**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the development of comprehensive care plan that meets allof a residnt's need for 1 of 18 residents (Resident #37) reviewed for advance directives. The facility failed to ensure that Resident #37's advanced directive preference was included in care plan or stored in DNR binder at the nurses' station. The facility failed to have the advanced directive in the binder and failed to implement their policies for implementing advance directives This failure could place residents at risk of receiving treatments that go against their personal preferences and does not allow them to make an informed decision about their care. Finding included: Record review of the Resident #37's face sheet dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: cerebral infarction stroke), presence of cardiac pacemaker, and metabolic encephalopathy (brain swelling). Further investigation of face sheet revealed that resident resided on unit 3 (300 hall). Record review of Resident #37's admission MDS dated [DATE] revealed: no BIMS score, and Resident #37 was rarely or never understood. Record review of Resident #37's care plan dated [DATE] revealed no evidence of advanced directive code status. Record review of Resident #37's electronic physician orders dated [DATE] revealed DNR-DO NOT RESUSCITATE. Record review of Resident #37's OOH-DNR dated [DATE] revealed adult child signed and dated form, two witnesses signed form, and physician signed form. During an interview on [DATE] at 2:49 PM, the DON stated the facility ensures direct care nurses are notified of resident's code status by locating information in DNR binder. She stated the facility does not add code status to resident's care plans. During an observation on [DATE] at 2:58 PM, DNR binder observed at nurses' station for 300 hall and no information about Resident #37's advanced directive wishes observed inside of binder. During an interview on [DATE] at 3:08 PM, RN B stated direct care staff would look in the DNR binder at nurses' station to see if resident had a DNR code status. She stated nurses' station on 400 halls housed DNR binder for residents that resided on 400 hall and nurses' station on 300 halls housed DNR binder for residents that resided on 300 hall of nursing facility. During an interview on [DATE] at 3:20 PM, LVN C stated typically residents DNR status would be identified on admission by the admission nurse. She stated admission nurse was responsible for placing resident's information in DNR binder at nurses' station. She stated she did not know why Resident #37's information was not in DNR binder on 300 halls. She stated Resident #37 was admitted on [DATE] and her DNR status should have been placed in DNR binder. During a follow up interview on [DATE] at 3:26 PM, the DON stated she expected for a resident that was a DNR to be identified by admission nurse on admission and the admission nurse should add resident's information to DNR binder at nurses' station. She stated nurses monitor code status information by performing chart audits including ADON and DON. She did not know why Resident #37's information was not in DNR binder or why is had not been identified prior to [DATE]. She stated the effect of information being left out of the binder could lead to delay of resuscitation. She stated nurses could look into electronic medical record to see information on code status as well. During an interview on [DATE] at 4:03 PM, the ADMN stated her expectation was for DNR binders to be updated when a change in code status occurred. She stated she expected facility policy to be followed. She stated the facility policy stated social worker or designee would monitor advanced directive information in DNR binders at nurses' stations were up to date. She stated she did not know why information was not present in DNR binder for Resident #37. She stated the effect of not having information in the DNR binder could potentially lead to advanced directive not being followed in an emergency. During a phone interview on [DATE] at 4:20 PM, Resident #37's son stated he expected the facility to follow their advanced directive wishes. He stated he expected for her wishes to be honored and no CPR to be performed. Record Review of facility policy titled Code Status Listing revised date 11/2007 revealed: 1. All residents will be informed of their opportunity to file advanced directives upon admission and at least annually. 2. The residents with code status will be kept in a binder at each nurse's station. 3. Social Serviced, or designee, will keep the code status list current and updated whenever a change occurs. 4. ID team will discuss advanced directives with resident/responsible party during annual care plan conference and update as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure no expired medication/treatment products were not on 1 of 1 Treatment cart reviewed for medication storage. The facility failed to remove expired box of collagen dated 08/2023 from treatment cart. This failure could result in delayed healing of wound. Findings included: During an observation on [DATE] at 1:00 PM wound treatment supplies and products being set up for a treatment, LVN A observed expired box of collagen (a protein in the body that encourages wounds to heal quickly and effectively) sheets. The expiration date: 08/2023. During an interview on [DATE] at 1:01 PM LVN A stated the expired supplies should not have been left on the cart. She stated that using expired wound care products (collagen sheet) could have caused the treatment to not be as effective due to the matrix of product. She stated she did not know why expired collagen was on the cart. LVN A stated she had checked the cart earlier in the day but did not see that this dressing was expired at that time. During an interview on [DATE] at 1:50 PM the DON stated her expectations was expired treatment products should not have been applied to resident, and the treatment nurse should have checked expiration dates prior to using and discard any expired products immediately. The DON stated the treatment nurse audits their cart weekly and nursing management monitors as well. She stated treatment products were to promote healing and if expired product was used it could have interfered with the healing process and could have delayed healing of resident wound. She stated she did not know what had caused the failure. During an interview on [DATE] at 2:15 PM the ADMN stated the expectation would have been that treatment products or medications were used on/or before the expiration date. She stated it was the responsibility of treatment nurse to ensure products and medications were not expired and should have been double checked by nursing management. She stated possible harm to the resident could have been the potency of treatment could have been decreased if not used prior to or by the expiration date. She stated the facility had been training new staff on wound care and it could have possibly been missed due to this. Record review of facility's policy titled, Care and Treatment Subject: Medication Access and Storage, dated 05/2007 revealed: 13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman for one (Resident #1) of two residents reviewed for transfer and discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #1 was discharged home on 7/14/23. This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. Findings included: Record review of Resident #1's electronic face sheet, dated 10/31/23 revealed she was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include fracture of unspecified part of neck, Depressive Disorder, and type 2 diabetes mellitus. Review of Resident #1's progress notes dated 7/14/23 indicated Resident #1 discharged home with her prescriptions and personal items. Resident #1's family member was at the facility to assist with the discharge and transport he resident home. The resident was in stable condition at time of discharge. Electronic communication via email dated 11/1/23 Ombudsman wrote: The Ombudsman Program has not received any 30-day discharge notices since 3.21.2022 and has not received transfer/discharge reports since 6.7.2023, from the facility. During an interview on 11/1/23 at 3:15 PM the ADMIN stated the social worker should be the one that handles all discharges and documentation even with the Ombudsman. She stated a spreadsheet of all residents who were transferred out of the facility should be kept and emailed to the Ombudsman monthly. During an interview on 10/26/2022 at 2:25 the SW stated that for long term care discharges there was 30-day notice but if they were only in the facility for skilled care then it could be up to 48 hours. He stated that he did not know he needed to contact the Ombudsman of all transfers and discharges. Record review of facility policy on 11/1/23 titled: Criteria for Transfer and Discharge revealed: It is the policy of this facility that each resident will remain in the facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the facility transfers or discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately notify resident's family/representative(s) when a significant change in condition that required hospitalization occurred for 1 or 3 (Resident #1) residents reviewed for change of condition. The facility failed to notify Resident #1's family/POA when he was admitted to the hospital for serious medical complications for more than 24 hours after he was admitted . This failure could place all residents at risk for not having their family or legal representative notified when having a change in condition. Findings included: Record review of Resident #1's Face Sheet, dated [DATE], revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. Diagnoses were noted as Non-ST Elevation (NSTEMI) Myocardial Infarction (type of heart attack involving a partly blocked coronary artery [surround the heart] that causes reduced blood flow), Thromboangiitis Obliterans or Buerger's Disease (disease that affects blood vessels in the body, most commonly in the arms and legs, causing vessels to swell which can prevent blood flow), Type II Diabetes Mellitus (Chronic disease in which your blood glucose or blood sugar, levels are too high) with Hyperglycemia (high blood glucose), End Stage Renal Disease (medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), Chronic (long-term) Pulmonary Edema (condition caused by too much fluid in the lungs), Kidney Transplant Status (has received a kidney transplant), Chronic (long-term) Obstructive Pulmonary Disease (diseases that cause airflow blockage and breathing-related problems), Acquired Absence of Left Leg Below Knee (surgically amputated), and Dependence on Renal Dialysis (treatment to clean your blood when your kidneys are not able to). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 05 which indicated a severe cognitive impairment. Functional status in Section G of the MDS indicated Resident #1 required extensive assistive and total dependence with daily living activities of personal care. Resident #1 required extensive assistance with the assistance of at least two staff to move to and from a lying position in bed or turn from side to side. Resident #1 required total staff assist to transfer from his bed to a wheelchair or bed . Record review of Resident #1's Care Plan, dated [DATE], revealed Resident #1 had renal failure due to end stage kidney disease and had the need for hemodialysis every Monday, Wednesday, and Friday. The care plan revealed Resident #1 had impaired circulation due to diabetes, infections, Buerger's Disease, PVD, and CAD. During an interview on [DATE] at 3:15 p.m., the DON said she was aware Resident #1's family had not been notified when Resident #1 had been sent out to the hospital on the morning of Monday, [DATE] . The DON said on [DATE] at approximately 1:30 p.m., the Infection Control RN had informed her she had not contacted the family immediately after Resident #1 had been transported to the hospital. The DON said Resident #1 had been transported to the ER due to edema and shortness of breath at approximately 9:10 a.m. on [DATE]. During an interview on [DATE] at 4:10 p.m., the Infection Control RN said she had been at the facility for approximately two (2) years. The Infection Control RN said she was on duty and the nurse who made the decision to send Resident #1 out to the ER on [DATE]. The Infection Control RN said she entered Resident #1's room and observed his face and arms to be swollen and made the determination to call the paramedics to transport Resident #1 to the hospital. The Infection Control RN said she contacted his physician, the DON, the Dialysis Provider, and the Administrator. The Infection Control RN said she did not contact the family of Resident #1 immediately because she became busy checking the vital signs of another resident, received a personal phone call, and became distracted and overlooked calling the family. During an interview on [DATE] at 4:32 p.m., Resident #1's Family Member A said Resident #1 was sent to the hospital on the morning of [DATE], which was Monday, at approximately 9:30 a.m. and he was not notified until Tuesday morning ([DATE]). Resident #1's Family Member A said a member of his family was first notified by the hospital that Resident #1 had been admitted to the hospital. Resident #1's Family Member A said the nursing facility contacted his family member several hours after the hospital had call to notify the family Resident #1 had been sent out to the hospital the morning of [DATE]. Resident #1's Family Member A said he was upset because Resident #1 could have died and he would have not known until 24 hours later. During an observation on [DATE] at 9:05 a.m., Resident #1 was observed in the ICU unit of the local hospital. Resident #1 was lying in a hospital bed on his back and wearing a lightweight oxygen tube in his nose. Observed an intravenous (into or within the vein) pole by his bed with an intravenous bag attached. Resident #1 was observed with his eyes closed, grimacing, and moaning. During an interview on [DATE] at 9:15 a.m., ICU RN said Resident #1 was moved to ICU from the third floor of hospital on [DATE] due to unstable blood pressure and unsteady cardiac rhythm. During an interview on [DATE] at 9:45 a.m., Resident #1's Family Member/POA said she was Resident #1's responsible party and Power of Attorney for his medical care. Resident #1's Family Member/POA said she had received a call on Tuesday, [DATE] at approximately 10:00 a.m. from the local hospital requesting permission to complete a medical procedure on Resident #1. Resident #1's Family Member/POA said she was not aware Resident #1 was in the hospital at the time of the call. Resident #1's Family Member/POA said she was not contacted by the nursing facility until approximately 2:00 p.m. on Tuesday, [DATE]. Resident #1's Family Member/POA said the Infection Control RN called her and explained that Resident #1's blood pressure had dropped the morning of Monday, [DATE] and he was sent to the hospital by ambulance at approximately 9:30 a.m. Resident #1's Family Member/POA said the Infection Control RN told her she was the nurse who made the decision to send Resident #1 to the hospital by ambulance. Resident #1's Family Member/POA said the Infection Control RN said she had prepared Resident #1 to go to the hospital and then the Infection Control RN said she assisted another resident and forgot to call Resident #1's family. During an interview on [DATE] at 1:15 p.m., the DON said the fact that the Infection Control RN did not contact Resident #1's family immediately after Resident #1 was transported to the hospital on [DATE] did not meet her expectation. The DON said with Resident #1's fragile medical condition, Resident #1 could have expired. The DON said she immediately took action and started an in-service to inform all staff that family/Responsible Party/POAs must be notified immediately when a resident was sent to the emergency room or hospital and she took disciplinary action against the Infection Control RN for her oversight. Record review of the form, Counseling/Disciplinary Notice, dated [DATE] and signed by the Infection Control RN on [DATE] revealed the Infection Control RN was given a written warning for not notifying family when a resident was sent out to the hospital by ambulance. Record review of an In-service Attendance Record, dated [DATE], revealed the DON and ADON initiated an all-staff in-service training that informed staff, When a resident is sent out of facility family must be notified. No matter what the time of send out, a call is to be made to the emergency contact until they are reached and or the second contact is reached. Once family is contacted it is to be documented. Documentation should include the name of who you spoke with and what information was given. Record review of the facility policy, Resident Rights, not dated, revealed it was the policy of the facility to notify the family/responsible party of changes in the resident's condition and/or status. The charge nurse would notify the resident's family/responsible party when: (E). It was necessary to transfer the resident to a hospital.

Based on observation, interviews and record reviews the facility failed to maintain an environment that remained free of accident hazards. The facility failed to keep cleaning agents out of the reach of residents. This failure placed residents at risk of accidental ingestion of chemicals. Findings included: In an observation on 4/10/23 at 12:29 PM, residents were being served and eating their noon meal in the facility dining room. On a countertop in the dining room there was a bottle of Comet cleaner with bleach sitting on top of counter with a white washcloth on top of the bottle. There were three dining tables near the counter with residents at each table. In an interview on 4/10/23 at 12:42 PM with ICP, she said the cleaner should not have been out on the countertop within reach of the residents. She said the residents could suffer an adverse reaction from the chemicals. In an interview on 4/10/23 at 12:50 PM with the ADM, she said the Comic cleaner with bleach should not have been out on the countertop within reach of the residents. She said residents should not have easy access to the cleaner. She said anyone knows what could potentially happen. ADM did not wish to elaborate further on a potential safety hazard. Record review of MSDS for Comic cleaner with bleach undated revealed: eye damage irritation. Corrosive 2 metals. Handling and storage use personal protective equipment as required. Keep container closed when not in use . Keep out of reach of children. Keep containers tightly closed in a dry, cool and well-ventilated place. Store in corrosive resistant container. First aid measures. Eye contact rinse with plenty of water. Get medical attention immediately if irritation persists. Skin contact. Rinse with plenty of water. Get medical attention if irritation develops and persists. Ingestion. Drink one or two glasses of water. Do not induce vomiting. Get medical attention immediately if symptoms occur. Inhalation. Made fresh air. If symptoms persist call a physician. Accidental release measures. Personal precautions. Use personal protective equipment. Do not get in eyes, on skin, or on clothing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments for 1 of 2 medication carts, and unsecured respiratory medications at resident bedside, reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication cart #1 was locked when unattended by RN-A. The facility failed to ensure Resident #25srespiratory treatments were not left at bedside and used unsupervised . This failure could place residents at risk of having access to unauthorized medications, leading to possible harm or drug diversions. Findings include: 1.During observation on 04/10/2023 at 10:20 PM, Station 3 Nurses Station, med cart #1 was unlocked with a pill cup that included one pill on top of the med cart accessible to residents. Observation also at that time revealed a resident who walked up to Station 3 Nurses Station. During an interview on 04/10/2023 at 10:25 PM, the RN-A stated, a resident had refused a medication and placed the pill cup with one pill on top of the cart, leaving the cart unlocked and walked away. He stated the negative impact to residents, if accessed, would have been a possible overdose and/or an adverse reaction. His failure, he stated, was not locking the med cart, and having not disposed the refused medication properly. During an interview on 04/12/2023 at 3:45 PM, the DON stated, the negative impact to residents were, they could get into the open med cart or the pill sitting on top of cart possibly causing an allergic reaction. She stated the charge nurse should have ensured the carts were locked and herself and ADON should have been monitoring all shifts. The failures she felt was an isolated incident and did not comment further. Her expectations were for the med cart to have been locked immediately before walking away. The discarding of refused meds should have been discarded immediately upon refusal. 2.Record review of Resident #25 face sheet dated for 12/2023 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis list that included: Acute combined CHF (primary), pulmonary hypertension due to left heart disease, COPD, Alzheimer's disease (late onset), cognitive communication deficit. Record review of Resident #25's Quarterly MDS dated [DATE] revealed a BIMS of 4 meaning severe cognitive deficit. Resident did not utilize oxygen while a resident of the facility. Resident did not have shortness of breath. Resident had no functional range of motion impairment of upper extremities. There was no answer for functional cognition for remembering to take medication as resident was not on an admission skilled stay at that time. Record review of Resident #25's Care Plan dated 4/12/2023 revealed: Focus: has altered respiratory status/dyspnea r/t pulmonary HTN, A-FIB, pulmonary edema, COPD. Goal: Will have no complications related to SOB though the review date. Will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Will not have a rehospitalization within 30 days. Interventions: . Inhalers albuterol and Spiriva per MD orders . Provide oxygen as ordered. Care plan does not address that resident may keep albuterol inhaler at bedside. Record review of Resident #25's Physician Order dated 4/12/2023 revealed: Albuterol Sulfate Aerosol Powder Breath Activated 108 (90 Base) MCG/ACT 2 puff inhale orally four times a day for COPD. Start date 11/3/2022. Order does not state that resident may keep inhaler at bedside. During observation on 4/10/2023 at 10:25 AM with Resident #25. She had an albuterol inhaler laying on her bedside table. The label on the albuterol inhaler stated the medication and directions to use four times a day. The resident and roommate both stated, it was always on the bedside table. She stated, the nurse would then come by to ensure she took the inhaler when she was supposed to. Resident #25 stated, the nurse did not assist with the inhaler only to come back to check it she had taken it. Resident #25 stated, she knew how to use the inhaler and then she took it four times a day not only when she needed. Resident was wearing oxygen via nasal cannula with the oxygen setting at 2 liters per minute. Resident said she wears oxygen continuously and she has had issues in the past with her lungs. During observation on 4/12/2023 at 4:20 PM, Resident #25 was not in her room, her roommate stated, she went out with family and had left her albuterol inhaler on the bedside table. The Roommate stated that no nurse had taken the inhaler from her bedside table within the last 3 days (4/10/2023 through 4/12/2023). During an interview on 4/12/2023 at 4:28PM, the LVN-D stated, if a resident had an order a specific medication could be kept at bedside, it would be acceptable. The nurse would still have needed to do a respiratory assessment each time per say, if it were a respiratory medication such as an inhaler and ask the resident if they had taken it. LVN-D stated if a resident had a medication that could be kept at the bedside, it would been addressed in the care plan as well. She also stated, if a resident did not have an order, to be kept at bedside, the medication was to be kept locked in the medication cart. During an interview on 4/12/2023 at 4:3 3PM, the DON stated, regarding a resident with a medication at bedside, first would be the residents desire to keep a medication at bedside, then a SMA Assessment would be conducted. The DON then stated, if the assessment revealed the resident was safe and competent, a discussion would be made with the resident's physician. It would have been then, if the physician agreed, the resident could safely keep the medication at bedside, then that specific medication's order would include could be kept at bedside. If the physician had written an order resident were allowed to keep med at bedside, the care plan needed to be updated to state as such. If there were no order for it to be kept at bedside, the care plan would not be included that it could be kept at bedside. The DON stated cognition would have been a factor with the SMA assessment with having had a BIMS of 4, Resident #25 would not have been able to keep a medication at bedside. She stated, the physician's orders would not be a general May keep at bedside order but would be with the specific medication could be kept at bedside. Without that specification in the medication order, the medication should have been stored in the medication cart. Record Review of undated facility Policy and Procedure-Nursing Clinical revealed: Section: Care and Treatment Subject: Medication Access and Storage Policy: It is the policy of this facility to store all drugs and biological in locked compartments Procedures: 2. Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 3. Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations interviews and record reviews, the facility failed to maintain an infection prevention and control program for 2 (RN-A, RN-E) of 8 staff and 1(Resident #21) of 5 residents reviewed for infection control. Facility staff failed to wear facemask properly. Facility staff failed to perform hand hygiene prior to donning surgical gloves for a sterile dressing change of Resident #21's PICC line. These failures placed residents at risk of infection. Findings included: During an observation on 04/10/23 at 9:45AM, entrance of facility had a whiteboard that had information regarding Covid-19. It stated, On 11/28/22 Texas Health & Human Services released the following guidance . 5. Due to HIGH county transmission rate Masks ARE REQUIRED. A poster that included Facemask Do's and Don'ts The poster included that the proper way to wear a mask was on the face and covering the nose and mouth. Many ways not to wear it included not at all and/or not covering the nose and mouth. During an observation on 04/10/2023 at 10:20 PM, RN-A (charge nurse) was sitting at Station 3 Nurses Station with no mask on. Residents were present in hallway at this time walking towards nurses station and walking in hallways. During an interview on 04/10/2023 at 10:25 PM, RN-A stated, it was only mandatory to wear his surgical mask when performing resident care, and not in the hallways or Nurses Station. During an interview on 04/11/2023 at 4:20 PM, the ADM stated, the county positivity rate was considered high, therefore wearing surgical masks should be worn in all areas of the facility with the exceptions of Offices, or mask break areas. She stated, the charge nurse should have been monitoring actions of staff keeping them accountable when ADM was not in the facility such as the night shift. The leadership team, (Charge nurse, ADM, and DON), were ultimately responsible for monitoring the wearing of masks throughout facility at all times. The ADM stated the negative impact to residents would have been exposure to outside factors. The failure she stated, it was harder for the leadership team to monitor the night shift, and the charge nurse not following the proper protocols of such. The expectations were for the charge nurse to wear his mask and to show ownership and responsibilities of a nurse. Record review of Resident #21 Facesheet dated 4/12/23 revealed: a [AGE] year old male admitted to the facility on [DATE] with a diagnosis list that included: Other acute osteomyelitis, right tibia and fibula (primary), Other bacterial infections of unspecified sites, Other specified bacterial agents as the cause of diseases classified elsewhere, Resistance to multiple antibiotics, Metabolic encephalopathy, gangrene not elsewhere classified, acquired absence of left finger, Buergers disease(disease of blood vessels of arms and legs), NSTEMI (heart attack), Pleural effusion, Type one diabetes mellitus with hypoglycemia without coma, Peripheral vascular disease, End stage renal disease, Altered mental status, Cognitive communication deficit, Unspecified dementia, moderate, with other behavioral disturbance, Acquired absence of left leg below knee, Dependence on renal dialysis Unspecified protein calorie malnutrition. Record review of Resident #21 Quarterly MDS dated [DATE] revealed: A BIMS of 5 meaning severe cognitive impairment. IV medication while a resident of the facility. Record review of Resident #21 Care plan dated 4/12/23 revealed: Focus: on IV medications related to osteomyelitis to right tibia and fibula, resistance to multiple antibiotics. initiated 2/22/23. Goal: Will not have any complications related to IV therapy through the review date. Intervention: . change PICC line dressing every 7 days per order. Record review of Resident #21 Medication Administration Record dated 4/11/23 revealed: PICC line dressing change weekly and PRN one time a day every Tuesday for infection control. May change if dressing is falling off, notify if site won't stop bleeding, if arms circumference changes or if external catheter length changes. Order date 3/21/23. During an observation on 4/11/23 at 2:16 PM, RN-E performed a dressing change of Resident #21's PICC line. He washed his hands and donned clean gloves. RN-E opened all supplies for PICC line dressing change. He then placed a mask on resident and preceded to use an alcohol swab to assist in removal of old PICC line dressing. RN-E doffed gloves then donned sterile gloves without performing any hand hygiene. He then cleaned skin around Resident #21's PICC line port access. RN-E then utilized a skin prep wipe to protect the skin and placed a clear window dressing cover over Resident #21's PICC line. He placed a label on the dressing that included the date and RN-E's initials. RN-E then flushed the PICC line with an immediate blood return and 10CC's of normal saline. During an interview on 4/11/23 at 2:40 PM, RN-E said hand hygiene should be performed before starting the procedure and then after the procedure. He said staff should also wash hands with soap and water after doffing gloves and before donning sterile gloves. RN-E said the PICC line went directly into a resident's brachial artery that leads to the heart and allowed for IV fluids to circulate the body faster. RN-E said there was potential for greater infection with the PICC line. During an interview on 4/12/23 at 4:15PM, DON said hand hygiene should be performed between glove changes. She said it was preferred that soap and water hand washing would be performed before donning surgical gloves for a sterile procedure. Record review of facility Infection Control Covid-19 information labeled Nursing Home Visitation revised 9/23/22 revealed: Face covering or mask (covering mouth and nose) in accordance with CDC .If the nursing home's county Covid-19 transmission is high, everyone in a healthcare setting should wear face coverings or masks. Record review of Covid-19 CDC guidance accessed on 4/18/23 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed: 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 . 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 . HCP could choose not to wear source control when they are in well-defined areas that are restricted from patient access. Record review of facility policy labeled Handwashing dated 9/20 revealed: It is the policy of this community to cleanse hands to prevent transmission of possible infectious material and to provide a clean, healthy environment for residents and staff. Handwashing is considered the most important single procedure for preventing the spread of infections. Record review of the National Institute of Health last updated 9/5/22 accessed at https://www.ncbi.nlm.nih.gov/books/NBK459338/ on 4/13/23 revealed: By definition, a central catheter is a venous access device that ultimately terminates in the superior vena cava (SVC) or right atrium (RA). They can be inserted centrally (centrally inserted venous catheter; CICC) or peripherally (PICC). PICCs are placed through the basilic, brachial, cephalic, or medial cubital vein of the arm. The right basilic vein is the vein of choice due to its larger size and superficial location. Additionally, it has the straightest route to its destination, as it courses through the axillary vein, then through the subclavian, and finally, settles in the SVC. Other factors that have been thought to make the basilic vein the superior choice for PICC lines are that it has the least number of valves, better hemodilution capabilities and has a shallower angle of insertion compared to other veins.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the menu was followed, for 1 of 1 observed lunch meal on 04/10/2023. The facility failed to ensure residents received a fresh baked role or an approved alternative during the lunch meal. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss. The findings include: Observation and review of posted daily facility menu for Monday 04/10/06/2023 revealed: Lunch: Sweet/Sour Meatballs, Steamed Rice, Seas [NAME] Beans, Roll/[NAME], Iced Brownie, Beverage and Whole Milk. Observation of the meal on 04/10/2023 at 11:30 AM revealed residents were served Sweet/Sour Meatballs, Steamed Rice, [NAME] Beans, and an Iced Brownie. Resident trays were served without a roll or an approved alternative. During an interview on 4/10/2023 at 11:45 AM the DM stated resident trays were served without a roll. The DM stated the cook should have substituted a slice of bread, if there were no rolls. The DM stated she did not know why there was no rolls served. During an interview on 04/11/2023 at 10:15 AM the DM stated her expectation was that staff were to follow the menu and if an item was not available for some reason it would need to be substituted. The DM did not know why the roll was missing from food tray yesterday. The DM stated the cooks and herself were responsible for monitoring the menu being followed. During an interview on 04/12/23 at 3:36 PM the ADMN stated her expectation was that staff follow menus and needed to notify staff and residents of substitution. The ADMN stated the roll should have been substituted with adequate substitution. The ADMN stated the DM was responsible to monitor to ensure menus were being followed. The ADMN stated what led to failure was inconsistent training structures. The ADMN stated the effect on residents when menus were not followed was resident did not get proper nutrition. Review of facility's policy titled, Nutrition and Menu Planning undated revealed: Menu and Nutritional Adequacy: Understands and follows prescribed diet orders, menu spreadsheets and corresponding recipes, Understands menu substitutions and use of nutritionally equivalent foods. Prepares appropriate quantity of food based on menu spreadsheets.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed . The facility failed to ensure foods were sealed and/or labeled properly in refrigerator. The facility failed to ensure all food was not past expiration date. The facility failed to ensure that staff utilized proper personal hygiene practices. These failures could place residents that eat from the kitchen at risk for food borne illnesses. Findings included: Observation of the kitchen on 04/10/23 between 10:15 AM to 11:15 AM revealed the following: Refrigerator 1. A container of Pimento Cheese with a use by 4/7/23. 2. A bag of broccoli with a use by date of 3/17/23. 3. A package of bologna not sealed open to air. 4. A plastic bag with a seal not sealed contained grated cheese. 5. A plastic bag with a seal not sealed contained lettuce. 6. A plastic bag with a seal not sealed contained sliced white cheese. 7. Two bags of lettuce with a use by date of 4/7/23. 8. A container containing BBQ pork without a prep or use by date. 9. A plastic bag with seal not sealed containing ham. 10. A container of refried beans with a use by date of 4/7/23. 11. A container of pasta with a use by dated of 4/9/23. Observation on 04/10/2023 at 11:30 PM revealed DS C entered the kitchen without washing hands, walked thru kitchen carrying personal food and drink itmes, entered into the office with items, then returned to kitchen without personall items, went to warmer and removed food containers before washing hands. While DS C washed her hands, she turned off water with bare clean hands and then grabbed a paper towel to dry hands; and went to get food containers out of warmer. During observation on 04/11/23 at 10:40 AM revealed DS B failed to perform hand hygiene while pureeing food, DS B touched mask, pulled down mask, adjusted glasses picked up food containers numerous times without performing hand hygiene. During an interview on 04/11/2023 at 10:15 AM the DM stated her expectation was the food needed to be sealed and labeled with item description, date prepared and date needed to be discarded. The DM stated items needed to be discarded when dated. The DM stated the effect on residents would be that residents could have received food poisoning. The DM stated staff should perform hand hygiene every time they enter kitchen, touch something on their person or change tasks. The DM stated what led to failures were staff were rushing and trying to do too much at one time. The DM stated all dietary staff should have been monitoring but ultimately fell on cooks and DM to monitor. The DM stated staff are trained on proper hand hygiene and food storage and labeling at hire thru the facility's online training system and when complete food handler's certificate. During an interview on 04/12/23 at 3:36 PM the ADMN stated her expectation was that staff follow policy for hand hygiene and food storage and labeling. The ADMN stated staff should have washed hands anytime they changed tasks. The ADMN stated the DM was responsible to ensure staff followed policy. The ADMN stated the effect on residents was food could have lost nutrient content or have been spoiled. The ADMN stated what led to failure of items not being stored properly was inconsistent training structure. The ADMN stated what led to failure of staff not performing hand hygiene was lack of accountability. Review of Facility policy titled, Infection Control Policy/Procedure dated 05/2007 revealed: Wash hands carefully with soap and water whenever they become soiled, immediately before work in the morning, after using the bathroom, after coughing, sneezing, or blowing the nose, after touching the hair, mouth, or cigarettes, after handling raw unwashed food and dirty dishes; Before touching food, clean dishes and silverware. Review of FDA Food Code 2022 accessed https://www.fda.gov/media/164194/download revealed on page 20: (C) TO avoid recontaminating their hands or surrogate prosthetic devices, FOOD EMPLOYEES may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a HANDWASHING SINK or the handle of a restroom door . FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms . Before donning gloves to initiate a task that involves working with FOOD; (I) After engaging in other activities that contaminate the hands.