32.<BR/>During an interview on 4/23/2024 at 12:20 PM, MDS Coordinator D and MDS Coordinator E both said they were not aware that Resident #32 had new diagnosis of mental illness that included PTSD or major depressive disorder. They both said if a resident was a new admission, then the nursing department, and MDS Coordinators were responsible for entering the diagnosis. They said the ADON's were responsible for adding new diagnosis after admission to the facility. They both said Resident #32 received a new diagnosis of PTSD and major depressive disorder from the psychiatric doctor. MDS Coordinator D said going forward they would submit a new PL1 for Resident #32 today (4/23/2024), would get the form 1012 signed, and contact the local authority. MDS Coordinator D said she started as one of the MDS coordinators for the facility on March 11, 2024. MDS Coordinator E stated she had been employed at the facility since 2021. They stated neither one of them were aware that Resident #32 had new mental illness diagnosis. Both said residents could be at risk of missing services that they needed if they were not aware of a new diagnosis.<BR/>Record review of a Mental Illness/dementia Resident Review Form 1012 dated 4/23/2024 by MDS Coordinator D for Resident #32 indicated the resident did not have a dementia diagnosis but did include diagnosis of mood disorder dated 2/19/2022 and PTSD dated 2/19/2022. If any of the responses were answered as yes, the nursing facility needed to complete a new PL1 and a full PASSR Evaluation would be conducted after the nursing facility submitted the new positive PL1. The form had not been signed by the physician.<BR/>During an interview on 4/24/2024 at 9:30 AM, the DON and Administrator said the MDS Coordinators were responsible for PASSR coordination. They both said during the care plan meetings they talked about psychiatric visits and anything that was new or needed to be updated. Both said they were not aware that Resident #32 did not have a new PL1 completed and it should have been completed after the new mental illness diagnosis was added. The DON said she had training on PASSR in the past but was not too familiar with the process. Both said going forward at each care plan meeting they would review new diagnoses. Both said residents could be at risk of not getting all the support and help they needed and it could worsen their mental health. <BR/>Record review of a facility policy titled PASRR Level 1 Screen Policy and Procedure revised 3/6/2019 indicated, .PASRR is a federally mandated program requiring all states to prescreen all individuals seeking admission to a Medicaid-certified nursing facility. The PASRR program has 3 goals: 1. To identify individuals with MI, ID, or DD/RC (this included adults and children); 3. To ensure individuals receive the required services for their MI, ID, or DD .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise the person-centered care plan to reflect the current condition for 5 of 20 residents (Resident #42, Resident #47, Resident #49, Resident #54, and Resident # 61) reviewed for care plan revisions.<BR/>The facility failed to ensure Residents #42, #47, #49, #54 and #61 care plans were reviewed quarterly.<BR/>This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. <BR/>Findings:<BR/>Record review of facility face sheet dated 03/14/2023 indicated Resident #42 admitted to the facility on [DATE] with diagnoses schizoaffective disorder bipolar type (mental disorder), type 2 diabetes (high blood sugar), and cardiac arrhythmia (irregular heart rate).<BR/>Record review of Resident # 42's medical record revealed the comprehensive care plan was initiated on 04/22/2022, revised on 11/28/2022, and had not been revised after 11/28/2022.<BR/>Record review of facility face sheet dated 03/14/2023 indicated Resident #47 admitted to the facility on [DATE] with diagnoses Covid-19, Alzheimer's (memory changes) and malnutrition (low weight).<BR/>Record review of Resident # 47's medical record revealed the comprehensive care plan was initiated on 10/20/2021, revised on 12/10/2021 and had not been revised or reviewed after that date. <BR/>Record review of facility face sheet dated 03/14/2023 indicated Resident #49 admitted to the facility on [DATE] with diagnoses hypertension (high blood pressure), atrial fibrillation (irregular heart rate) and dysphagia (difficulty swallowing). <BR/>Record review of Resident #49's medical record revealed a comprehensive care plan was initiated on 10/14/2021, revised on 11/16/2022 and had not been revised or reviewed until 03/14/2023.<BR/>Record review of facility face sheet dated 03/15/2023 indicated Resident #54 was admitted to the facility on [DATE] with diagnoses Parkinson's disease (body tremors), major depressive disorder, and abnormalities of gait and mobility.<BR/>Record review of Resident #54's medical record revealed the comprehensive care plan was initiated on 06/03/2021, revised on 07/26/2021, 10/24/2021, 04/22/2022, and had not been revised or reviewed after that date.<BR/>Record review of facility face sheet dated 03/14/2023 indicated Resident #61 admitted to the facility on [DATE] with diagnoses dementia (memory loss), UTI (urinary tract infection), and dysphagia (difficulty swallowing).<BR/>Record review of Resident # 61's medical record revealed a comprehensive care plan was initiated on 10/14/2021, revised on 11/16/2022 and had not been revised or reviewed until 03/14/2023.<BR/>During an interview on 03/15/23 at 11:30 am with MDS Coordinator and Long Term MDS Coordinator, both nurses said they were having quarterly care plan meetings and going over the care plans, but they had no documentation regarding the meetings. They both said they had not been updating in PCC (Point Click Care) because they did not know how, or that they were supposed to do that. They said they received training from the regional nurse on care plans. They said they were responsible for scheduling care plan meetings and doing the revisions. They said the risk of care plans not being updated would be residents not receiving appropriate care. <BR/>During an interview on 03/15/2023 at 11:59 am the social worker said that MDS nurses were responsible for getting the care plan meetings on the calendar and she would send out the letters for the meetings. She said the MDS nurses are responsible for ensuring care plan meetings are documented. <BR/>During an interview on 03/15/2023 at 12:50 pm the DON said that she was responsible for overseeing the MDS nurse coordinators but was not aware they were not updating care plans in the charting system PCC. She said that she and direct care staff could update sections of the care plan as needed, but she had not been monitoring to see the MDS nurses were reviewing and updating as required. She said by not having care plans revised and updated could put residents at risk due to staff not being able to provide the proper care. She said they would audit all care plans and start updating them.<BR/>During an interview on 03/15/2023 at 12:55 pm the administrator said he was responsible for all functions in the facility and would see that both MDS nurses were properly revising and updating all care plans. He said the risk of care plans not being updated would be inaccurate resident information and the care needed. He said he would have the DON and corporate nurse perform an audit and put in place a new monitoring system. <BR/>Record review of Facility policy titled Comprehensive Care Planning undated, stated .resident's care plan will be reviewed after each admission, quarterly, annual and/or significant change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards and each resident received adequate supervision as is possible for 2 of 6 resident (Resident #1 and Resident #2) reviewed for accidents and hazards.<BR/>1.The facility failed to ensure Resident #1 did not wander outside of the facility and down the road while wearing a wander guard. On 1/04/2025 Resident #1 while wearing a wander guard left the facility through the front door and was seen walking down the road by another resident's family member who notified the facility of Resident #1's whereabouts. <BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 01/04/2025 and ended on 01/08/2025. The facility corrected the non-compliance before surveyor's entrance. <BR/>2.The facility failed to ensure Resident #2 was properly strapped down in the van to prevent Resident #2's wheelchair from flipping over backwards during transport. On 2/21/2025 during transport to dialysis by the contract transport service Resident #2's wheelchair flipped over backwards in the van causing Resident #2 to have head and neck pain.<BR/>The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/21/2025 and ended on 02/25/2025. The facility corrected the non-compliance before surveyor's entrance. <BR/>This failure could place residents at risk of harm and serious injuries due to lack of supervision and failure to follow protocols.<BR/>Findings included:<BR/>Record review Resident #1's Face sheet dated 3/25/2025 indicated Resident #1 was admitted to the facility on [DATE] with the most recent admission on [DATE]. Resident #1 was a [AGE] year-old female admitted with diagnosis of severe dementia with anxiety (agitation, restlessness, and difficulty concentrating stemming from confusion and disorientation), hypertension (high blood pressure), and muscle weakness.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 04 indicating severe cognitive impairment. The MDS Assessment indicated Resident #1 required supervision or touching assistance with walking 150 feet.<BR/>Record review of Resident#1's care plan dated 11/04/2021 indicated: Resident #1 was at risk for wandering, Resident #1 had a wander guard in place with interventions that included: .3. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. 4. Identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. 5. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. <BR/>Record review of Resident #1's medication administration record dated January 2025 indicated: Monitor for function of wander guard every shift and as needed for preventative and was signed as functioning on 1/3/2025 night shift. <BR/>Record review of Resident #1's weekly skin assessment dated [DATE] indicated Resident #1 did not have any skin issues.<BR/>Record review of Resident #1's elopement risk assessment dated [DATE] indicated a score of 9 which indicated low risk for elopement.<BR/>Record review of incident report dated 01/04/2025 revealed: elopement on 1/04/2025 at 9:10am from the reception/lobby. No injuries were observed at the time of the incident and Resident #1 was not taken to the hospital.<BR/>Record review of the facility's Provider Investigation report dated 01/09/2025 revealed the following: The resident went out the front door and was observed by another family member about 60 yards away from the facility. They notified the facility, and the resident was returned with no injuries.<BR/>During an observation on 3/25/2025 at 3:00 PM the Administrator and DON demonstrated Resident #1's wander guard at the front door and the door did not alarm or lock. The Corporate Maintenance Director provided a new wander guard and when approached at the front door the door locked, when the new wander guard approached the front door when the door was open, and alarm sounded.<BR/>During an interview on 3/25/2025 at 3:00 PM the DON said Resident #1 went out the front door of the facility. She said Resident #1's wander guard did not lock the front door or alarm. The DON said the wander guard had been checked on the night shift prior to the morning of the incident and said it was functioning. She said after the incident and Resident #1 was returned to the facility the malfunctioning wander guard was replaced with a new one and Resident #1 was placed on 1 to 1 supervision. She said Resident #1 was discharged later that day to a facility with a secured unit.<BR/>During an interview on 3/25/2025 at 3:00 PM the Administrator said the Resident #1's wander guard did not lock the front door or alarm. He said sometime between it being checked on the night shift and the incident the wander guard malfunctioned and did not work. He said another resident's family member took a picture of the resident walking down the road and showed it to the facility and the facility went and retrieved Resident #1 without incident. Resident #1 was returned to the facility and a new wander guard was placed on Resident #1. He said a head-to-toe assessment was completed on Resident #1 with no injuries found. He said later that same day the resident was transferred to another facility with a secured unit.<BR/>Record review of QAPI notes dated 01/04/2025 indicated that the meeting was attended by the following members: Administrator, DON, ADON, Medical Director, Social Services, Dietary, MDS Nurse, Activity Director, Therapy, and Medical Records. The interventions and plan for correction included: <BR/>1. <BR/>Self report to HHSC.<BR/>2. <BR/>Interview the resident completed on 1/4/2025. <BR/>3. <BR/>Take statements from everyone involved or with potential knowledge/involvement completed 1/4/2025.<BR/>4. <BR/>Determine if resident will be able to remain in the facility with any new interventions. Resident #1 was transferred to a new facility with a secured unit on 1/4/2025.<BR/>5. <BR/>1 on 1 monitoring for resident involved until evaluated by the IDT and further instructions are provided. Completed on 1/4/2025.<BR/>6. <BR/>Complete risk management entry for elopement and complete elopement event note and elopement risk assessment for the resident involved. Document conclusion in the risk management entry of PCC (records system). Completed on 1/4/2025.<BR/>7. <BR/>Complete an elopement risk assessment for all other residents. Completed 1/4/2025. <BR/>8. <BR/>Complete the QA tool for elopements. Completed 2/4/2025.<BR/>9. <BR/>Update the care plan for the resident who exited with new interventions. Completed 1/4/2025. <BR/>10. <BR/> Review and update the plan of care as needed of any resident who has been assessed to be a high risk for elopement. Completed 1/4/2025. <BR/>11. <BR/> Perform trauma informed PRN assessment on affected resident and initiate/update care plan interventions as needed. Completed 1/4/2025.<BR/>12. <BR/> If known, in-service staff related to findings and ways to prevent residents exiting. In-services on abuse, neglect, and elopement initiated on 1/4/2025.<BR/>13. <BR/> Notification to families to mindful of residents attempting to exit the facility and not to share the door code with the residents. Completed on 1/10/2025. <BR/>14. <BR/> Place signage at visitor exits to be mindful of residents attempting to exit the facility and not to share a door code with the residents. Completed 1/4/2025. <BR/>15. <BR/> The Medical Director was notified of this plan. Completed 1/4/2025. <BR/>Record review of Resident #1's electronic medical record indicated Resident #1 discharged from the facility on 1/4/2025.<BR/>Record review of 1 to 1 monitoring sheets dated 1/4/2025 from 9:30 AM to 3:45 PM. <BR/>Record review of Missing Resident/Elopement Monitoring tool dated 1/4/2025 through 2/4/2025 indicated: 1. The locking mechanism or alarm functioned properly on all exit doors of the facility. 2. Wander guard bracelets were in place every shift.<BR/>Record review of Trauma Informed PRN Assessment dated 1/4/2025 indicated Resident #1 had no trauma from the incident. <BR/>Record review of Elopement Risk Assessment dated 1/4/2025 indicated a score of 28 which indicated high risk for elopement. <BR/>Record review of the care plan for Resident #1 indicated revised on 1/4/2025 indicated a new intervention for 1 to 1 monitoring of Resident #1 until alternate placement could be arranged. <BR/>Record review of in-services dated 1/4/2025-1/5/2025 titled Abuse, Neglect, Elopement, ways to prevent resident exiting, reporting concerns with 135 employee signatures. <BR/>Record review of elopement drills dated 1/7/2025, 1/9/2025, 1/15/2025, 1/17/2025, 1/21/2025, and 1/23/2025 indicated multiple drills across multiple shifts had been conducted. <BR/>Observation of signage on the front door of the facility on 3/25/2025 at 3:00 PM notifying families to be mindful of residents attempting to exit the facility and not to share door code with the residents. <BR/>On 3/25/25 at 10:51 am the Administrator, and DON were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 1/04/2025 and ended on 2/4/2025. The facility had corrected the noncompliance before the investigation began.<BR/>2. Record review of the electronic face sheet dated 3/24/2025 for Resident #2 indicated Resident #2 was admitted to the facility on [DATE] with diagnosis that included: end stage renal disease (kidneys do not function properly), hyperkalemia (excessive amount of potassium in the blood), and muscle weakness. <BR/>Record review of Resident #2's quarterly MDS dated [DATE] indicated Resident #2 had a BIMS score of 11 which indicated mild cognitive impairment. The MDS assessment indicated Resident #2 required supervision or touching assistance for transfers. <BR/>Record review of Resident #2's care plan dated 9/22/2023 and revised on 2/5/2024 indicated Resident #2 had end stage renal disease and was on dialysis on Mondays, Wednesdays, and Fridays with interventions that included: 1. Encourage resident to do for the scheduled dialysis appointments, resident received dialysis on Mondays, Wednesdays, and Fridays. The resident had an ADL self-care performance deficit with interventions that included: 1. the resident uses a wheelchair. The resident was at risk for falls gait/balance problems with interventions that included: 1. Skin assessment, new pain medication, xrays ordered, neuros started, 3rd party transportation on hold for in-servicing their staff on van safety/buckling and monitoring in place.<BR/>Record review of nursing progress note dated 2/21/2025 at 6:00 AM written by LVN C indicated Notified by transport driver, while on the way to drop off resident at dialysis, residents wheelchair tilted backwards resulting in resident falling backwards in chair. Driver states resident stated he was ok to continue to dialysis appointment.<BR/>Record review of nursing progress note dated 2/21/2025 at 10:30 AM written by LVN C indicated Resident returned from dialysis and is complaining of neck pain post fall from this morning. New order received for xray of neck due to neck pain.<BR/>Record review of nursing progress note dated 2/21/2025 at 10:30 AM written by the DON indicated Resident denied any pain medication at this time and stated he would let us know if he needed anything.<BR/>Record review of nursing progress note dated 2/21/2025 at 11:40 AM written by the DON indicated Down to check on resident at this time to see how he is doing; resident is stating that his head/neck is bothering him and asked if he could get something for pain at this time. MD was notified and new order for Tylenol 325mg every 4 hours as needed for pain. (medication was administered at this time to resident) Attempted to notify [family] but no answer at this time.<BR/>Record review of nursing progress note dated 2/21/2025 at 12:03 PM written by the DON indicated Down to follow up with resident and he does state that the Tylenol was effective.<BR/>Record review of nursing progress note dated 2/21/2025 at 1:46 PM written by the DON indicated Went down to check on resident at this time and he stated that he was feeling ok. Inquired again if resident was wanting to go to ER (resident had been asked when incident initially occurred if he would like to go be he did not feel he needed to go at that time and wanted to proceed going to dialysis) to get checked out and he stated well I feel like I guess I should. Explained that xrays had been taken and results were pending when I last looked however if felt he needed to be checked out we could certainly send him. He thought for a minute and stated he felt like he ought to go ahead and go just to be safe. MD notified of request and new orders given to transport to ER for evaluation and treatment.<BR/>Record review of nursing progress noted dated 2/21/2025 at 5:42 PM written by ADON B indicated Resident returned via wheelchair with [facility] van transport from [hospital] ER related to fall, resident cleared from ER and sent back to facility with no changes in medications or orders.<BR/>Record review of facility incident report dated 2/21/2025 at 6:00 AM indicated Resident #2 had a fall with no other information. <BR/>Record review of hospital paperwork dated 2/21/2025 indicated no acute findings and Resident #2 was discharged back to the facility with no new orders.<BR/>During an interview on 3/24/2025 at 10:33 AM Resident #2 said on the day he fell in the van the Contract Van Driver did not strap him down in the van. He said the Contract Van Driver was trying to go up the hill in the driveway and his wheelchair flipped backwards. He said the Contract Van Driver stopped and picked him back up in the van. He said he told the Contract Van Driver he was having pain but the Contract Van Driver continued on to dialysis. He said he told them at dialysis he was in pain also. He said when he got back to the facility the nurse checked him over and he complained of head and neck pain. He said the facility sent him out to the ER to get checked out. He said he no longer is having any pain to his head and neck.<BR/>During an interview on 3/24/2025 at 11:10 AM the Contract Van Driver said on 2/21/2025 at approximately 5:00 AM he got to the facility and put the resident on the van. He said he placed Resident #2 on the ramp and raised the ramp. He said he then pushed Resident #2 forward, he said he usually used 2 front straps, and 2 back straps when securing a resident in the van. He said when he drove off and going up the incline in the facility parking lot Resident #2 flipped back in his wheelchair. He said he stopped the van and got out to check if Resident #2 was ok, and said Resident #2 told him that he was fine and to continue on to dialysis. He said he picked Resident #2 upright in his wheelchair and continued on to dialysis. He said he did not notify anyone of the fall until later on that day. He said he had no idea how the incident happened.<BR/>During an interview on 3/24/2025 at 11:30 AM the Facility Van Driver said she picked up Resident #2 from dialysis on the day he fell on the Contract Van. She said when she picked him up about 10:30am the Dialysis Tech pushed him out to the van that day and said Resident #2 was complaining of severe head and neck pain because he fell backwards in the Contract Van that morning. She said she brought Resident #2 straight back to the facility and said when she got there the Contract Van Driver was at the facility to report the fall that happened that morning. Said she reported to the nurse that Resident #2 was complaining of head and neck pain. She said to properly secure a resident's wheelchair in the van there should be 2 tie down straps at the front of the wheelchair and 2 tie down straps at the back of the wheelchair, she said then there is a seatbelt that goes across the resident to hold the resident in the chair. She said if all straps are applied appropriately there would be no way a resident's wheelchair could flip over backwards.<BR/>During an interview on 3/24/2025 at 12:26 PM the Dialysis Tech said on 2/21/2025 Resident #2 never complained of pain until the end of his treatment and then he told her that he had fallen in the van on his way to dialysis that morning. She said she did not administer anything for pain while he was at dialysis that day. She said the Contract Van Driver did not notify anyone at dialysis that Resident #2 had fallen that morning. <BR/>During an Observation and interview on 3/24/2025 at 12:43 PM the Contract Van Driver demonstrated how to correctly strap down a wheelchair in the van. At the end of the demonstration the surveyor asked the Contract Van Driver if it was plausible that on the day Resident #2 fell in the van that Resident #2 was not secured properly in the van and the Contract Van Driver said yes.<BR/>During an interview on 3/25/2025 at 10:25 AM the Corporate Maintenance Director said to properly secure a resident's wheelchair in the van there should be 2 tie down straps at the front of the wheelchair and 2 tie down straps at the back of the wheelchair, he said then there is a seatbelt that goes across the resident to hold the resident in the wheelchair. He said if all straps are applied appropriately there would be no way a resident's wheelchair could flip over backwards and the wheelchair should not move in the van. <BR/>During an interview on 3/25/2025 at 10:40 AM the DON said on 2/21/2025 at approximately 10:30 AM the Contract Van Driver came to the facility to report to her that Resident #2 had fallen in the van that morning. She said the Contract Van Driver did not report it to the facility that morning when it happened but waited until later in the day. She said the Contract Van Driver told her he asked Resident #2 if he was ok and Resident #2 said he was, so he continued with transporting Resident #2 to dialysis. She said the Contract Van driver said he had not reported the incident to dialysis.<BR/>During an interview on 3/25/2025 at 11:04 AM the Administrator said on 2/21/2025 he received a call from the Contract Van Drivers supervisor stating the Contract Van Driver was going to the facility to let them know about and incident that had happened that morning. He said at approximately 10:30 AM he overheard the Contract Van Driver telling the DON that Resident #2 had fallen in the van that morning. He said the Contract Van Driver said he loaded Resident #2 on the van and when leaving the facility parking lot incline Resident #2 flipped backwards in his wheelchair. He said the Contract Van Driver immediately stopped the vehicle and asked Resident #2 if he was ok and Resident #2 said lets just go on to dialysis. He said Resident #2 denied any pain, so he continued transport to dialysis. <BR/>Record review of Contract Van Drivers successful completion of the Passenger Assistance Safety and Sensitivity 7.0 Two-day Driver Certification Program including sensitivity training, left operating procedures, wheelchair and occupant securement valid January 09, 2025, through January 09, 2027. <BR/>Observation of training video titled Retractable wheelchair tie-downs to secure wheelchair superior van and mobility. Video was accessed at https://youtu.be/mY_GThwGdbI?si=zQH-3ntbRIcPyck0 which indicated there should be 2 tie down straps in the front of the wheel chair and 2 tie down straps at the back of the wheelchair and the seatbelt that goes across the resident. <BR/>Surveyor requested the facility policy and procedure regarding wheelchair tie down procedure and none was provided. <BR/>Record review of QAPI notes dated 02/21/2025 indicated that the meeting was attended by the following members: Administrator, DON, ADON, Medical Director, Social Services, Dietary, MDS Nurse, Activity Director, Therapy, and Medical Records. The interventions and plan for correction included: <BR/>1. <BR/>Self report to HHSC. Completed 2/21/2025.<BR/>2. <BR/>The Contract van services was removed from service for resident transport on 2/21/2025.<BR/>3. <BR/>The Contract Van Services were to educate drivers before services to be reinstated. Completed on 2/25/2025. <BR/>4. <BR/>The Contract Van Driver was not allowed to transport for the facility pending investigation. Completed 2/21/2025.<BR/>5. <BR/>Take statements from everyone involved or with potential knowledge/involvement. Completed 2/21/2025.<BR/>6. <BR/>Begin abuse/neglect in-service for all staff who transport or assist with transporting residents in the van. Started on 2/21/2025.<BR/>7. <BR/>In-service staff who transport or assist with transporting residents in the van on the following (with return demonstration): How to safely load and unload residents in the van using the lift, properly securing a resident in the van, ambulatory resident -securing with a seatbelt, Non-ambulatory resident-securing the wheel chair and the resident. Started 2/21/2025. <BR/>8. <BR/>Maintain a list of staff who have completed training and provided return demonstration regarding transporting a resident in the van. Staff not listed will not transport residents. Completed on 2/24/2025. <BR/>9. <BR/>Complete risk management entry as other in PCC. Attempt to determine the root cause of the incident. Document conclusion in this risk management entry of PCC. Fall Note completed 2/21/2025.<BR/>10. <BR/> Perform trauma informed PRN assessment on affected resident and initiate/update care plan interventions as needed. Completed 2/21/2025. <BR/>11. <BR/> The medical director was notified of this plan. Completed on 2/21/2025. <BR/>Record review of in-service titled Van Training/Proper Tie Down Procedures Dated 2/24/2025 provided by the Corporate Maintenance Director and signed by the Facility Van Driver. <BR/>Record review of Education Sign in Sheet with the topic Wheelchair securement during Transport dated 2/25/2025 signed by the Contract Van Service 6 employees.<BR/>Record review on plan of correction submitted to the facility by the Contract Van Services indicated: 1. All transporters will receive reinforcement education of reasons for following all safety precautions, with visual confirmation. Education for log implementation will be provided also with the date to be completed of 2/26/2025. 2. Log to be implemented to record daily checks that all belts are to be checked daily prior to vehicle use to confirm safe and correct functioning to be completed daily with implementation by 2/26/2025. Supervisor will check logs of all vehicles used weekly to ensure compliance. If a vehicle is not used on a given day, it should be marked as not used on the log for that day. 3. [Contract Van Driver] will show correct use of all safety belts and sign acknowledgement of importance for checking safe functioning and ensuring correct use every time. He will also acknowledge who and how to reach out for support if he is unsure of a procedure or safe functioning completed 2/26/2025. Supervisor will monitor patients for safe travel and follow up with [Contract Van Driver] weekly for 2 months, then as needed, to ensure compliance and provide support for [Contract Van Driver] to be successful in safely transporting patients.<BR/>Record review of Follow up Training Completion Sheet 2025 for the Contract Van Driver indicated his supervisor had signed completion for 4 weeks dated 2/21/2025 through 3/21/2025. <BR/>Record review of Daily Checklist for Securement Device(s) Functionality dated March 2025 for multiple transport vehicles dated 3/3/2025 through 3/23/2025. <BR/>Record review of facility in-services titled Abuse, Neglect, Resident Rights dated 2/21/2025 with 130 facility employee signatures. <BR/>Record review of Trauma informed PRN assessment dated [DATE] at 12:40 PM indicated Resident #2 did not experience any trauma from the incident.<BR/>Record review of employee questionnaires on abuse/neglect completed on 2/21/2025 with no concerns noted.<BR/>Record review of resident safe surveys on abuse/neglect completed on 2/21/2025 with no concerns noted. <BR/>Record review of monitoring of the Facility Van Driver completed 2/21/2025 through 2/27/2025 with no concerns noted. <BR/>On 3/25/25 at 10:51 am the Administrator, and DON were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 2/21/2025 and ended on 2/25/2025. The facility had corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and offered a therapeutic diet when there was a nutritional problem and the healthcare provider orders a therapeutic diet for 1 of 4 residents (#15) reviewed for weight loss and nutrition. <BR/>The facility failed to provide Resident #15 with therapeutic meals as indicated by the physician orders for double portions on 4/22/2024 and 4/23/2024.<BR/>These failures could place residents at risk for unplanned weight loss, malnutrition, and failure to thrive.<BR/>The findings included:<BR/>Record review of a face sheet for Resident #15 dated 4/23/2024 indicated he admitted to the facility 2/15/2024 and was [AGE] years old with diagnosis of Parkinsonism (caused by a brain condition with slowed movements and stiffness), dementia, dysphagia (difficulty swallowing), protein calorie malnutrition, and GERD.<BR/>Record review of a Quarterly MDS assessment dated [DATE] for Resident #15 indicated he had significant impairment in thinking with a BIMS score of 3. He was dependent on staff with all ADL's. The swallowing/nutritional status indicated his weight in the last 30 days was 125 lbs. He had weight loss of 5% or more in the last month or loss of 10 % or more in last 6 months and was not on a physician prescribed weight loss regimen. He had mechanically altered diet while a resident during the 7 days look back period.<BR/>Record review of a care plan dated 7/2/2021 and revised on 10/17/2023 for Resident #15 indicated he was at risk for malnutrition, puree diet. Interventions included double portions initiated on 2/5/2024 and offer diet as ordered by the physician initiated on 7/2/2021. He had a significant unplanned/unexpected weight loss initiated on 03/13/2024 and revised 03/15/2024 that included a goal for his weight to stabilize within 4 weeks. Interventions included double portions at all meals dated 3/25/2024.<BR/>Record review of a nursing progress note dated 4/5/2024 by ADON F for Resident #15 indicated, .Res referred to dietician related to Weight loss she emailed: -He is on several medications that could be r/t wt loss (Carbidopa-Levodopa and Paxil). His Bun/Creatinine ratio (kidney function) was elevated as well as sodium which could mean some dehydration or possibly CHF (heart failure). He is already on nutritional support double portions with meals, fortified foods and snacks BID and his PO intake averages &gt;75%. There is not much more we can do nutritionally other than start a probiotic. He does have some GI (stomach) issues and vitamin deficiencies so he would benefit from that. It's possible that wt loss is r/t to age PLUS comorbidities. I would continue to offer cuing and meal assistance along with the probiotic and make sure he is getting &gt;1500ml fluid each day. MD gave new orders for Probiotic daily .<BR/>Record review of active orders dated 4/23/2024 for Resident #15 indicated a diet order for a Regular diet Pureed texture, Regular consistency, No grapefruit or grapefruit juice, Double portions at all meals. Fortified pudding lunch/dinner; Fortified milk<BR/>Breakfast and dinner; fortified eggs at breakfast with a start date of 4/17/2023 after State Surveyor intervention.<BR/>Record review of weight logs for Resident #15 revealed:<BR/>4/17/2024 13:49 <BR/>121.0 Lbs <BR/>wheelchair <BR/>4/9/2024 12:56 <BR/>120.8 Lbs <BR/>hoyer (mechanical lift) <BR/>4/3/2024 15:01 <BR/>119.3 Lbs <BR/>hoyer <BR/>3/27/2024 10:45 <BR/>120.8 Lbs <BR/>hoyer <BR/>3/20/2024 11:14 <BR/>121.5 Lbs <BR/>hoyer <BR/>3/13/2024 11:16 <BR/>123.2 Lbs <BR/>hoyer <BR/>3/6/2024 16:47 <BR/>125.2 Lbs <BR/>hoyer<BR/>During an observation on 4/22/2024 at 12:45 pm in the room of Resident #15, his lunch tray card read regular, puree (smooth, pudding textured), assist with completion of meals, pudding on tray. Staff was present and assisted him to eat. His tray did not have double portions.<BR/>Attempted a phone interview with a family member for Resident #15 on 4/22/2024 at 2:24 PM, left a message for a return phone call.<BR/>During an observation and interview on 4/23/2024 at 12:30 PM, Resident #15 was in the dining room for lunch being assisted by staff. His tray card read regular, puree texture-assist with completion of meal. Diet observed did not have double portions on tray. The DON was in the dining room and questioned about his meal. She said it looked like there was a lot of food on his tray and verified that Resident #15 should have double portions at all meals.<BR/>During an interview on 4/23/2024 at 3:42 PM, CNA G had been employed at the facility for 6 years and worked the day shift from 6am-6pm. She said she was assigned to work the hall where Resident #15 was every day she worked. She said Resident #15 had to be fed and needed total assistance with care. She said he was on a puree diet with double portions. She said sometimes she fed him at breakfast, and he had double portions and a super pudding on his tray. She said it said double portions on his tray card. She said Resident #15 always ate 100% of meals and never refused but said since his diet was puree, she noticed his weight fluctuated. She said there was always a red glass on his tray for staff to indicate weight loss that would be upside on the tray.<BR/>During an interview on 4/23/2024 at 4:11 PM, ADON F said she had been employed in her position for a year and was responsible for weights, pharmacy recommendations, dietary recommendations, and psychiatric consents. She said Resident #15 admitted to the facility a year ago and was on several different dietary recommendations such as fortified foods, hard to gain weight, and on weight watchers at this time. She said he triggered for a weight loss 2/7/2024 at 125 lbs. and on 3/13/2024 was 123 lbs. She said on 4/5/2024 the dietician visited the facility and said Resident #15 was on several medications that could be causing his weight loss such as carbidopa/levodopa (used to treat Parkinson's disease) and Paxil (used to treat depression). She said he was on nutritional supplements along with double portions and fortified foods and the dietician suggested adding a probiotic. She said he had been on double portions for a while. She said they had a staff member designated to weigh the residents and she checked the tray cards for the residents in the dining room on Mondays-Fridays. She said if residents did not get their assigned diet orders, they could potentially lose weight<BR/>During an interview on 4/24/2024 at 7:57 AM, the [NAME] said she had been employed at the facility for 2 years. She said she worked on yesterday (4/23/2024) but was not assigned to cook. She said today 4/24/2024 was her first time to cook and she would be the cook full time. She said there was another cook on 4/22/2024 and 4/23/2024, but he was not working today and his last day to work at the facility would be this Friday 4/26/2024. She said there were a few residents in the facility that had diet orders for double portions. She said Resident #15 did not have an order for double portions on his tray card ticket before today and was not aware if he had received double portions or not on his meal trays. She said double portions was added to the tray card this morning to indicate he would be receiving double portions. She said double portions meant that each item that was on the tray, they should have two scoops. She said residents could be at risk of losing weight if they had orders for double portions and were not provided the portion sizes and get sicker if they did not receive it.<BR/>During an interview on 4/24/2024 at 8:05 AM, the DM said he had been employed at the facility for 8 years. He said nursing staff sent him diet orders and then he entered the orders into the dietary system. He said the kitchen staff followed the orders that were printed on the tray card tickets. He said Resident #15 was entered into the dietary system for double portions this morning and prior to today, he was not on double portions according to the tray cards. He said the last diet order for Resident #15 that he received was on 2/5/2024 with a change to full liquid and prior to that diet order on 4/7/2023, there was an order to change to a pureed diet. He said Resident #15 did have an order for double portions in the charting system but was not sure why it only showed a regular diet, pureed, and did not include the special instructions of double portions. He said double portions meant to place two scoops of everything on the tray. He said he was responsible for ensuring diet orders were followed through. He said residents could be at risk for weight loss or going to the hospital for a number of things. He said going forward he would ensure his staff followed what the ticket said and would get with ADON F to ensure orders matched. He said he had been meeting with ADON F weekly before to discuss weight loss and orders. <BR/>Record review of a nursing-dietary communication form dated 2/5/2024 for Resident #15 indicated a readmission with a diet order of full liquid.<BR/>Record review of a nursing-dietary communication form dated 4/7/2023 for Resident #15 indicated an order for pureed.<BR/>During an interview on 4/24/2024 at 9:30 AM, the DON and Administrator both said diet orders were the responsibility of the ADON's for ensuring diet changes were given to the dietary manager. They both said they were not aware until yesterday 4/23/2024 when the State Surveyor brought it to their attention about Resident #15 not having double portions on his lunch tray. Both said they would conduct random audits every 2 weeks to ensure orders were correct. Both said residents could be at risk for weight loss.<BR/>Record review of a facility policy titled Diet Orders/Diet Manual undated indicated, .To ensure correct understanding and interpretation of therapeutic diets, all diets are ordered as stated in the diet manual. The physician will prescribe diets in accordance with the approved diet manual. A written order must appear on the medical record before the resident may be served. 3. Upon admission, nursing service transcribed the diet order as it is written by the physician on the diet order transmittal form. Forms are sent to dietary service prior to meal service .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 of 9 residents (Resident #65) reviewed for oxygen usage. <BR/>The facility failed to ensure Resident #65 had oxygen humidification when in use on 4/22/2024 and 4/23/2024. <BR/>This deficient practice could place residents at risk of respiratory infections and irritation to nasal passages. <BR/>The findings were:<BR/>Record review of a facility face sheet dated 4/23/2024 indicated Resident # 65 was a [AGE] year-old male that admitted to the facility on [DATE] with a diagnosis of fluid overload. <BR/>Record review of a comprehensive care plan dated 02/15/2024 indicated Resident # 65 required oxygen therapy, monitor for signs and symptoms of respiratory distress, and had a possibility of respiratory infections, and to administer oxygen as ordered. <BR/>Record review of a quarterly MDS assessment dated [DATE] indicated Resident # 65 had a BIMS score of 14 indicating intact cognition, had shortness of breath, and required oxygen therapy. <BR/>Record review of a consolidated physician order summary report dated 4/23/2024 indicated an order from 01/27/2023 for oxygen at 5 liters per nasal cannula every shift. <BR/>During an observation on 4/22/2024 at 9:12 am Resident # 65 had oxygen in place at 5 liters per nasal cannula and the prefilled humidifier bottle was empty and not dated.<BR/>During an observation and interview on 4/23/2024 at 8:11 am Resident # 65 was in the bed with oxygen in place at 5 liters per nasal cannula. The prefilled humidifier bottle was empty and not dated. Resident #65 stated the staff changed it a few days ago but could not remember when. He said when there was no water in the bottle his nose would get very dry, and it was uncomfortable. <BR/>During an interview on 4/23/2024 at 8:17 am LVN C said she had worked at the facility for 3 years. She said Resident #65 was on a high flow of oxygen and should have water humidification. She said the bottle of water was changed frequently because of his high flow liters but was not aware that the humidifier bottle was empty. She said the bottle should be dated as well. She said that the resident could have infections or nasal dryness if the humidifier bottle was not changed appropriately. <BR/>During an interview on 4/24/2024 at 8:33 am the ADON said she was responsible for competency checks for the nurses and aides. She said that the nurses were to check their oxygen setup with rounds to ensure the oxygen was working properly and to check the humidification system. She stated if the resident was on high flow oxygen, he should have humidified oxygen to prevent nasal dryness and irritation. <BR/>During an interview on 4/24/2024 at 9:53 am the DON said the nursing administration was responsible for oversight of the nursing staff for oxygen administration. She said the nurses were trained to check resident oxygen setup with rounds and should ensure the humidification system had water if the resident was on a high flow of oxygen. She said if oxygen was not humidified it could cause dryness of the nares and thickened secretions. She said that she expected all nurses to check each residents oxygen and change the humidification system as needed. <BR/>During an interview on 4/24/2024 at 10:04 am the Administrator said that oxygen training was the responsibility of the nursing administration. He said he expected all staff to follow the facility's policy for oxygen delivery to prevent resident discomfort. <BR/>Record review of a facility policy titled Oxygen Administration dated February 13, 2007, indicated, .all sources require humidification to prevent drying of mucous membranes and thickening of respiratory secretions if used routinely. 5. Assemble the concentrator: fill the humidifier container, note the water in the humidifier is bubbling .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program to help prevent the development and transmission of communicable diseases and infections for 5 of 9 residents reviewed for infection control. (Residents #1, #2, #3, #4 and #9). <BR/>1. Med Aide A, CNA A, Restorative Aide, Laundry Staff, and Wound Care Nurse failed to maintain proper donning of facemasks within 3 feet of residents during a COVID-19 outbreak.<BR/>This failure could place all residents at risk for development and spread of infection.<BR/>Findings included:<BR/>Review of Resident #1's Face Sheet, revealed he was a [AGE] year-old male, admitted on [DATE], with diagnoses including: cerebral infarction, dementia with behavioral disturbance, severe major depressive disorder, dysphagia, other speech and language deficits following cerebrovascular disease, psychotic disturbance, mood disturbance, and anxiety. <BR/>Review of Resident #1's Care Plan, revised 10/27/2022, revealed he was a smoker, with a history of a stroke related to cerebrovascular disease and was unaware of safety needs with interventions to include: educate me/my family/caregivers about safety reminders .<BR/>Review of Resident #1's Minimum Data Set (MDS), dated [DATE] revealed he had a Brief Interview for Mental Status Score (BIMS) score of 09.<BR/>Review of Resident #2's Face Sheet, revealed she was an [AGE] year-old female, admitted on [DATE], with diagnoses including: vitamin B12 deficiency anemia, vitamin deficiency, dementia without behavioral disturbance, hyperlipidemia (blood lipid elevation), allergic rhinitis (hay fever), age-related osteoporosis, hypothyroidism (underactive thyroid), glaucoma, and essential primary hypertension (high blood pressure).<BR/>Review of Resident #2's Care Plan, dated 02/03/2023, revealed she had a problem of acute COVID-19 infection, required isolation precautions specifically related to active COVID-19 infection, and an intervention to include ensuring good infection control measures and use of personal protective equipment when working with her. <BR/>Review of Resident #2's Minimum Data Set (MDS), dated [DATE], revealed she had a Brief Interview for Mental Status (BIMS) score of 13.<BR/>Review of Resident #3's Face Sheet revealed she was a [AGE] year old female, admitted on [DATE], with diagnoses including: COVID-19, cirrhosis of liver (impaired liver function), methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere, chronic embolism and thrombosis (blood clot) of unspecified deep vein of right lower extremity, vitamin D deficiency, dietary folate deficiency anemia, morbid (severe) obesity due to excess calories, other disorders of bilirubin metabolism, hypoosmolality and hyponatremia (lower than normal levels of electrolytes, chemicals, and other solutes in the blood), hypokalemia (low potassium), essential primary hypertension (high blood pressure), chronic obstructive pulmonary disease (lung disease), urinary tract infection, hepatomegaly (enlarged liver), and other ascites (abnormal buildup of fluid).<BR/>Review of Resident #3's Care Plan, revised 01/23/2022, revealed she was on hospice and had a focus of acute COVID-19 infection that required isolation precautions specifically related to active COVID-19. Intervention included to ensure good infection control measures and to use personal protective equipment when working with her. <BR/>Review of Resident #3's Minimum Data Set (MDS), dated [DATE], revealed she had a Brief Interview for Mental Status (BIMS) score of 11. <BR/>Review of Resident #4's Face Sheet revealed he was a [AGE] year-old male, initially admitted on [DATE] with diagnoses including: dementia, anemia, urinary tract infection, heart failure, vitamin D deficiency, type 1 diabetes mellitus, vitamin C deficiency, and acute bronchitis. <BR/>Review of Resident #4's Care Plan, revised 1/12/2023, revealed he had shortness of breath at times with oxygen at bedside, altered respiratory status and difficulty breathing with an intervention to include assisting him or caregiver in learning signs of respiratory compromise. <BR/>Review of Resident #4's Minimum Data Set (MDS), dated [DATE], revealed he had a Brief Interview for Mental Status (BIMS) score of 06. <BR/>Review of Resident #9's Face Sheet revealed she was a [AGE] year-old female, admitted on [DATE], with diagnoses including: infection following a procedure, heart failure, chronic kidney disease, type 2 diabetes mellitus with kidney complications, high blood pressure, and absence of right and left legs below knees. <BR/>Review of Resident #9's Care Plan, initiated date 1/19/2023, revealed she had medically imposed restrictions related to COVID-19 precautions with an intervention of follow facility protocol for COVID-19 screening/precautions. <BR/>Review of Resident #9's Minimum Data Set (MDS), dated [DATE], revealed she had a Brief Interview for Mental Status (BIMS) score of 15. <BR/>Observation on 01/31/2023 at 12:11 p.m., Med Aide A administered medication to a resident sitting in her wheelchair near the nurse station. The Med Aide A had a facemask on that did not cover her nose and mouth and the resident was not wearing a facemask. <BR/>Interview on 01/31/2023 at 12:27 p.m., the Administrator, DON, and ADON stated the facility had a COVID-19 outbreak. The Administrator stated half of their staff and several residents had tested positive. The DON stated the facility was not designating staff to the COVID-19 unit and was operating under crisis staffing operation. The DON stated on 1/31/2023, there were five residents on the COVID-19 unit and one positive dietary staff. The DON stated the county community transmission level was high and that facemasks were required for all staff since the beginning of the outbreak. The DON stated there were six COVID-19 related hospitalizations and one COVID-19 related death on hospice care. The DON stated the COVID-19 related death was a resident that had been declining on hospice prior to obtaining a positive result, had exhibited no symptoms, and was due to recover from COVID-19 on the day she expired. <BR/>Interview on 01/31/2023 at 2:07 p.m., Med Aide B stated facemasks were required and available for all staff. Med Aide B stated the facility had provided training on infection control and how to properly put on facemasks via in-services. The Med Aide B stated Med Aide A worked on the COVID-19 unit on 1/31/2023. <BR/>Observation on 01/31/2023 at 2:03 p.m., revealed CNA A exited a resident room and entered Resident #1's room with a facemask put on that did not cover CNA A's nose and mouth. Resident #1 was sitting in his wheelchair in the room within 3 feet of CNA A. <BR/>Observation on 01/31/2023 at 2:15 p.m., the CNA A was sitting near three staff in the breakroom with the door propped open to the hallway area near the nurse station. The CNA A was wearing a facemask below his nose and mouth when talking with staff. CNA A did not have any food or drink and no social distancing was apparent.<BR/>Interview on 02/02/2023 at 9:58 a.m., Representative stated there was a lack of infection control and had received concerns regarding no use of COVID-19 precautions from her sister that visited the facility every other day. Representative stated Resident #4 tested positive along with two additional residents in one week. <BR/>Interview on 02/02/2023 at 1:05 p.m., the Administrator stated facemasks were upgraded from a surgical mask to a N95 mask for all staff on 01/31/2023. <BR/>Interview on 02/02/2023 at 1:38 p.m., Med Aide A stated she was required to wear a facemask upon entering the facility and had received training to upgrade her facemask to a N95 for source control on 01/31/2023. The Med Aide A stated she did not intentionally wear her facemask below her nose and mouth while providing care to a resident and that it was important for staff to properly put on their facemasks to prevent the spread of COVID-19. The Med Aide A stated improper wearing of facemasks could pose a risk of spreading infection to all residents.<BR/>Interview on 02/02/2023 at 2:17 p.m., LVN A stated he received training on how to wear facemasks via in-services and that all staff were required to wear a facemask in the facility. LVN A stated if he observed staff with improperly wearing facemasks below their nose and mouth, he would remind them to properly wear their facemask and cover their nose and mouth.<BR/>Observation on 02/02/2023 at 2:38 p.m., CNA A had a facemask on below his nose and mouth talking within 3 feet of LVN A in the hallway.<BR/>Interview on 02/02/2023 at 2:55 p.m., CNA A stated he had been at the facility for three months. CNA A stated that all staff were required to wear facemasks in the facility and that facemasks were available. CNA A stated he was taking care of one COVID-19 positive resident on his hall and the remainder were non-positive. CNA A stated he received several in-services on infection control and how to wear facemasks. CNA A said it was important for staff to wear their facemasks to prevent further spread of the outbreak. CNA A said he was wearing his facemask below his nose and mouth near residents and staff on 1/31/2023 and 02/02/2023 so he could catch a breath. CNA A said he tested positive for COVID-19 during this outbreak. CNA A stated improper wearing of facemasks could pose a risk of spreading infection to all residents.<BR/>Interview and observation on 02/02/2023 beginning at 5:40 p.m., CNA A had a facemask on below his nose and mouth walking within 3 feet of Resident #2 eating in the dining room. Resident #2 stated she had a concern that her roommate tested positive for COVID-19. <BR/>Observation on 02/03/2023 at 9:25 a.m., revealed Restorative Aide had no facemask on talking within 3 feet to Resident #3 that was sitting in her wheelchair near the nurse station. Laundry Staff had a facemask on that did not cover her nose and mouth talking to the Housekeeping Supervisor within 3 feet of Resident #3.<BR/>Interview on 02/03/2023 at 9:45 a.m., Restorative Aide stated that facemasks were available, and staff were required to wear facemasks in the facility. The Restorative Aide stated she did not have a facemask on when talking to Resident #3 because she removed her mask after the administrator instructed her to properly wear her facemask straps. The Restorative Aide stated the facility had provided training on infection control and proper wearing of facemasks via in-services. The Restorative Aide stated it was important for staff to wear their facemasks properly and that improper wearing of facemasks could pose a risk of spreading infection to all residents.<BR/>Interview on 02/03/2023 at 10:00 a.m., Laundry Staff stated employees were required to wear facemasks in the facility and that there was not a time when facemasks could be worn below the nose and mouth. Laundry Staff stated she removed her facemask near Resident #3 to catch her breath and had difficulty talking with the facemask on. Laundry Staff said it was important for staff to wear their masks properly to prevent the spread of infection and improper wearing of facemasks could pose a safety risk to all residents. Laundry Staff stated the facility had provided training on proper wearing of facemasks via computer training and in-services.<BR/>Interview, observation, and record review on 02/03/2023 at 10:40 a.m., Wound Care Nurse had a facemask on with the top and bottom straps placed at the back of her neck while she provided wound care treatment to Resident #9. The Wound Care Nurse said it was important for facemasks to be properly worn to be effective with one strap placed above her ears and one strap at the back of her neck. The Wound Care Nurse said the top strap may have slipped down without her knowledge. Review of the COVID-19 Positive Resident List indicated Resident #9 tested positive on 1/22/2023.<BR/>Interview on 02/03/2023 at 12:00 p.m., Regional Compliance stated staff must wear a facemask during the outbreak and had continued to provide in-services and reminders to staff on proper wearing of facemasks. Regional Compliance said it was important for staff to wear their masks near residents to prevent the spread of COVID-19.<BR/>Review of COVID-19 Positive Resident List revealed 34 residents tested positive beginning on 1/6/2023.<BR/>Review of COVID-19 Positive Staff List revealed 16 staff tested positive beginning on 1/12/2023.<BR/>Review of In-service, dated 1/31/2023, revealed the following training was provided to nursing staff: In-service Training Topic: Facemasks - Please ensure mask is properly being worn.<BR/>Review of Personnel Record for CNA A revealed training was provided for Infection Control standard precautions and proper use of personal protective equipment on 08/26/2022. <BR/>Review of Personnel Record for Restorative Aide revealed training was provided for Infection Control standard precautions and proper use of personal protective equipment on 05/20/2022.<BR/>Review of Personnel Record for Laundry Staff revealed training was provided for Infection Control and personal protective equipment on 05/01/2021 and attendance was recorded for in-service on wearing masks on 06/30/2022.<BR/>Record review of facility's policy titled, COVID-19 Response Plan, updated 06/2021, revealed the following:<BR/>Introduction<BR/>Residents of nursing facilities (NFs) are most susceptible to COVID-19 infection and the detrimental impact of the virus than the general population. In addition to the susceptibility of residents, a long-term care (LTC) Environment presents challenges to infection control and the ability to contain an outbreak, resulting in potentially rapid spread among a highly vulnerable population.<BR/>Purpose <BR/>The purpose of this document is to provide NFs with response guidance in the event of a positive COVID-19 case associated with the facility:<BR/>Rapid identification of COVID-19 situation in a NF<BR/>Prevention of spread within the facility<BR/>Protection of residents, HCP, and visitors<BR/>Provision of care for an infected resident(s)<BR/>Recovery from an in house NF COVID-19 event .<BR/>Protection/PPE - Protect workforce and residents through appropriate hand hygiene and face mask . Refer to DSHS guidance .<BR/>Core principles of COVID-19 Infection Prevention .<BR/>Source Control<BR/>All HCP (Health Care Personnel) and visitors must wear facility approved face covering<BR/>Personal Protective Equipment (PPE) and Testing<BR/>PPE per CDC guidance and the facility's policy for both HCP and visitors.<BR/>Review of Centers for Disease Control (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/23/2022, at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control -recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Fnursing-home-long-term-care.html#anchor_1604360738701 revealed the following:<BR/>1. <BR/>Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic<BR/> .<BR/>Implement Source Control Measures<BR/>Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing<BR/>When SARS-CoV-2 Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients.<BR/> .When Community Levels are high, source control is recommended for everyone.<BR/>Review of CDC's SARS-CoV-2 Community Transmission Levels on 01/31/2023 at https://covid.cdc.gov/covid-data-tracker/#county-view?list_select_state=Texas&data-type=Risk&list_select_county=48005 revealed Community Transmission Level was High for the county.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 1 of 10 residents (Resident #77) reviewed for call lights.<BR/>The facility failed to ensure Resident #77's emergency call button in the bathroom had a pull cord.<BR/>This failure could place residents at risk of injury, pain, and hospitalization.<BR/>The findings included:<BR/>Record review of a face sheet dated 4/23/2024 for Resident #77 indicated she was a 94-year female admitted [DATE] with diagnosis of CKD Stage 3 (moderate kidney damage), age related osteoporosis (brittle bones), and neuromuscular dysfunction of bladder (lack of bladder control).<BR/>Record review of a quarterly MDS dated [DATE] for Resident #77 indicated she did not have any impairment in thinking with a BIMS score of 13. She required setup/clean up assistance with toileting.<BR/>Record review of a care plan dated 2/12/2024 revised on 4/5/2024 for Resident #77 indicated she performed self in and out catheterizations (removing urine from the bladder by placing a tube into the bladder), has signed a NRA (negotiated risk agreement) understanding the risks involved with performing her own in/out catheterizations. Interventions included to educate the resident on risks.<BR/>During an observation and interview on 4/22/2024 at 8:52 AM the bathroom call button in Resident #77's room did not have a pull string. The call button was attached to the wall in the bathroom by the grab bar. Resident #77 was in the room and said she had been at the facility since January 2024 and used her bathroom all the time.<BR/>During an interview on 4/23/2024 at 3:42 PM, CNA G said she had been employed at the facility for 6 years and was assigned to the hall where Resident #77 resided. She said Resident #77 admitted to the facility not long ago and was independent. They would assist her to the shower but other things she could do on her own. She said she went to the bathroom on her own and they never had to go into the bathroom with her.<BR/>During an observation and interview on 4/23/2024 at 11:10 AM in the bathroom of Resident #77, the Maintenance Supervisor said he had been employed at the facility for 2 months. He said he was responsible for checking the calls lights in all the rooms in the facility and checked them weekly on Mondays. He said he checked Resident #77's call lights, where Resident #77 resided on yesterday 4/22/2024 in the room and the bathroom, and they worked properly. When asked about the string for the call light in the bathroom, he said the string needed to be longer. He said he was unaware that the strings for the bathroom call lights needed to be close to the floor in the event a resident had a fall. He said a resident would be on the floor for a while if they had a fall and could not reach the string to call for help. He said he would add a string to the call light in the bathroom.<BR/>Record review of a Call light log for the month of April by the facility indicated Resident #77's room was checked on 4/22/2024, no issues noted.<BR/>During an interview on 4/24/2024 at 9:30 AM, the DON and Administrator both said typically the call light strings were handled by maintenance and they should be long enough to reach the floor. They said when maintenance did the weekly checks, they would add to make sure the strings were long enough. They said if the call light strings in the bathrooms were not long enough, residents could fall and not be able to call for help. A copy of their policy on call lights was requested and was told the facility does not have a policy on call lights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow established policy regarding smoking, smoking areas, and smoking safety for 2 of 8 residents reviewed for smoking (Resident #9 and #60). <BR/>The facility failed to keep cigarette butts out of the trash can in the smoking area (Resident #9 was observed putting butts in the trash can) and failed to implement their smoking policy, ignition source was at beside of Resident #60).<BR/>This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment.<BR/>Findings included: <BR/>1.Physician orders dated March 2023, indicated Resident #9, admitted [DATE], was [AGE] years old with diagnosis of Renal Failure (decreased kidney function), Chronic Pulmonary Disease (inability to exchange oxygen), and Communication deficit. <BR/>Record Review of MDS dated [DATE] indicated Resident #9 had mild impaired cognition (BIMS 13) and required extensive assistance and used tobacco. <BR/>Record Review of care plan revised 8/8/22 indicated Resident #9 was a smoker and at risk for injury. Goal: will smoke in designated area without occurrence of injury over the next 90 days. One of the approaches was to perform the smoking assessment at least quarterly according to facility policy. Monitor PRN when smoking to assure resident safety. Keep all smoking material at nurse's station.<BR/>During an observation and interview on 03/13/23 at 11:10 AM Resident #9 was sitting in his wheelchair, a smoking cigarette butt was on the patio floor between his feet and Resident #9 had a lit cigarette in his hand. There were 5 cigarette butts observed sitting on the lid of the trash can., The trash can was full of paper items including empty cigarette boxes and cigarette butts. Resident #9 said he puts the butts on the ground and makes sure they are out before he puts them in the trash can. An empty ash tray is sitting about 10-12 feet away from the resident. <BR/>During an observation and interview on 3/13/23 11:15 AM the Administrator walked by this surveyor and the resident. The administrator observed the cigarette butts on the ground and sitting on the trash can rim. He brought the ashtray closer to the smoking resident and said he would make sure the trash can was removed from the area.<BR/>During an observation and interview on 3/13/23 at 3:00 PM the Administrator said Resident #9 should be using the ash tray and no resident should be putting the cigarette butts in the trash can. The Administrator said that putting butts in the can could cause a fire and his expectation was that staff members ensure that the butts are put into the ash tray. The Administrator said the staff have been educated on safe smoking and would be in-serviced again. The resident would be assessed again for safe smoking and re-educated on safe smoking.<BR/>2. Physician orders dated March 2023, indicated Resident #60, admitted [DATE], was [AGE] years old, with diagnosis of bipolar disorder, (episodes of mood swings), COPD, (Chronic Obstructive Pulmonary Disease), Depression, Insomnia, (difficulty falling and staying asleep), Migraines, (a recurrent throbbing headache), IBS (irritable bowel syndrome), seizure disorder, cervical (neck) spine surgery and wound care.<BR/>Record Review of MDS dated [DATE] indicated Resident #60 had a BIMS (brief interview for mental statis), score of 14 which indicates she was cognitively intact, and was independent with care. <BR/>Record Review of care plan dated 03/01//23 indicated Resident #60 was a smoker and was at risk for injury. Goal: will smoke in designated smoking area without occurrence of injury over the next 90 days. One of the approaches was to perform the safe smoking assessment every month. Ensure that the resident and/or responsible party is made aware of the facility smoking policy. No smoking materials or igniter's will be stored in the resident's room. <BR/>During an observation on 03/13/23 at 09:51 AM, Resident #60 was asleep in bed and did not wake up when surveyor knocked and entered her room. Her breakfast tray was untouched at bedside, and there was pack of cigarettes and a lighter laying on the bedside table.<BR/>During an observation on 03/13/23 at 11:55 AM, Resident #60 was asleep in bed and does not acknowledge surveyor, there were two packs of cigarettes and a lighter on bedside table.<BR/>During an observation on 03/13/23 at 3:00 PM with the Administrator Resident #60 was asleep in the bed and there are two packs of cigarettes and a lighter on the bedside table. Administrator picked up her cigarette lighter and lit it. Administrator then took cigarettes' and lighter to be locked up in medication room. He said she was not supposed to have her cigarettes and lighter in her room. <BR/>During an interview with the Administrator on 03/13/23 at 03:09 PM he said they needed to make sure all safe smoker assessments were completed and smoking paraphernalia was secure per facility policy. He said not keeping her lighter secure could cause a fire. <BR/>During an interview on 03/13/23 at 3:30 PM, with the DON she said the resident had been sent to the hospital because there was some redness to her surgical wound site, and they sent her to the hospital to get it checked out. She said the cigarettes were laying on the bedside table because the resident was preparing to go to the hospital. <BR/>During an interview with the DON on 03/13/23 at 4:31PM, she said they had to make sure safe smoker assessments were done quarterly to prevent a negative outcome. She said smoking paraphernalia was kept secure to avoid injury to the resident or a possible fire. <BR/>A Smoking Safety Evaluation, dated 2/12/19 indicated Resident #9's last smoking evaluation was performed on 2/12/19. <BR/>A Smoking Safety Evaluation, dated 02/27/23 indicated Resident #60s smoking evaluation was performed on admission [DATE]. <BR/>Record review of smoking Policy dated 11/1/17, smoking policies must be adopted by the facility. The policies must comply with all applicable codes, regulations, and standards, including local ordinances. The facility is responsible for informing residents, staff, visitors, and other affected parties of the smoking policies through distribution and/ or posting. The facility is responsible for enforcement of smoking policies which must include at least the following provisions . 1. Matches lighters or other ignition sources for smoking are not permitted to be kept or stored in a resident's room. 10. Ashtrays of noncombustible materials and safe design will be provided in all areas where smoking is permitted. Ashtrays will be a metal container with a self-closing cover device into which trays may be emptied. Ashtrays will be readily available in all areas where smoking is permitted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program to help prevent the development and transmission of communicable diseases and infections for 5 of 9 residents reviewed for infection control. (Residents #1, #2, #3, #4 and #9). <BR/>1. Med Aide A, CNA A, Restorative Aide, Laundry Staff, and Wound Care Nurse failed to maintain proper donning of facemasks within 3 feet of residents during a COVID-19 outbreak.<BR/>This failure could place all residents at risk for development and spread of infection.<BR/>Findings included:<BR/>Review of Resident #1's Face Sheet, revealed he was a [AGE] year-old male, admitted on [DATE], with diagnoses including: cerebral infarction, dementia with behavioral disturbance, severe major depressive disorder, dysphagia, other speech and language deficits following cerebrovascular disease, psychotic disturbance, mood disturbance, and anxiety. <BR/>Review of Resident #1's Care Plan, revised 10/27/2022, revealed he was a smoker, with a history of a stroke related to cerebrovascular disease and was unaware of safety needs with interventions to include: educate me/my family/caregivers about safety reminders .<BR/>Review of Resident #1's Minimum Data Set (MDS), dated [DATE] revealed he had a Brief Interview for Mental Status Score (BIMS) score of 09.<BR/>Review of Resident #2's Face Sheet, revealed she was an [AGE] year-old female, admitted on [DATE], with diagnoses including: vitamin B12 deficiency anemia, vitamin deficiency, dementia without behavioral disturbance, hyperlipidemia (blood lipid elevation), allergic rhinitis (hay fever), age-related osteoporosis, hypothyroidism (underactive thyroid), glaucoma, and essential primary hypertension (high blood pressure).<BR/>Review of Resident #2's Care Plan, dated 02/03/2023, revealed she had a problem of acute COVID-19 infection, required isolation precautions specifically related to active COVID-19 infection, and an intervention to include ensuring good infection control measures and use of personal protective equipment when working with her. <BR/>Review of Resident #2's Minimum Data Set (MDS), dated [DATE], revealed she had a Brief Interview for Mental Status (BIMS) score of 13.<BR/>Review of Resident #3's Face Sheet revealed she was a [AGE] year old female, admitted on [DATE], with diagnoses including: COVID-19, cirrhosis of liver (impaired liver function), methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere, chronic embolism and thrombosis (blood clot) of unspecified deep vein of right lower extremity, vitamin D deficiency, dietary folate deficiency anemia, morbid (severe) obesity due to excess calories, other disorders of bilirubin metabolism, hypoosmolality and hyponatremia (lower than normal levels of electrolytes, chemicals, and other solutes in the blood), hypokalemia (low potassium), essential primary hypertension (high blood pressure), chronic obstructive pulmonary disease (lung disease), urinary tract infection, hepatomegaly (enlarged liver), and other ascites (abnormal buildup of fluid).<BR/>Review of Resident #3's Care Plan, revised 01/23/2022, revealed she was on hospice and had a focus of acute COVID-19 infection that required isolation precautions specifically related to active COVID-19. Intervention included to ensure good infection control measures and to use personal protective equipment when working with her. <BR/>Review of Resident #3's Minimum Data Set (MDS), dated [DATE], revealed she had a Brief Interview for Mental Status (BIMS) score of 11. <BR/>Review of Resident #4's Face Sheet revealed he was a [AGE] year-old male, initially admitted on [DATE] with diagnoses including: dementia, anemia, urinary tract infection, heart failure, vitamin D deficiency, type 1 diabetes mellitus, vitamin C deficiency, and acute bronchitis. <BR/>Review of Resident #4's Care Plan, revised 1/12/2023, revealed he had shortness of breath at times with oxygen at bedside, altered respiratory status and difficulty breathing with an intervention to include assisting him or caregiver in learning signs of respiratory compromise. <BR/>Review of Resident #4's Minimum Data Set (MDS), dated [DATE], revealed he had a Brief Interview for Mental Status (BIMS) score of 06. <BR/>Review of Resident #9's Face Sheet revealed she was a [AGE] year-old female, admitted on [DATE], with diagnoses including: infection following a procedure, heart failure, chronic kidney disease, type 2 diabetes mellitus with kidney complications, high blood pressure, and absence of right and left legs below knees. <BR/>Review of Resident #9's Care Plan, initiated date 1/19/2023, revealed she had medically imposed restrictions related to COVID-19 precautions with an intervention of follow facility protocol for COVID-19 screening/precautions. <BR/>Review of Resident #9's Minimum Data Set (MDS), dated [DATE], revealed she had a Brief Interview for Mental Status (BIMS) score of 15. <BR/>Observation on 01/31/2023 at 12:11 p.m., Med Aide A administered medication to a resident sitting in her wheelchair near the nurse station. The Med Aide A had a facemask on that did not cover her nose and mouth and the resident was not wearing a facemask. <BR/>Interview on 01/31/2023 at 12:27 p.m., the Administrator, DON, and ADON stated the facility had a COVID-19 outbreak. The Administrator stated half of their staff and several residents had tested positive. The DON stated the facility was not designating staff to the COVID-19 unit and was operating under crisis staffing operation. The DON stated on 1/31/2023, there were five residents on the COVID-19 unit and one positive dietary staff. The DON stated the county community transmission level was high and that facemasks were required for all staff since the beginning of the outbreak. The DON stated there were six COVID-19 related hospitalizations and one COVID-19 related death on hospice care. The DON stated the COVID-19 related death was a resident that had been declining on hospice prior to obtaining a positive result, had exhibited no symptoms, and was due to recover from COVID-19 on the day she expired. <BR/>Interview on 01/31/2023 at 2:07 p.m., Med Aide B stated facemasks were required and available for all staff. Med Aide B stated the facility had provided training on infection control and how to properly put on facemasks via in-services. The Med Aide B stated Med Aide A worked on the COVID-19 unit on 1/31/2023. <BR/>Observation on 01/31/2023 at 2:03 p.m., revealed CNA A exited a resident room and entered Resident #1's room with a facemask put on that did not cover CNA A's nose and mouth. Resident #1 was sitting in his wheelchair in the room within 3 feet of CNA A. <BR/>Observation on 01/31/2023 at 2:15 p.m., the CNA A was sitting near three staff in the breakroom with the door propped open to the hallway area near the nurse station. The CNA A was wearing a facemask below his nose and mouth when talking with staff. CNA A did not have any food or drink and no social distancing was apparent.<BR/>Interview on 02/02/2023 at 9:58 a.m., Representative stated there was a lack of infection control and had received concerns regarding no use of COVID-19 precautions from her sister that visited the facility every other day. Representative stated Resident #4 tested positive along with two additional residents in one week. <BR/>Interview on 02/02/2023 at 1:05 p.m., the Administrator stated facemasks were upgraded from a surgical mask to a N95 mask for all staff on 01/31/2023. <BR/>Interview on 02/02/2023 at 1:38 p.m., Med Aide A stated she was required to wear a facemask upon entering the facility and had received training to upgrade her facemask to a N95 for source control on 01/31/2023. The Med Aide A stated she did not intentionally wear her facemask below her nose and mouth while providing care to a resident and that it was important for staff to properly put on their facemasks to prevent the spread of COVID-19. The Med Aide A stated improper wearing of facemasks could pose a risk of spreading infection to all residents.<BR/>Interview on 02/02/2023 at 2:17 p.m., LVN A stated he received training on how to wear facemasks via in-services and that all staff were required to wear a facemask in the facility. LVN A stated if he observed staff with improperly wearing facemasks below their nose and mouth, he would remind them to properly wear their facemask and cover their nose and mouth.<BR/>Observation on 02/02/2023 at 2:38 p.m., CNA A had a facemask on below his nose and mouth talking within 3 feet of LVN A in the hallway.<BR/>Interview on 02/02/2023 at 2:55 p.m., CNA A stated he had been at the facility for three months. CNA A stated that all staff were required to wear facemasks in the facility and that facemasks were available. CNA A stated he was taking care of one COVID-19 positive resident on his hall and the remainder were non-positive. CNA A stated he received several in-services on infection control and how to wear facemasks. CNA A said it was important for staff to wear their facemasks to prevent further spread of the outbreak. CNA A said he was wearing his facemask below his nose and mouth near residents and staff on 1/31/2023 and 02/02/2023 so he could catch a breath. CNA A said he tested positive for COVID-19 during this outbreak. CNA A stated improper wearing of facemasks could pose a risk of spreading infection to all residents.<BR/>Interview and observation on 02/02/2023 beginning at 5:40 p.m., CNA A had a facemask on below his nose and mouth walking within 3 feet of Resident #2 eating in the dining room. Resident #2 stated she had a concern that her roommate tested positive for COVID-19. <BR/>Observation on 02/03/2023 at 9:25 a.m., revealed Restorative Aide had no facemask on talking within 3 feet to Resident #3 that was sitting in her wheelchair near the nurse station. Laundry Staff had a facemask on that did not cover her nose and mouth talking to the Housekeeping Supervisor within 3 feet of Resident #3.<BR/>Interview on 02/03/2023 at 9:45 a.m., Restorative Aide stated that facemasks were available, and staff were required to wear facemasks in the facility. The Restorative Aide stated she did not have a facemask on when talking to Resident #3 because she removed her mask after the administrator instructed her to properly wear her facemask straps. The Restorative Aide stated the facility had provided training on infection control and proper wearing of facemasks via in-services. The Restorative Aide stated it was important for staff to wear their facemasks properly and that improper wearing of facemasks could pose a risk of spreading infection to all residents.<BR/>Interview on 02/03/2023 at 10:00 a.m., Laundry Staff stated employees were required to wear facemasks in the facility and that there was not a time when facemasks could be worn below the nose and mouth. Laundry Staff stated she removed her facemask near Resident #3 to catch her breath and had difficulty talking with the facemask on. Laundry Staff said it was important for staff to wear their masks properly to prevent the spread of infection and improper wearing of facemasks could pose a safety risk to all residents. Laundry Staff stated the facility had provided training on proper wearing of facemasks via computer training and in-services.<BR/>Interview, observation, and record review on 02/03/2023 at 10:40 a.m., Wound Care Nurse had a facemask on with the top and bottom straps placed at the back of her neck while she provided wound care treatment to Resident #9. The Wound Care Nurse said it was important for facemasks to be properly worn to be effective with one strap placed above her ears and one strap at the back of her neck. The Wound Care Nurse said the top strap may have slipped down without her knowledge. Review of the COVID-19 Positive Resident List indicated Resident #9 tested positive on 1/22/2023.<BR/>Interview on 02/03/2023 at 12:00 p.m., Regional Compliance stated staff must wear a facemask during the outbreak and had continued to provide in-services and reminders to staff on proper wearing of facemasks. Regional Compliance said it was important for staff to wear their masks near residents to prevent the spread of COVID-19.<BR/>Review of COVID-19 Positive Resident List revealed 34 residents tested positive beginning on 1/6/2023.<BR/>Review of COVID-19 Positive Staff List revealed 16 staff tested positive beginning on 1/12/2023.<BR/>Review of In-service, dated 1/31/2023, revealed the following training was provided to nursing staff: In-service Training Topic: Facemasks - Please ensure mask is properly being worn.<BR/>Review of Personnel Record for CNA A revealed training was provided for Infection Control standard precautions and proper use of personal protective equipment on 08/26/2022. <BR/>Review of Personnel Record for Restorative Aide revealed training was provided for Infection Control standard precautions and proper use of personal protective equipment on 05/20/2022.<BR/>Review of Personnel Record for Laundry Staff revealed training was provided for Infection Control and personal protective equipment on 05/01/2021 and attendance was recorded for in-service on wearing masks on 06/30/2022.<BR/>Record review of facility's policy titled, COVID-19 Response Plan, updated 06/2021, revealed the following:<BR/>Introduction<BR/>Residents of nursing facilities (NFs) are most susceptible to COVID-19 infection and the detrimental impact of the virus than the general population. In addition to the susceptibility of residents, a long-term care (LTC) Environment presents challenges to infection control and the ability to contain an outbreak, resulting in potentially rapid spread among a highly vulnerable population.<BR/>Purpose <BR/>The purpose of this document is to provide NFs with response guidance in the event of a positive COVID-19 case associated with the facility:<BR/>Rapid identification of COVID-19 situation in a NF<BR/>Prevention of spread within the facility<BR/>Protection of residents, HCP, and visitors<BR/>Provision of care for an infected resident(s)<BR/>Recovery from an in house NF COVID-19 event .<BR/>Protection/PPE - Protect workforce and residents through appropriate hand hygiene and face mask . Refer to DSHS guidance .<BR/>Core principles of COVID-19 Infection Prevention .<BR/>Source Control<BR/>All HCP (Health Care Personnel) and visitors must wear facility approved face covering<BR/>Personal Protective Equipment (PPE) and Testing<BR/>PPE per CDC guidance and the facility's policy for both HCP and visitors.<BR/>Review of Centers for Disease Control (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/23/2022, at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control -recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Fnursing-home-long-term-care.html#anchor_1604360738701 revealed the following:<BR/>1. <BR/>Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic<BR/> .<BR/>Implement Source Control Measures<BR/>Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing<BR/>When SARS-CoV-2 Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients.<BR/> .When Community Levels are high, source control is recommended for everyone.<BR/>Review of CDC's SARS-CoV-2 Community Transmission Levels on 01/31/2023 at https://covid.cdc.gov/covid-data-tracker/#county-view?list_select_state=Texas&data-type=Risk&list_select_county=48005 revealed Community Transmission Level was High for the county.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Resident #11 and Resident #47) reviewed for beneficiary notice.<BR/>The facility failed to ensure Resident #11 and Resident #47 was given a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when discharged from skilled services at the facility prior to covered days being exhausted.<BR/>This failure could place the residents at risk of not having knowledge of changes to services in a timely manner.<BR/>Findings:<BR/>Record review of face sheet dated 03/13/2023 indicated Resident #11 was admitted on [DATE] for diagnosis of UTI (urinary bladder infection), reduced mobility, and speech disturbance. <BR/>Record review of Quarterly MDS dated [DATE] indicated Resident #11 received occupational and physical therapy. <BR/>Record review of physician order dated 02/13/2023 indicated Resident #11 was discharged from skilled services. <BR/>During a record review of the SNF Beneficiary Notification indicated Resident # 11 did not receive the SNF ABN notification prior to discharge from skilled services when remaining in the facility. Resident #11 was admitted to skilled services on 01/20/2023, discharged from skilled services on 02/12/2023 and remained in the facility. The NOMNC (Notice of Medicare Non-coverage) was issued on 02/10/2023 but facility failed to issue the SNF ABN.<BR/>Record review of face sheet dated 03/13/2023 indicated Resident #47 was admitted on [DATE] with diagnosis of Covid-19, urinary tract infection, and muscular wasting.<BR/>Record review of Part A PPS (Prospective Payment System) discharge MDS dated [DATE] indicated Resident #47 received speech therapy.<BR/>Record review of physician order dated 02/17/2023 indicated Resident #47 was discharged from skilled services. <BR/>During a record review of SNF Beneficiary Notification indicated Resident # 47 did not receive the SNF ABN notification prior to discharge from skilled services when remaining in the facility. Resident #47 was admitted to skilled services on 02/06/2023, discharged from skilled services on 02/16/2023 and remained in the facility. The NOMNC was issued on 02/14/2023 but the facility failed to issue the SNF ABN.<BR/>During an interview on 03/13/2023 at 2:48 pm the MDS coordinator stated she had been employed for 2 years and was responsible for overseeing residents that were discharged from skilled services. She stated she was not aware a SNF ABN had to be given to residents discharged from skilled services and remained in the facility and had only been issuing the NOMNC. She stated the corporate MDS nurse trained her but that was never addressed in training. She stated the risk to the resident would be the resident was unaware of the appeal process. She stated she would see that all proper notifications were given from now on. <BR/>During an interview on 03/13/23 at 4:30 PM the DON stated the team met every morning to discuss Medicare discharges and the MDS coordinator was responsible for providing the discharge notifications to skilled residents. She stated that process is overseen by the administrator. The risk could be resident not being prepared for discharge. She stated she would get with administrator to correct the issue.<BR/>During an interview on 03/13/2023 at 4:40 pm the Administrator stated the MDS coordinator was responsible for issuing notifications to residents discharging from skilled services and discharges were overseen by corporate compliance reviewer. He stated the reviewer sends him a report to review but that information had not been discussed. He stated he was not aware that the SNF ABN was not being given and the negative affect would be resident unaware of discharge appeal process. He stated going forward the plan would be for the MDS coordinator to complete all notices required per regulation and put in a monitoring system to review notices. He stated he was unsure if the facility had a policy related to SNF ABN notifications. <BR/>Record review of CMS guidelines Beneficiary Notice Guidelines, approved by CMS-10124-DENC December 31, 2011, revealed Scenario Part A stay will end because: SNF (Skilled Nursing Facility) determines the beneficiary no longer requires daily skilled services. Resident has days remaining in the benefit period. Resident will remain in the facility (custodial care) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) CMS-10055 (2018) and Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (12/31/11)) to be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess each resident quarterly (every 3 months) using the MDS (minimum data set) form specified by the state and approved by CMS for 4 of 12 residents (Resident # 42, Resident # 47, Resident # 49, and Resident # 61) reviewed for quarterly assessments. <BR/>The facility failed to ensure Residents # 42, # 47, # 49 and # 61 had a quarterly MDS assessment completed within 3 months from the previous assessment.<BR/>This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions.<BR/>Findings:<BR/>Record review of facility face sheet dated 03/14/2023 indicated Resident #42 admitted to the facility on [DATE] with diagnoses schizoaffective disorder bipolar type (mental disorder), type 2 diabetes (high blood sugar), and cardiac arrhythmia (irregular heart rate).<BR/>Record review of Resident #42's medical record revealed a quarterly MDS was completed on 11/16/2022 and subsequent quarterly MDS dated [DATE] was in progress and was 26 days overdue.<BR/>Record review of facility face sheet dated 03/14/2023 indicated Resident #47 admitted to the facility on [DATE] with diagnoses Covid-19, Alzheimer's (memory changes) and malnutrition (low weight).<BR/>Record review of Resident # 47's medical record revealed an annual MDS was completed on 11/09/2022 and subsequent quarterly MDS dated [DATE] was in progress and was 32 days overdue.<BR/>Record review of facility face sheet dated 03/14/2023 indicated Resident #49 admitted to the facility on [DATE] with diagnoses hypertension (high blood pressure), atrial fibrillation (irregular heart rate) and dysphagia (difficulty swallowing). <BR/>Record review of Resident # 49's medical record revealed an annual MDS was completed on 10/27/2022 and subsequent quarterly MDS dated [DATE] was in progress and was 32 days overdue.<BR/>Record review of facility face sheet dated 03/14/2023 indicated Resident #61 admitted to the facility on [DATE] with diagnoses dementia (memory loss), UTI (urinary tract infection), and dysphagia (difficulty swallowing).<BR/>Record review of Resident # 61's medical record revealed an annual MDS was completed on 11/07/2022 and subsequent quarterly MDS dated [DATE] was in progress and was 34 days overdue.<BR/>During an interview on 03/14/2023 at 3:21 PM the long-term care MDS coordinator stated she had been doing MDS for over 4 years and employed at facility for 1 year. She stated she was trained through corporate MDS nurse and was aware of timeframes for all MDS completion and submission. She stated she was responsible for MDS completion and submission and each quarterly MDS should be submitted 92 days from each other. She stated she had been behind and unable to get caught up. She stated she monitors the schedule through the facility computer system and the corporate MDS nurse monitors the facilities progress as well. She stated she was not aware of any new changes made to ensure MDS were completed timely. She stated the negative outcome for the resident would be improper submission of MDS information. She stated she would work on them and get them caught up. <BR/>During an interview on 03/14/2023 at 3:33 PM the DON stated the MDS coordinators were responsible for MDS completion and submissions. She stated the corporate MDS nurse oversees the MDS coordinators at the facility and she thought there was an action plan already in place due to submission timeframes. She stated she was unable to find an action plan to submit during survey. She stated the risk to the resident would be incomplete MDS reports with resident conditions. <BR/>During an interview on 03/14/23 at 3:38 PM the Administrator stated he was not aware MDS completion and submissions were overdue. He stated the MDS due dates are discussed in the morning meetings, and it is reviewed at QAPI if it is brought to our attention. He stated the regional reimbursement nurse audits the MDS submissions periodically and submits a report, but he was responsible for oversight in the facility. He stated the negative outcome would be improper MDS data submission of resident conditions and payment. He stated he would put in place a better monitoring system and report for MDS coordinators to use. <BR/>During an interview on 03/14/2023 at 3:47 PM the Regional Reimbursement nurse stated she was responsible for training and oversight of the MDS nurses at the facility. She stated she ran a MDS transmission report and reviewed the facility dashboard periodically to ensure the MDS were being completed. She stated she did an audit a month ago and made the MDS nurse aware of which residents were past due but had not followed up to ensure they were completed. She stated she would run a report today and see that the MDS submissions were corrected. She stated the risk would be not capturing resident conditions. <BR/>Record review of facility policy titled, Resident assessment dated 2003 indicated, .4. the facility will examine each resident and review the minimum data set expanded core elements specified in RAI no less than once every three months and as appropriate. Results must be recorded to assure continued accuracy of the assessment.<BR/>Review of the RAI manual dated October 2019 indicated quarterly assessments are completed by calculating from the ARD (assessment reference date) of the previous assessment plus 92 calendar days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 2 of 20 residents (Resident #11 and Resident #54) reviewed for ADLs, in that:.<BR/>Resident #11 missed 11 scheduled baths in January 2023, 12 scheduled baths in February 2023, and 5 scheduled baths in March 2023.<BR/>Resident #54 missed 12 scheduled baths in January 2023, 12 scheduled baths in February 2023, and 5 scheduled baths in March 2023.<BR/>These failures could cause all residents not to receive daily personal hygiene services and cause the residents to have health, social, and emotional issues.<BR/>Findings included:<BR/>1. <BR/>Record review of a face sheet dated 3/15/23 for Resident #11 indicated she was a [AGE] year-old female with diagnoses including: urinary tract infection, major depressive disorder, abnormalities of gait and mobility, reduced mobility, and heart failure. <BR/>Record review of a 5-day Medicare MDS dated [DATE] for Resident #11 indicated she did not have any impairment in thinking with a BIMS score of 13. She required extensive assist with dressing, toileting, and personal hygiene. According to section G, she had not received a bath or shower in previous 7 days. <BR/>Record review of a Care plan dated 3/15/23 for Resident #11 indicated resident had an ADL Self Care Performance Deficit and required staff x1 for assistance with bathing. <BR/>Record review of task documentation reports for Resident #11 dated 3/15/23 for the month of January, February, and March 2023 indicated that residents scheduled bath days were Monday, Wednesday, and Friday. Bathing task documentation was blank for the following days:<BR/>January: 1/2/23, 1/4/23, 1/6/23, 1/9/23, 1/11/23, 1/13/23, 1/20/23, 1/23/23, 1/25/23, 1/27/23, and 1/30/23.<BR/>February: 2/1/23, 2/3/23, 2/6/23, 2/8/23, 2/10/23, 2/13/23, 2/15/23, 2/17/23, 2/20/23, 2/22/23, 2/24/23, and 2/27/23.<BR/>March: 3/1/23, 3/3/23, 3/6/23, 3/8/23, and 3/13/23.<BR/>2. <BR/>Record review of face sheet dated 3/15/23 for Resident #54 indicated she was a [AGE] year-old female with diagnoses including: Parkinson's disease, major depressive disorder, and abnormalities of gait and mobility.<BR/>Record review of a quarterly MDS dated [DATE] for Resident #54 indicated that she did not have any impairment in thinking with a BIMS score of 15. MDS section G also indicated that Bathing/Showering did not occur in the previous 7-day period. She required limited assist for bed mobility, supervision for dressing and locomotion, and had limited ROM in bilateral lower extremities. <BR/>Record review of a Care Plan dated 3/15/23 for Resident #54 indicated that she had an ADL Self Care Performance Deficit and required staff assist X 1 for bathing. <BR/>Record review of task documentation reports for Resident #54 dated 3/15/23 for the month of January, February, and March 2023 indicated that residents scheduled bath days were Monday, Wednesday, and Friday. Bathing task documentation was blank for the following days:<BR/>January: 1/2/23, 1/4/23, 1/6/23, 1/9/23, 1/11/23, 1/18/23, 1/16/23, 1/18/23, 1/20/23, 1/23/23, 1/25/23, and 1/30/23.<BR/>February: 2/1/23, 2/3/23, 2/6/23, 2/8/23, 2/10/23, 2/13/23, 2/15/23, 2/17/23, 2/20/23, 2/22/23, 2/24/23, and 2/27/23.<BR/>March: 3/1/23, 3/3/23, 3/6/23, 3/8/23, and 3/13/23.<BR/>During an observation and interview with Resident #11 on 03/13/23 at 09:38 AM she indicated that she had not had a bath in about a month, no bodily orders were observed, but hair did appear to be oily and unwashed. She said that it made her feel dirty when she did not receive a bath and she did not like that feeling. <BR/>During an observation and interview with Resident #54 on 3/14/23 at 11:00 AM she said that she did not get a shower. Her hair was noted to be clean, and she said that she washed it herself in the bathroom sink because the aides would never take her to the shower. She said when she asked, they would say they would come back and get her, but they never would. She stated that DON told her not to get in the shower by herself, because she could fall and hurt herself. Resident said that since the aides would never come and help her shower, she would just get in by herself because she felt so grungy. Said that she went 8 weeks one time with no shower and finally just started getting in there when no-one was in there and doing it herself.<BR/>During an interview with hall CNA A on 03/14/23 at 04:15 PM she said they have a shower tech and the aides on the halls would get the residents to the shower tech for the showers as scheduled: B beds on T/Th/Sat, and A beds on M/W/F. She said that the shower tech was supposed to document that the showers were given.<BR/>During an interview with DON on 03/14/23 at 04:20 PM she said that they had had a problem previously with residents getting showers, but they had rehired the shower tech. She said that she knew of no-one on 100 hall that was not receiving their showers. She said that the Charge nurse and Shower tech were responsible for ensuring the showers/baths were documented.<BR/>During an interview with Shower Aide on 03/15/23 at 10:29 AM she said that showers were on a set schedule and A beds were showered on Mondays, Wednesdays, and Fridays, and B Beds were showered Tuesdays, Thursdays, and Saturdays. She said that the CNAs on the halls brought the residents to her for their showers. She said that she would document her showers in the kiosk, but if she got too busy, she would sometimes get the hall CNAs to help her to document. She said that she would tell the CNAs which ones they need to document. She was unable to answer why documentation was missing from Resident #53's record. She said that Resident #11 received a bed bath and was unable to answer why the hall CNA was not documenting her baths.<BR/>During an interview with DON on 03/15/23 at 08:40 AM she said that if the residents do not receive their showers/baths that it could put them at risk for skin breakdown and infection. She said they were now working on improving the shower issue. Said that they were now going to have a shower sheet for aides to document the shower of each resident and monitor it every day to ensure each resident received their showers. Department heads are to ask each ask resident during their Champion rounds if they received their shower so they can monitor better. She said that they will be discussing their findings every morning during the morning meeting. She said that residents could be at risk for skin breakdown and infection by not receiving baths/showers. <BR/>During an interview with the Administrator on 3/15/23 at 12:45pm he said that they were already doing champion rounds, and they have added a section asking about showers and they will review that every morning in the morning meeting. He said that residents could be at risk for skin breakdown and infection by not receiving baths/showers. <BR/>Record review of facility policy titled Bath, Tub/Shower, undated, stated .Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed .10. Assist to stand in the shower or sit on a stool or chair in the shower or tub, inform the resident of the use of the rails for support in getting in and out to prevent falls. 11. Remain with the resident if he is weak or assistance is needed in washing .16. Assist out of the tub or shower, wrap in the bath towel, allow to sit on a chair, and assist to dry if needed, especially in the skin folds. 17. Assist to dress if needed or supply aids for dressing independently.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (nurse cart 400 hall) reviewed for labeling and storage.<BR/>The facility failed to remove expired glucose control solution from the nurse medication cart on hall 400. <BR/>This deficient practice could place residents at risk for improper glucose monitoring and could result in residents not receiving the intended therapeutic effects of their medications causing a health decline.<BR/>Findings include:<BR/>During observation and interview on 03/14/23 at 8:35 AM of the medication cart on 400 hall revealed the glucose control solution used to calibrate the glucometer with each new bottle of testing strips, lot #16821092102202 on 400 hall medication cart was dated as opened on 7/01/2022 and the package insert indicated to discard 90 days after opening. The DON stated she had been employed at the facility for 2 years. She stated the nurses were responsible for checking glucometer controls. She was not aware how long control solution was good for. She stated the risk could be ineffective glucose control checks and inaccurate blood sugar readings. <BR/>. <BR/>During an interview on 03/14/23 at 2:50 PM, the DON said she and the ADON were responsible for ensuring the carts are checked for expired medications and supplies. The DON stated the nurses were responsible for checking for expired medications and she had no formal system in place for monitoring medication carts, but the plan was to schedule routine cart audits and provide retraining to the staff. The DON said they had just had an extra pharmacy consultant visit last week to check for expired medications and controls and she was shocked that the glucose controls were out of date. The DON said she would add a warning to the glucometer check log to remind staff to ensure the solutions were discarded after 90 days of use. <BR/>During an interview on 03/14/2023 at 5:00 PM, the Administrator stated the DON and ADON were responsible for oversight in the nursing department. He stated he would assist with overseeing the DON and ADON retraining nursing staff on policy and procedures and those policies were followed. <BR/>Record review of glucometer testing logs for hall 400 indicated the glucose control solutions lot #16821092102202 was opened 07/01/2022 and was currently in use 03/14/23.<BR/>Record review of the facility policy and procedure titled Glucometer/ Quality Control Testing, dated 02/13/2007, indicated, Quality of Control solutions and test strips, 1. Do not use test strips or control solutions after the expiration date. 2. Bottle must be labeled with open date. 3. Control solution is good for 3 months the discard. and .2. Perform quality control testing by using Control Solutions: High and Low per manufacturers recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow established policy regarding smoking, smoking areas, and smoking safety for 2 of 8 residents reviewed for smoking (Resident #9 and #60). <BR/>The facility failed to keep cigarette butts out of the trash can in the smoking area (Resident #9 was observed putting butts in the trash can) and failed to implement their smoking policy, ignition source was at beside of Resident #60).<BR/>This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment.<BR/>Findings included: <BR/>1.Physician orders dated March 2023, indicated Resident #9, admitted [DATE], was [AGE] years old with diagnosis of Renal Failure (decreased kidney function), Chronic Pulmonary Disease (inability to exchange oxygen), and Communication deficit. <BR/>Record Review of MDS dated [DATE] indicated Resident #9 had mild impaired cognition (BIMS 13) and required extensive assistance and used tobacco. <BR/>Record Review of care plan revised 8/8/22 indicated Resident #9 was a smoker and at risk for injury. Goal: will smoke in designated area without occurrence of injury over the next 90 days. One of the approaches was to perform the smoking assessment at least quarterly according to facility policy. Monitor PRN when smoking to assure resident safety. Keep all smoking material at nurse's station.<BR/>During an observation and interview on 03/13/23 at 11:10 AM Resident #9 was sitting in his wheelchair, a smoking cigarette butt was on the patio floor between his feet and Resident #9 had a lit cigarette in his hand. There were 5 cigarette butts observed sitting on the lid of the trash can., The trash can was full of paper items including empty cigarette boxes and cigarette butts. Resident #9 said he puts the butts on the ground and makes sure they are out before he puts them in the trash can. An empty ash tray is sitting about 10-12 feet away from the resident. <BR/>During an observation and interview on 3/13/23 11:15 AM the Administrator walked by this surveyor and the resident. The administrator observed the cigarette butts on the ground and sitting on the trash can rim. He brought the ashtray closer to the smoking resident and said he would make sure the trash can was removed from the area.<BR/>During an observation and interview on 3/13/23 at 3:00 PM the Administrator said Resident #9 should be using the ash tray and no resident should be putting the cigarette butts in the trash can. The Administrator said that putting butts in the can could cause a fire and his expectation was that staff members ensure that the butts are put into the ash tray. The Administrator said the staff have been educated on safe smoking and would be in-serviced again. The resident would be assessed again for safe smoking and re-educated on safe smoking.<BR/>2. Physician orders dated March 2023, indicated Resident #60, admitted [DATE], was [AGE] years old, with diagnosis of bipolar disorder, (episodes of mood swings), COPD, (Chronic Obstructive Pulmonary Disease), Depression, Insomnia, (difficulty falling and staying asleep), Migraines, (a recurrent throbbing headache), IBS (irritable bowel syndrome), seizure disorder, cervical (neck) spine surgery and wound care.<BR/>Record Review of MDS dated [DATE] indicated Resident #60 had a BIMS (brief interview for mental statis), score of 14 which indicates she was cognitively intact, and was independent with care. <BR/>Record Review of care plan dated 03/01//23 indicated Resident #60 was a smoker and was at risk for injury. Goal: will smoke in designated smoking area without occurrence of injury over the next 90 days. One of the approaches was to perform the safe smoking assessment every month. Ensure that the resident and/or responsible party is made aware of the facility smoking policy. No smoking materials or igniter's will be stored in the resident's room. <BR/>During an observation on 03/13/23 at 09:51 AM, Resident #60 was asleep in bed and did not wake up when surveyor knocked and entered her room. Her breakfast tray was untouched at bedside, and there was pack of cigarettes and a lighter laying on the bedside table.<BR/>During an observation on 03/13/23 at 11:55 AM, Resident #60 was asleep in bed and does not acknowledge surveyor, there were two packs of cigarettes and a lighter on bedside table.<BR/>During an observation on 03/13/23 at 3:00 PM with the Administrator Resident #60 was asleep in the bed and there are two packs of cigarettes and a lighter on the bedside table. Administrator picked up her cigarette lighter and lit it. Administrator then took cigarettes' and lighter to be locked up in medication room. He said she was not supposed to have her cigarettes and lighter in her room. <BR/>During an interview with the Administrator on 03/13/23 at 03:09 PM he said they needed to make sure all safe smoker assessments were completed and smoking paraphernalia was secure per facility policy. He said not keeping her lighter secure could cause a fire. <BR/>During an interview on 03/13/23 at 3:30 PM, with the DON she said the resident had been sent to the hospital because there was some redness to her surgical wound site, and they sent her to the hospital to get it checked out. She said the cigarettes were laying on the bedside table because the resident was preparing to go to the hospital. <BR/>During an interview with the DON on 03/13/23 at 4:31PM, she said they had to make sure safe smoker assessments were done quarterly to prevent a negative outcome. She said smoking paraphernalia was kept secure to avoid injury to the resident or a possible fire. <BR/>A Smoking Safety Evaluation, dated 2/12/19 indicated Resident #9's last smoking evaluation was performed on 2/12/19. <BR/>A Smoking Safety Evaluation, dated 02/27/23 indicated Resident #60s smoking evaluation was performed on admission [DATE]. <BR/>Record review of smoking Policy dated 11/1/17, smoking policies must be adopted by the facility. The policies must comply with all applicable codes, regulations, and standards, including local ordinances. The facility is responsible for informing residents, staff, visitors, and other affected parties of the smoking policies through distribution and/ or posting. The facility is responsible for enforcement of smoking policies which must include at least the following provisions . 1. Matches lighters or other ignition sources for smoking are not permitted to be kept or stored in a resident's room. 10. Ashtrays of noncombustible materials and safe design will be provided in all areas where smoking is permitted. Ashtrays will be a metal container with a self-closing cover device into which trays may be emptied. Ashtrays will be readily available in all areas where smoking is permitted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise the person-centered care plan to reflect the current condition for 5 of 20 residents (Resident #42, Resident #47, Resident #49, Resident #54, and Resident # 61) reviewed for care plan revisions.<BR/>The facility failed to ensure Residents #42, #47, #49, #54 and #61 care plans were reviewed quarterly.<BR/>This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. <BR/>Findings:<BR/>Record review of facility face sheet dated 03/14/2023 indicated Resident #42 admitted to the facility on [DATE] with diagnoses schizoaffective disorder bipolar type (mental disorder), type 2 diabetes (high blood sugar), and cardiac arrhythmia (irregular heart rate).<BR/>Record review of Resident # 42's medical record revealed the comprehensive care plan was initiated on 04/22/2022, revised on 11/28/2022, and had not been revised after 11/28/2022.<BR/>Record review of facility face sheet dated 03/14/2023 indicated Resident #47 admitted to the facility on [DATE] with diagnoses Covid-19, Alzheimer's (memory changes) and malnutrition (low weight).<BR/>Record review of Resident # 47's medical record revealed the comprehensive care plan was initiated on 10/20/2021, revised on 12/10/2021 and had not been revised or reviewed after that date. <BR/>Record review of facility face sheet dated 03/14/2023 indicated Resident #49 admitted to the facility on [DATE] with diagnoses hypertension (high blood pressure), atrial fibrillation (irregular heart rate) and dysphagia (difficulty swallowing). <BR/>Record review of Resident #49's medical record revealed a comprehensive care plan was initiated on 10/14/2021, revised on 11/16/2022 and had not been revised or reviewed until 03/14/2023.<BR/>Record review of facility face sheet dated 03/15/2023 indicated Resident #54 was admitted to the facility on [DATE] with diagnoses Parkinson's disease (body tremors), major depressive disorder, and abnormalities of gait and mobility.<BR/>Record review of Resident #54's medical record revealed the comprehensive care plan was initiated on 06/03/2021, revised on 07/26/2021, 10/24/2021, 04/22/2022, and had not been revised or reviewed after that date.<BR/>Record review of facility face sheet dated 03/14/2023 indicated Resident #61 admitted to the facility on [DATE] with diagnoses dementia (memory loss), UTI (urinary tract infection), and dysphagia (difficulty swallowing).<BR/>Record review of Resident # 61's medical record revealed a comprehensive care plan was initiated on 10/14/2021, revised on 11/16/2022 and had not been revised or reviewed until 03/14/2023.<BR/>During an interview on 03/15/23 at 11:30 am with MDS Coordinator and Long Term MDS Coordinator, both nurses said they were having quarterly care plan meetings and going over the care plans, but they had no documentation regarding the meetings. They both said they had not been updating in PCC (Point Click Care) because they did not know how, or that they were supposed to do that. They said they received training from the regional nurse on care plans. They said they were responsible for scheduling care plan meetings and doing the revisions. They said the risk of care plans not being updated would be residents not receiving appropriate care. <BR/>During an interview on 03/15/2023 at 11:59 am the social worker said that MDS nurses were responsible for getting the care plan meetings on the calendar and she would send out the letters for the meetings. She said the MDS nurses are responsible for ensuring care plan meetings are documented. <BR/>During an interview on 03/15/2023 at 12:50 pm the DON said that she was responsible for overseeing the MDS nurse coordinators but was not aware they were not updating care plans in the charting system PCC. She said that she and direct care staff could update sections of the care plan as needed, but she had not been monitoring to see the MDS nurses were reviewing and updating as required. She said by not having care plans revised and updated could put residents at risk due to staff not being able to provide the proper care. She said they would audit all care plans and start updating them.<BR/>During an interview on 03/15/2023 at 12:55 pm the administrator said he was responsible for all functions in the facility and would see that both MDS nurses were properly revising and updating all care plans. He said the risk of care plans not being updated would be inaccurate resident information and the care needed. He said he would have the DON and corporate nurse perform an audit and put in place a new monitoring system. <BR/>Record review of Facility policy titled Comprehensive Care Planning undated, stated .resident's care plan will be reviewed after each admission, quarterly, annual and/or significant change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions . <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, as based on the comprehensive assessment of the residents; in that: 4 out of 5 residents reviewed incontinence (Resident #5, #6, #7, #8) <BR/>The facility failed to ensure Residents #5, #6, #7, and #8 were not wearing two briefs after incontinent care was provided. Residents #5, #6, #7, and #8 were observed wearing two briefs at the same time. <BR/>These deficient practices could place residents at-risk for infections and skin break downs due to improper care practices.<BR/>The findings included:<BR/>Record review of a facility face sheet dated 3/26/25 for Resident #6 indicated she was a [AGE] year-old female admitted to the facility 4/6/2022 with diagnoses including Seizures, Morbid Obesity, and Pressure Ulcer.<BR/>Record review of a Comprehensive MDS assessment dated [DATE] for Resident #6 revealed a BIMS score of 11, indicating moderate cognitive impairment. She required maximal assistance with all ADLs, and she was incontinent to bowel and bladder.<BR/>Record review of a care plan dated 3/26/25 for Resident #6 indicated potential/actual impairment to skin integrity related to immobility and Obesity.<BR/>Record review of a comprehensive care plan dated 3/26/25 for Resident #6 indicated impaired cognitive function/dementia or impaired thought processes related to diagnosis of Alzheimer's. <BR/>Record review of a facility face sheet dated 1/01/2024 for Resident #5 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (stroke), pneumonia, pressure ulcer to the head and urinary tract infection.<BR/>Record review of a Comprehensive MDS assessment dated [DATE] for Resident #5 revealing a BIMS score of 13, indicating intact cognitive functioning. She required maximal assistance with all ADLs, and incontinent to bowel and bladder.<BR/>Record review of a comprehensive care plan dated 1/01/2024 for Resident #5 indicated he was dependent on staff for immobility, physical limitations, and social interactions.<BR/>Record review of a facility face sheet dated 3/26/25 for Resident #8 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Type-2 Diabetes mellitus, foot ulcer, hypertension, cerebral infraction (Stroke).<BR/>Record review of a Comprehensive MDS assessment dated [DATE] for Resident #8 revealed a BIMS score of 10, indicating moderate cognitive impairment. She required maximal assistance with all ADLs and was incontinent to bowel and bladder.<BR/>Record review of a comprehensive care plan dated 3/26/25 for Resident #8 indicated potential/actual impairment to skin integrity.<BR/>Record review of a comprehensive care plan dated 3/26/25 for Resident #8 indicated had impaired cognitive function/dementia or impaired thought processes neurological symptoms with cardiovascular accident.<BR/>Record review of a facility face sheet dated 3/27/25 for Resident #7 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Type-2 Diabetes mellitus, foot ulcer, hypertension, cerebral infraction.<BR/>Record review of a Comprehensive MDS assessment dated [DATE] for Resident #7 revealed a BIMS score of 10, indicating moderate cognitive impairment. He required maximal assistance with all ADLs, and he was incontinent to bowel and bladder.<BR/>Record review of a comprehensive care plan dated 3/27/25 for Resident #7 indicated the potential for further pressure ulcer development and worsening of current pressure ulcer with cognitive deficits, physical limitations, and fragile skin.<BR/>Record review of a comprehensive care plan dated 3/27/25 for Resident #7 indicated he had impaired cognitive function/dementia or impaired thought processes dementia.<BR/>During an interview and observation on 3/25/2025 10:50am with Resident #6 she said she had on two briefs and wears 2 brief every day. She said she did not ask to be doubled briefed but had not complained about it because she felt it helped her not soil her bed. She said she did not get changed every two hours and sometimes it was more than 3 hours Resident #6 was observed with two briefs at that time.<BR/>During an interview and observation on 3/25/2025 11:10am with Resident #8 he said he wears 2 briefs at one time every day and night. He said he did not ask for the briefs and not remember staff asking him if he wants the briefs or not. Resident #8 was observed with two briefs at that time.<BR/>During an interview and observation on 3/25/2025 11:30am with Resident #7 he said he wear briefs and do not know how many they put on but thinks they put on two briefs each time they change him. Resident #7 was observed with two briefs at that time.<BR/>During an interview and observation on 3/25/2025 11:45am with Resident #5 he said he know he wears briefs but do not know how many briefs he has on and never asked anyone. Resident #5 was observed with two briefs at that time.<BR/>During an interview on 3/25/2025 at 1:11pm CNA K she said she do not know about any resident being double briefed and she as well as other CNA's use single briefs daily on several of the incontinent residents. She said she was not sure of the number of residents that use briefs in the facility. She said that's the way it was done when she started work at the facility, and she just continued with the resident's normal daily care. She said they have frequent in-services on abuse/neglect, incontinent care, residents' rights, and other direct care trainings. <BR/>During an interview on 3/24/2025 at 3:25pm CNA I she said she uses briefs on some residents but do not use two at one time. She said she have witnessed double briefing a couple of times in the past but not lately and do not know who applied the double briefs. She said she know that double briefing is wrong and not sure of the negative effects but knows to only use one brief at a time.<BR/>During an interview on 3/24/2025 at 2:14pm with CNA J she said she have witness aides doubled briefing residents. She said she reported to the charge nurses when she found double briefing. She said double briefing or leaving briefs on too long could cause skin break downs and irritation to residents.<BR/>During an interview on 3/24/2025 at 2:45pm with LVN L she said she have not witnessed any residents wearing double briefs. She said she normally observes her residents very close. She said she knows they wear briefs but do not know if they are care planned to wear briefs. She said wearing briefs increase the chance of residents having skin issues and urinary tract infections.<BR/>During an interview on 3/25/2025 at 2:20pm with the RN G, she said she's aware of aides double briefing some residents. She said she never reported the inappropriate practice due to it becoming a normal thing in the facility. She said she's aware that she should have reported the neglectful practice. She said double briefing the residents and leaving them up in one position too long may increase the chance of skin break downs and urinary tract infections.<BR/>During an interview on 3/25/2025 at 3:00pm with the DON she said she was not aware of staff double briefing residents. She said double briefing residents was a big no, no. She said a brief can increase chances of urinary tract infections and ulcers/sores. Double briefing will hold the moister, warmth and bacteria more and cause a greater chance for the resident to have negative effects from using briefs.<BR/>During an interview on 3/25/2025 at 3:20pm with the administrator he said he did not know the staff were double briefing residents. He said double briefing is not proper practice and could cause negative effects to the residents by irritating their skin and increase chances of infections. <BR/>Record review on 3/25/2025 of a facility policy titled Abuse/Neglect revised on March 29, 2018, read . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse to any resident in the facility. <BR/>Record review on 3/25/2025 of a facility policy titled Residents Rights dated 2003 revised on November 28, 2016, read .<BR/>Planning and implementing care-The resident has the right to be informed of, and participate in, his or her treatment, including: <BR/>1. The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. <BR/>2. The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:<BR/>3.The right to be informed, in advance, by the physician or other practitioner or professional that will furnish care.<BR/>4. The right to be informed in advance, by the physician or other practitioner or professional, of the risk and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. <BR/>5.The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Based on interview and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 (Kitchen 1) of 1 kitchen reviewed for food safety requirements .The facility failed to ensure temperatures of foods were checked as required for food safety on 9/1/25, 9/3/25, 9/4/25, 9/7/25 through 9/10/25, 9/13/25 through 9/24/25, 9/26/25, 9/30/25, 10/3/25 through 10/9/25, and 10/11/25 through 11/4/25.This failure could place residents at risk for food-borne illnesses and decreased quality of life.Findings included:Record review of temperature log forms provided by DM indicated: 9/1/25 - No log was provided. 9/3/25 - No temperatures were documented for Supper. 9/4/25 - No log was provided. 9/7/25 - No log was provided. 9/8/25 - No log was provided. 9/9/25 - No log was provided. 9/10/25 - No temperatures were documented for Supper. 9/13/25 - No temperatures were documented for Supper. 9/14/25 - No temperatures were documented for Lunch or Supper. 9/15/25 - No temperatures were documented for Lunch or Supper. 9/16/25 - No log was provided. 9/17/25 - No log was provided. 9/18/25 - No log was provided. 9/19/25 - No log was provided. 9/20/25 - No temperatures were documented for Supper. 9/21/25 - No temperatures were documented for Breakfast, Lunch, or Supper. 9/22/25 - No log was provided. 9/23/25 - No log was provided. 9/24/25 - No log was provided. 9/25/25 - No log was provided. 9/26/25 - No temperatures were documented for Lunch or Supper. 9/27/25 - No temperatures were documented for Lunch or Supper. 9/28/25 - No log was provided. 9/29/25 - No log was provided. 9/30/25 - No log was provided. 10/3/25 - No temperatures were documented for Lunch or Supper. 10/4/25 - No temperatures were documented for Breakfast, Lunch, or Supper. 10/5/25 - No temperatures were documented for Lunch or Supper. 10/6/25 - No temperatures were documented for Lunch or Supper. 10/7/25 - No log was provided. 10/8/25 - No temperatures were documented for Lunch or Supper. 10/9/25 - No temperatures were documented for Supper. 10/11/25 - No temperatures were documented for Lunch or Supper. 10/12/25 - No temperatures were documented for Supper. 10/13/25 - No temperatures were documented for Lunch or Supper. 10/14/25 through 11/4/25 - No log was provided.Temperature logs did not have any staff names or signatures to indicate who checked the temperatures or who was responsible for checking them.During an interview on 11/4/25 at 12:35 p.m., DM said the cooks were responsible for checking food temperatures before serving. He said he did not know why they had not been doing it, as he provided thermometers for each food there for their use. He said ensuring the cooks checked temperatures appropriately was his responsibility. He said he provided all the temperature logs that he could find. He said the logs that did not have temperatures recorded on them meant the cook did not document any temperatures for that meal. He said the missing days (the days logs were not provided) also indicated there was no documentation for temperatures for that day.During an interview on 11/4/25 at 2:10 p.m., the Administrator said if food was not cooked to required temperatures and served at appropriate temperatures, residents could be at risk for food borne illnesses. He said, going forward, he would ensure they were kept up to date. He said DM and himself would be responsible for ensuring temperatures were checked appropriately.During an interview on 11/4/25 at 2:23 p.m., DM said if food was not cooked to appropriate temperatures, they could make residents sick, or they may have to go to the hospital. He said he would be in-servicing the staff and would have them show the temperature logs before leaving for the day. He said he expected his cooks to check the foods to ensure they were cooked to the appropriate temperatures before serving. He said they had been short staffed recently, but that was no excuse for not checking the temperatures of the foods. He said all residents in the facility, except for two residents who were tube fed, ate from the facility kitchen.Record review of a facility policy titled Daily Food Temperature Control, dated 2012, read, .We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges. and .Temperatures are recorded on the Temperature Log or Production sheet form.