**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1's weight was recorded daily as ordered from 11/22/24 through 12/02/24. This failure could place residents at risk of not receiving care to maintain optimum health and placing them at risk for decline in health. Findings included: Review of Resident #1's face undated face sheet reflected he was admitted on [DATE] and discharged on 12/02/24. Review of Resident #1's admission MDS assessment, dated 11/22/24, Section A (Identification Information) reflected a [AGE] year-old male admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including atrial fibrillation (an irregular heartbeat), heart failure, hypertension (high blood pressure), cirrhosis (severe liver damage), morbid obesity, and diabetes mellitus (a condition that affects the way the body processes blood sugar). Section C (Cognitive Patterns) reflected a BIMS score of 14 indicating intact cognition. Review of Resident #1's care plan initiated on 09/20/24 reflected in part, Resident #1 is at risk for nutritional and/or dehydration risk related to diabetes, congestive heart failure, and morbid obesity. Will maintain nutritional status as evidenced by no significant weight changes through next review. Interventions included, Monitor weights, skin report, and labs . Review of Resident #1's physicians orders dated 11/20/24 reflected, Daily weight once a day 6:00 AM to 11:00 AM. Review of Resident #1's recorded weights reflected 11/19/24 441.5 lbs., 11/20/24 440.5 lbs., and 11/21/24 440 lbs. There were no weights recorded for 11/22/24 through 12/02/24 (11 days). During an interview on 12/04/24 at 12:05 PM, the NP stated it was important to monitor Resident #1's weight because of his heart conditions , chronic edema, and morbid obesity. She stated weight changes could indicate a change in status. During an interview on 12/04/24 at 3:52 PM, with LVN A, she stated the restorative aide was responsible for weighing residents. She stated weights were monitored to help assess changes in fluid balance or nutritional status. She stated Resident #1 had an order for daily weights, but she saw only three weights recorded in the record. She stated she did not weigh the resident and did not know if the resident had refused to be weighed. During an interview on 12/04/24 at 3:57 PM the ADON, stated the restorative aide was responsible for daily and weekly weights but anyone could weigh the residents. There were other staff who were responsible for weights when the restorative aide was not in the building. She stated the weights were included on a weekly report that went to the management team and the weights were reviewed at a meeting. She stated changes in weight could indicate fluid imbalance or CHF. During an interview on 12/04/24 at 4:34 PM, the DON stated the restorative aide was responsible to take and record the weights, but all nursing staff could have taken a weight. She stated the restorative aide was out of the facility, but she had left a message and requested a return call. She stated she found some papers on the restorative aide's desk which included a weight for Resident #1 on 11/26/24. The DON stated the weight was not recorded in Resident #1's electronic medical record. The DON stated it was her expectation that physician orders be followed. During an interview on 12/04/24 at 4:38 PM, the ADM stated it was her expectation that physician orders be followed. Review of the facility policy, Weighing the Resident, revised 02/26/24, reflected in part, Record all weights per facility protocol. The policy did not address daily weights. Review of the facility policy, Physician Orders, revised 05/05/23, reflected in part, 3. Upon admission, the Facility has physician orders for the resident's immediate care to include but not limited to: C. Routine care orders to maintain or improve the resident's functional abilities .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with dignity and respect and care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #1) of six residents reviewed for dignity. The facility failed to ensure MA A treated Resident #1 with dignity and respect when she spoke to the resident in a rude manner in front of others . This failure could place residents at the risk for psychosocial harm due to diminished self-esteem and quality of life. The findings were: Record review of Resident #1's face sheet, dated 08/07/24, reflected a [AGE] year-old-male who was admitted to the facility on [DATE]. His diagnoses included Severe protein-calorie malnutrition, Mood disorder, BMI 19.9 or less (Low body weight), Nausea with vomiting, Muscle weakness, Abnormalities of gait and mobility, Hypertension and chronic kidney disease . Record review of Resident #1's quarterly MDS assessment, dated 07/30/24. reflected a BIMS of 15, which indicated his cognition was intact. Record review of Resident #1's quarterly Care Plan, dated 07/30/24, reflected Resident #1 made verbal expressions of distress related to feeling depressed (Sad), fearful (not feeling safe), and anxiety (over needs and care) . The relevant interventions were: 1. Establish a trusting relationship with the resident and family. 2. Maintain a calm environment and approach to the resident. 3.Convey an attitude of acceptance toward the resident. 4.Acknowledge to the resident that the current situation must be difficult. 5.Allow resident to make decisions, to set realistic goals, and to participate in self-care. Record review of the incident report by the facility, dated 08/02/24, reflected on 08/02/24 at 6:15 PM, Resident #1 reported a rude interaction during meal services and was witnessed by MA B and CNA C. Resident #1 stated he was standing at the dining door with his water pitcher when MA A approached and asked him what he wanted. He explained to her he wanted to make a change to his meal and refill his pitcher. MA A told him he had to make meal changes earlier if he wanted, not possible now and asked him to walk around the corner and fill up his pitcher instead of getting it from the kitchen. In an observation and interview on 08/07/24 at 12:10 PM revealed Resident #1 was lying in bed in his room. When the State Surveyor asked about the incident that happened in the dining room on 08/02/24 at 5:20 PM, he stated he was upset about how the staff member, MA A, talked to him in the dining room while other residents were present. He said he was at the dining room door waiting for dietary staff to come out so he could tell the changes he wanted in his meal and fill up the water pitcher. He continued, that time MA A approached and asked him why he was waiting there. He stated he explained to her the reason why he was there. He stated, at that time she rudely told him he had to get his meal changes in by 3:00 PM and asked him not to stand at the door, instead walk around the corner and fill up the water pitcher. He said he asked for her name and instead of telling her name, asked him to look at her name tag and read. He stated he felt humiliated in front of others and did not want to go to the dining hall anymore . He stated he reported this to the ADON and decided to move out of the facility as he believed the staff at the facility were not treating him with dignity and respect . He also stated he was afraid MA A would do something with his food from the kitchen, as retaliation for complaining. During an interview over the phone on 08/07/24 at 1:30 PM, MA A stated she worked as a med aide for more than 30 years and was working at the facility for about a year. She stated she would never do anything that would harm any resident. She stated on 08/02/24 in the evening she was helping Resident #1 however her actions were misinterpreted. MA A said she was on suspension after the incident until the facility investigation was completed, however she decided to resign as she felt the facility did not have a stable policy. She stated she was following the facility's policy that no meal changes were allowed after 3:00 PM, however after the incident the facility changed their stand and blamed her for her actions. She stated some people thought she was rude due to her English. She added, she was from a different ethnicity and had a think English accent. MA A said she used hearing aids and sometimes it was difficult to hear and understand what others said. During an interview, over the phone on 08/07/24 at 2:00 PM, CNA C stated he went to throw trash at the dumpster and when he walked in through the door, he heard the resident asking MA A's name. CNA C said he heard MA A stated she didn't need to tell her name to residents, instead he could look at her name badge and read if he wanted. CNA C said MA A was rude and argumentative with Resident #1. The resident appeared upset and walked off. CNA C stated he did not know what they were talking about before then or why the resident asked for her name. CNA C stated MA A did not use any abusive or derogatory words; however, she was unpolite in her conversation and not helpful in her actions. During an interview on 08/07/24 at 2:30 PM, MA B stated she was present in the dining room when the incident occurred and Resident #1 asked MA A something at the dining room door. MA B said the only thing she heard was MA A telling the resident where the water station in his hall was. She said, when Resident #1 asked if could go to the hall close to the dining hall for filling his water pitcher, MA A asked him to go to his hallway and fill the water. MA B stated MA A could be stubborn and sometimes got into arguments with the residents. During an interview on 08/07/24 at 3:00 PM with the ADON, she stated at about 6:00 PM Resident #1 approached her to report MA A was very unkind with him when he asked for help. She stated, Resident #1 was visibly upset about it. The ADON stated there was no such rule stated that residents must let the dietary team know any meal changes before 3:00 PM. She said residents could request for a meal change anytime they wanted, and residents were free to collect drinking water from any hall. She stated ideally the staff ensured regular supply of water in residents' rooms, however some residents occasionally liked to collect it personally as well. The ADON stated MA A was under suspension until the facility investigation on the incident was completed. During an interview on 08/07/24 at 3:00 pm, the ADM stated the incident was under investigation and MA A was suspended until the investigation was completed. She stated the expectation from all the staff was treating every individual at the facility with dignity, respect and empathy. She stated any violation to this would never be tolerated and the facility was committed to ensure this policy was implemented. Record review of the policy Social Services Policies and Procedures: Resident Rights revised on 06/09/2023, reflected: The Facility employs measures to ensure patient and resident personal dignity, well-being, and self-determination are maintained and will educate patients and residents regarding their rights and responsibilities . The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes.

**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 was free of accident hazards for 1 of 7 residents (Resident #15) reviewed for accidents. The facility failed to ensure staff did not hand Resident #15 a cup of hot coffee and two sweetener packets while his hands were full or offered to assist him, leading to Resident #15 spilling the coffee on his leg (with no injury). This failure placed residents at risk of burns and embarrassment. Findings included: Review of the updated face sheet for Resident #15 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cellulitis (skin infection) of right lower limb, abnormalities of gait and mobility, muscle weakness, pain in right shoulder, lack of coordination, acquired absence of left leg above knee, age-related cognitive decline, dizziness and giddiness (feeling of being unbalanced or lightheaded), chronic pain, muscle wasting and atrophy, peripheral vascular disease (abnormal narrowing of arteries to the limbs which makes the healing of wounds in those areas more difficult), non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of muscle, and cognitive communication deficit (communication problems stemming from cognitive impairment). Review of the quarterly MDS assessment for Resident #52 dated 11/14/23 reflected a BIMS score of 12, indicating a moderate cognitive impairment. The section titled Functional Abilities and Goals reflected he required set-up or clean-up assistance in the activity of eating, which was defined as the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Review of the care plan for Resident #15 dated 10/20/23 reflected the following: (Resident #52) requires assistance with ADL's r/t AKA. Will maintain a sense of dignity by being clean, dry, odor free and well groomed over next 90 days. EATING: Assist of set up. Review of nursing progress notes for Resident #1 reflected the following: 11/29/2023 08:30 AM by DON Charge Nurse reported that resident spilled coffee this morning on his lap. She advised she had assessed and no areas of concern was noted. This nurse and (Nurse Practitioner) assessed approximately 20 min after. Spill occurred to LLE, Resident had compression sleeve and pants on. Clothing removed and skin assessed, no open areas, redness or swelling noted. Resident denies pain. Provider advised resident to notify nursing if skin concerns or pain arise. 11/30/2023 03:21 PM by LVN D Resident denies pain to LLE where resident spilled coffee. Compression sleeve removed and skin assessed no signs of burn or irritation to area and is wnl for resident. Review of a skin assessment for Resident #52 dated 11/29/23 at 08:42 AM reflected the following: Resident assessed post coffee spill. No open areas, redness, or swelling. Observation n 11/29/23 at 08:05 AM revealed Resident #52, who had an above-knee amputation of his left leg, self-ambulated in his wheelchair to the meal cart from which staff were delivering meal trays to the hall where he lived. He asked for coffee and said he did not get any coffee. Resident #52 was holding five bagged newspapers with his left hand by the tops of their plastic bags, and the ADON poured a cup of coffee from a small urn into a plastic mug with no lid and handed it to him. He accepted the cup of coffee with his right hand and asked for two sugars. Resident #52 moved the mug of coffee into his left hand, which was still holding the newspaper bags, and CNA K handed him two packets of sweetener, which he accepted with his right hand and placed into his left hand. His left hand was still holding the newspaper bags and the mug of coffee, and he struggled to balance the items, but was able to hold them all in his left hand and ambulated his electric wheelchair with his right hand to the door of another resident's room. Resident #52 began to move his coffee into his right hand, some spilled from the mug onto his left leg, and he cried out, oh! During an interview at this time, Resident #52 stated, yes it hurt, it's hot coffee! The ADON stated to Resident #52 she would check his leg shortly. During an interview on 11/30/23 at 08:20 AM, Resident #52 stated he had no injury on his leg or anywhere else. He stated the coffee stung for one second when it spilled but it did not hurt for long and did not injure him. During an interview on 11/30/23 at 08:39 AM, the ADON stated Resident #52 wanted something to do so he volunteered to pass out newspapers to the residents who had subscriptions. The ADON stated Resident #52 liked his coffee, and the morning of 11/29/23 he came to the meal cart and asked for it. The ADON stated she poured the coffee and gave it to Resident #52. The ADON stated Resident #52 asked for sugar, and one of the aides handed him the sugar. The ADON stated, as Resident #52 was delivering a newspaper to another resident, he spilled a little coffee on his leg. The ADON stated Resident #52 wore a compression sleeve on his left leg after his amputation, and the coffee did not burn him through the sleeve. The ADON stated they had the Nurse Practitioner come look at him, and he had no burns no redness. The ADON stated she saw Resident #52 daily and thought the coffee spilled because of the way he had been holding he newspapers. She stated normally, he was still in bed at that hour and would have his coffee on his overbed table in bed. The ADON stated Resident #52 could have been burned by the coffee, had he not been wearing a compression sleeve. Observation on 11/30/23 at 12:28 PM revealed the RD took the temperature of coffee in the coffee urn on the meal cart for Resident #52's hall, and it measured at 163.1 degrees. The coffee cups on the cart were being served with lids. During an interview on 11/30/23 at 03:39 PM, the DON stated she had not done specific training on safety with hot liquids. The DON stated she was not sure what the temperature should have been of the coffee, but she thought it was lower than the temperature of coffee in a regular coffee pot at home. She stated the failure could have had a range of adverse effects; it could have caused embarrassment, burns, and possible scarring. During an interview on 11/30/23 at 04:48 PM, the Administrator stated she would say everyone was responsible for preventing accidents in the resident population. She stated coffee should have been served with a lid on it to prevent burns. The Administrator stated it did not mean the resident could not drop the coffee and get burned, but it helped with prevention. The Administrator stated she had been told Resident #52 had newspapers in his hand and asked for coffee. The Administrator stated she would have either taken the newspapers and held them while serving the resident coffee or brought the coffee to his room for him. The Administrator stated Resident #52 was very independent and did not like a lot of help, but someone should have made sure he had the help he needed. The Administrator stated a potential outcome was that Resident #52 could have been burned. She stated there had been no harm to Resident #52, but it could have caused a burn. Review of facility policy dated 11/01/17 and titled Accidents/Incidents reporting reflected the following: The facility's leadership will follow the established guidelines for the reporting of accidents and incidents. In the event of a state, reportable incident, the facilities leadership will notify the state regulatory agency, according to applicable law and regulation. . An accident is an unexpected, unintended event that can result in bodily injury.

**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 incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of two residents reviewed for quality of care (Resident #88). The facility failed to ensure Resident #88's catheter was secured to his body with a catheter secure device. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections. Findings Included: Review of Resident #88's undated face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses including cerebral infarction (stroke), urinary tract infection, retention of urine, vitamin deficiency, dysphagia (difficulty swallowing food or fluids), type 2 diabetes mellitus (abnormal blood sugar levels), and gastrostomy status (presence of a tube into the stomach to provide nutrition). Review of Resident #88's 5-day MDS assessment dated [DATE] reflected he had no speech and rarely/never understands. He was assessed as being dependent for ADL care and had an indwelling urinary catheter. Review of Resident #88's care plan initiated 10/20/23 reflected the problem Resident has catheter and is at risk for increased UTIs. Approaches included catheter care per order, change catheter, tubing and bag per order, keep tubing/bag below the bladder do not kink tubing, and monitor urine and report abnormals. The care plan did not reflect a catheter leg strap or stabilization device. Review of Resident #88's physician orders dated 10/23/23 reflected, indwelling catheter 16fr (the size of the catheter), 10 cc (the amount of saline in the balloon holding the catheter in the bladder) for sacral pressure wound, and catheter leg strap in place - to secure catheter and facilitated flow of urine. Observation on 11/29/23 at 9:31 AM revealed Resident #88 in room in bed. Resident #88 had a urinary catheter in place without a device to secure the catheter to his leg. Observation and interview on 11/29/23 at 1:43 PM revealed Resident #88 in room in bed. Observation with LVN E revealed the resident had no catheter secure device in place. LVN E stated the resident should have had a catheter secure device in place. She stated the resident had a device in place earlier when she checked. LVN E stated without a device in place, the catheter could be tugged or pulled out. During an interview on 11/30/23 at 3:57 PM, the DON stated a catheter securing device was used on residents with a physician's order. She stated it was the responsibility of the nurse to ensure the device was intact and properly positioned. Review of the facility's policy titled Catheter - Urinary Catheter, Cleaning and Maintenance reflected, Lippincott Nursing Procedures 9th Ed., pages 432-435. Review of Lippincott Nursing Procedures 9th Ed. Pages 432-435 reflected in part: Make sure the catheter is properly secured. Assess the securement device daily, and change it when clinically indicated and as recommended by the manufacturer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adequately equip all residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 8 (Resident #56) residents reviewed for call light function. The facility failed to ensure Resident #56 had a functioning call light. This placed Resident #56 at risk of not having her needs met. Findings included: A record review of Resident #56's undated face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of fracture of unspecified part of neck of right femur, Parkinson's disease (problems with movement, balance and coordination), muscle wasting and atrophy (muscle loss), history of falling, weakness, unspecified abnormalities of gait and mobility and anxiety disorder. A record review of Resident #56's MDS assessment dated [DATE] reflected a BIMS score of 11, which indicated moderately impaired cognition. Resident #56's MDS assessment reflected she required substantial assistance with going from lying to sitting on the side of her bed. A record review of Resident #56's care plan last revised on 11/21/2023 reflected she required assistance with ADLs, was at risk for falls, and staff were to encourage her to use her call light for assistance. During an observation and interview on 11/28/2023 at 12:10 p.m., Resident #56 was observed lying in bed. Resident #56 stated the call light took a long time sometimes and it's been an ongoing issue with her call light not working. Resident #56 had a call light which also worked as a TV and bed control. Observed Resident #56 press her call light three times and it did not illuminate on her wall or outside her door. On the fourth try, Resident #56's call light turned on and LVN F walked in. LVN F stated she had not known Resident #56's call light to not work. LVN F then observed Resident #56 press the call light, LVN F observed it to not work, and so LVN F placed a new call button at Resident #56's bedside. During an observation and interview on 11/29/2023 at 9:30 a.m., Resident #56 stated she had tried using her call light that morning, and it did not work. Observed two call lights plugged in to Resident #56's wall and at her bedside-one was the TV remote call light and the other was a soft circular push device. Observed Resident #56 push her TV remote call light twice and the light did not illuminate on the wall or outside her room. Resident #56 then pressed the soft circular call light three times, and it came on the third time. During an interview on 11/29/2023 at 9:30 a.m., CNA J entered Resident #56's room and stated the squishy call light was easier for Resident #56 to press. CNA J stated Resident #56 had two call lights because she had been having a hard time with the TV call light. During an interview and observation on 11/30/2023 at 10:23 a.m., MA H entered Resident #56's room. Resident #56 was lying in bed, and she pressed her TV remote call light. MA H stated yes she could hear the call button click and no it did not illuminate on the wall or outside her door. MA H stated, that's strange and. Resident #56 then squeezed her circular call light and MA HA stated yes Resident #56 gave it a hard squeeze. MA H observed it had not illuminated the light on the wall nor outside Resident #56's door. MA H stated, I'll have to put that in our book. During an interview on 11/30/2023 at 10:46 a.m., the Maintenance Director stated he had worked at the facility for ten years. The Maintenance Director stated anyone that worked there could put in a maintenance request in the book. The Maintenance Director stated he checked the maintenance log every day. When asked who was responsible for ensuring call lights functioned, the Maintenance Director stated, if it's messed up, nursing will report it to him. The Maintenance Director stated checking for call light function was not part of his everyday monitoring. The Maintenance Director stated he fixed them when nursing identified it as an issue. The Maintenance Director stated someone from therapy had communicated to him verbally on Monday 11/27/2023 that Resident #56's call light did not work. During an observation and interview on 11/30/2023 at 11:23 a.m., Resident #56 was lying in bed. Resident #56 stated she had probably mentioned to staff that her call light did not work but she was not sure. During an interview on 11/30/2023 at 12:32 p.m., the Maintenance Director stated he only put maintenance requests in the book if he did not have time to address the issue right way. With Resident #56, he stated he checked her call light on Monday 11/27/2023 and it worked. The Maintenance Director stated he checked it Tuesday 11/28/2023 and Wednesday 11/29/2023, and it worked then as well. During an interview on 11/30/2023 at 3:48 p.m., the DON stated the facility's policy on call lights were that the needed to function 100% and that they press it, and it works. The DON stated there would be times when there were technical issues, but residents should always have a means to call for assistance. The DON stated once the issue was identified, it should have been rectified, or the resident should have been moved to a different room. The DON stated nursing did not monitor call lights for function and I assume it would be maintenance. The DON stated if staff or residents should report issues to maintenance. The DON stated there was a maintenance binder at each nurses' station where concerns should have been placed. The DON stated at the present point in time, Resident #56 had a touch pad call light and there were no issues. The DON stated she believed Resident #56 had trouble pressing the inflated circular call light. The DON stated if a resident's call light did not work, they would not get their need met. The DON stated she first became aware of Resident #56's call light not working on Tuesday 11/28/2023 when it was brought to her attention by an HHSC surveyor. The DON stated she could have put in an alternate call light system for Resident #56 and she had not done so yet since she observed Resident #56's call light to be working. During an interview on 11/30/2023 at 4:48 p.m., the Administrator stated she expected call lights to function and if something was mechanically wrong, she expected it to get fixed. The Administrator stated they usually did a room move until the call light issue was fixed. The Administrator stated monitoring for call light function should be part of the Maintenance Director's preventative maintenance. The Administrator stated the Maintenance Director did random checks of call lights and if staff noticed they were not working, they would report it to the Maintenance Director. The Administrator stated she liked for staff to put the maintenance concerns in the book but sometimes they would call or text the Maintenance Director. The Administrator stated, with an intermittently functioning call light, her needs wouldn't be met if she didn't have a call light. A record review of the facility's maintenance log dated 11/07/2023-11/29/2023 reflected no entry for Resident #56's call light. A record review of the facility's policy titled RESIDENT ROOM - ENVIRONMENTAL dated 11/01/2017 reflected the following: POLICY: The Facility provides the patient/resident with an environment that preserves dignity, privacy and contributes to a positive self-image. Resident rooms are designed and equipped for adequate nursing care comfort and privacy of residents. Promoting and preserving resident independence and self-sufficiency should be considered when arranging the resident living space. PROCEDURES: 8. The facility must be adequately equipped to allow residents to call for staff assistance at each resident bedside, bathing and toileting areas through a communication system which relays the call directly to a staff member or to a centralized staff work area. A. All portions of the system must be functioning, which means: 1) The system must be turned on, 2) The volume must remain at a level that can be heard, 3) The lights above the rooms must be working, 4) There must be staff at the nursing station or with- in hearing distance of the system. B. Adaptations should be considered as needed for resident's abilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 19 residents (Resident #85, #90, #92, #297) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #85 and Resident #90's Comprehensive Care plan reflected a care plan for post-traumatic stress disorder. 2. The facility failed to ensure Resident #92's Comprehensive Care plan reflected Resident #92 utilized a wearable cardioverter defibrillator (a vest worn by the resident which detects and treats life-threatening rapid heart rhythms in residents at risk of sudden cardiac death). 3. The facility failed to ensure Resident #297's Comprehensive Care plan reflected his communication deficits and devices used for communication. This facility placed residents at risk for unmet needs. Findings include: Review of Resident #85's undated face sheet, printed 11/28/23, reflected a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses of anxiety disorder, stroke (bleeding in the brain) that caused paralysis on the right side, and post-traumatic stress disorder. Review of Resident #85's Quarterly MDS assessment, dated 10/18/23, reflected that Resident #85 had a BIMS of 9, which indicated moderately impaired cognition. Review of the MDS did not reveal documentation regarding behaviors. Review of Resident #85's care plan, dated 09/25/23, reflected no care plan for post-traumatic stress disorder. Review of Resident #90's face sheet, undated, printed 11/28/23, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses of acute respiratory failure (not enough oxygen getting to the body), depression, diabetes, and chronic kidney disease. Review of Resident #90's admission MDS , dated 10/03/23, reflected Resident #90 had a BIMS of 14, which indicated intact cognition. Section I - Active Diagnoses of the MDS reflected that Resident #90 was marked as being diagnosed with post-traumatic stress disorder. Review of the MDS did not reveal documentation regarding behaviors. Review of Resident #90's care plan, dated 09/29/23, reflected no care plan for post-traumatic stress disorder. Review of Resident #92's 5-day MDS assessment, dated 10/31/23, reflected a [AGE] year-old male who was admitted on [DATE] with diagnoses of acute and subacute infective endocarditis (an infection of the inner lining and valves of the heart), presence of heart assistive device, essential hypertension (high blood pressure), heart failure, and bacteremia (bacteria present in the blood). The assessment reflected Resident #92 had a BIMS score of 14, which indicated intact cognition. Review of Resident #92's Care Plan, dated 10/29/23, reflected interventions for ADL assistance, dehydration risk, fall risk, and pain management. The care plan did not reflect the wearable cardioverter defibrillator. Review of Resident #92's physician's orders, dated 10/29/23, reflected Special Instructions: (Brand name) wearable cardioverter defibrillator instructions 1. Replace battery daily with fully charged battery and place other battery to charge 2. Never hit the response button 3. May remove vest for showering only but immediately place once dry 4. If Blue gel is observed on patient or 2 tone siren is alarming, do not touch the resident and call provider STAT. Observation and interview on 11/30/23 at 9:06 AM with Resident #92 revealed he was sitting up on the edge of the bed wearing a cardioverter defibrillator vest. A battery charger with an extra battery was observed on the nightstand. Resident #92 stated his implanted defibrillator had been removed due to an infection and he had to wear the vest until the infection resolved and the heart doctor thought it was safe to replace the internal device. He stated he wore the vest at all times except when he showered. He stated the nursing staff help him to change the battery daily. Review of Resident #297's MDS assessment, dated 11/10/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Section C of his MDS reflected that he had a BIMS of 14, which indicated intact cognition. Section B - Hearing, Speech, and Vision reflected that Resident #297 was Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time. Review of Resident #297's care plan, dated 11/6/23, reflected that he had a primary diagnosis of ALS (a progressive disease that affects nerve cells in the brain and spinal cord) and other diagnosis' including cognitive communication deficit, dysphagia and an age-related physical debility. The care plan did not reveal evidence of documentation regarding his communication deficit or communication devices he used to communicate. Review of Resident #297's Inventory Sheet, signed 11/4/2023, reflected ARTICLES RETAINED BY PATIENT .Tablet + Charger, Phone + Charger. During an observation and attempted interview on 11/28/23 at around 9:00 AM, Resident #297 was observed in his room, in bed. Resident #297 waved, then began to point behind him. A tablet-like device and cell phone were observed on a small dresser behind him; another tablet-like device was attached to the right side of his bed. Resident #297 was asked if he would like his phone and he nodded, Yes. A nearby CMA was alerted, who sanitized his hands, knocked and entered the room. The CMA grabbed Resident #297's phone and realized it needed to be charged. Resident #297 nodded, Yes, agreeing to continue the interview at another time. A follow-up interview was attempted on 11/30/23 at 10:07 AM with Resident #297, however, he stated he did not want to answer any questions. During an interview on 11/29/23 at 9:53 AM CNA L stated she worked at the facility for about 7 months. She stated she was familiar with Resident #297, adding that he communicated using a tablet or a phone; she stated there was also a tablet attached to his bed that he used to communicate. She stated Resident #297 used gestures as well to communicate his needs, for example, by rubbing his stomach if he was not feeling well. During an interview on 11/29/23 at 10:26 AM, CNA M stated she worked at the facility for 4.5 years and was familiar with Resident #297. She stated Resident #297 used his tablet and other devices to communicate. She stated upon rounds every 2-hours or when she responded to his call light, Resident #297 would use these devices to communicate his needs. She stated he could also answer yes/no questions. She stated he was a new admission and had the devices upon admission. During an interview on 11/30/23 at 10:30 AM, the DON stated that failure to care plan for post-traumatic stress disorder could have led to increased symptoms and missing triggers for Resident #85 and Resident #90 which could resulted in the residents not achieving their highest functional level. She stated care plans were the responsibility of the MDS nurse who was relatively new to the position. During an interview on 11/30/23 at 10:30 AM, the NP and the DON stated that Residents #85 and #90 were also in the care of the VA and records were difficult to obtain and it could be a slow process, but the DON was going to reach out again. During an interview on 11/30/23 at 11:34 AM, LVN E stated the battery for Residents #92's defibrillator vest was changed each day. The used battery was placed on the charger and charged overnight. She stated he wore the vest all the time except while he showered. She stated, after he showered, he had to dry off completely before he replaced the vest. During an interview on 11/30/23 at 10:41 AM, RN A stated he worked at the facility for approximately 1 month. He stated he communicated with Resident #297 using yes/no questions. He stated at other times, he observed Resident #297 use a tablet to communicate or Resident #297 has texted or wrote his needs, questions or concerns in his phone. During an interview on 11/30/23 at 4:17 PM, MDS LVN B stated, she was responsible for MDS assessments and care plans for the short-term residents at the facility. She stated she had been getting help with MDS assessments from traveling nurses. She stated she recently found out the traveling nurses had not completed all the care plans. She stated the care plan was due seven days after the assessment was completed, no later than day 21. She stated a wearable cardioverter defibrillator should be on the care plan . She stated accurate care plans ensured residents received the needed care. During an interview on 11/30/23 at approximately 4:15 PM, MDS LVN C stated she oversaw completing MDS assessments and care plans for long-term residents at the facility. She stated if a resident had impaired communication and used devices to communicate, this should be documented in their care plan. She stated depending on what was assessed for the resident, the social worker or nurse could also put information in care plans. She stated if the information was not present in a care plan, it was likely that that care area did not get relayed to the right department. She stated despite floor nurses having knowledge of how Resident #297 communicated, this information should have been in his care plan. During an interview on 11/30/23 at approximately 3:55 PM, the DON stated she had not provided any in-services specific to the wearable cardioverter defibrillator. She stated the device should have been on the care plan but all the things you needed to look for were in the order. During the interview, the DON stated if a resident had communication deficits, or used communication devices, this would be reflected in the care plan. She stated putting this information into a care plan was the MDS nurse's responsibility. She stated upon admission, Resident #297 was accompanied by his tablet and phone. She stated Resident #297 primarily used these devices to communicate in addition to pointing, head-nodding, and making noises; she added that he is good at communicating. She stated CNAs could access resident information, including information on how the resident communicated by accessing their POC system. She stated nurses could access resident care plans where communication information should be reflected. During an interview on 11/30/23 at 4:45 PM, the Administrator stated during QAPI meetings they looked at CASPER reports and talked about the MDSs and anything that needed to be care planned. She stated she expected to see the wearable cardioverter defibrillator on the care plan. She stated if a problem was not identified, the resident would not get the needed care. She stated, Everything needed to be on the care plan. Review of facility policy, titled Care Plan Process, Person-Centered Care, last revised 5/5/2023, reflected the following: The facility will develop and implement a . comprehensive care plan for each resident that includes instructions needed to provide effective and person-centered care for the resident that meet professional quality of care . Person-centered care includes trying to understand what each resident is communicating . and understanding the resident's life before coming to reside in the nursing home . The person-centered care plan includes: A. Date B. Problem C. Resident goals for admission and desired outcomes D. Time frames for achievement E. Interventions, discipline specific services, and frequency F. Refusal of services and/or treatments 1. Evaluation of resident's decision-making capacity 2. Educational attempts 3. Attempts to find alternative means to address the identified risk/need G. Discharge plans 1. Resident's preferences and potential for future discharge 2. Resident's desire to return to the community and any referrals to local contact agencies and/or other appropriate entities, for this purpose. H. Resolution/Goal Analysis

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 6.82 % based on 3 errors out of 44 opportunities, which involved 3 of 4 residents (Resident #88, Resident #57 and Resident #351) reviewed for pharmacy services. 1. LVN E administered multivitamin with minerals instead of the ordered multivitamins with folic acid to Resident #88. 2. MA G administered calcium carbonate 500 mg instead of the ordered calcium carbonate-vitamin D3 500 mg-5 mcg to Resident #57. 3. MA G administered calcium carbonate 500 mg instead of the ordered calcium carbonate 600 mg to Resident #351. These failures could affect residents and put them at risk for not receiving the intended therapeutic benefit of their medication and or adverse outcomes. The findings included: Resident #88 Review of Resident #88's undated face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses including cerebral infarction (stroke), urinary tract infection, retention of urine, vitamin deficiency, dysphagia (difficulty swallowing food or fluids), type 2 diabetes mellitus (abnormal blood sugar levels), and gastrostomy status (presence of a tube into the stomach to provide nutrition). Review of Resident #88's 5-day MDS assessment dated [DATE] reflected he had no speech and rarely/never understands. He was assessed as being dependent for ADL care and had an indwelling urinary catheter. Review of Resident #88's physician order dated 11/07/23 reflected, Tab-A-Vite (multivitamin with folic acid) tablet; 400 mcg, amt:1; gastric tube once a day. Observation on 11/29/23 at 7:25 AM revealed, LVN E prepared for administration of medications to Resident #88. LVN E retrieved a multivitamin with minerals tablet and placed it in a medication cup. LVN E placed the other 8 medications into individual medication cups. LVN crushed each medication individually and returned the crushed medication to the cup. LVN E gathered all the med cups and entered Resident #57's room. LVN E administered the medications individually through the gastrostomy tube. Resident #57 Review of Resident #57's undated face sheet reflected a[AGE] year-old female admitted on [DATE] with diagnoses including mild intellectual disabilities, atherosclerotic heart disease (the arteries of the heart are thick and stiff), hypertension (high blood pressure), vitamin deficiency unspecified, hyperlipidemia (high levels of fat in the blood), acute kidney failure, and vascular dementia (dementia caused by impaired blood flow to the brain). Review of Resident #57's quarterly MDS dated [DATE] reflected a BIMS score of 14 indicting intact cognition. Review of Resident #57's physician order dated 07/08/23 reflected, Calcium carbonate-vitamin D3 tablet; 500 mg-5 mcg (200 unit); amt:1 tablet; oral once a day. Observation on 11/29/23 at 8:06 AM revealed, MA G prepared for administration of medications to Resident #57. MA G retrieved a Calcium Carbonate 500 mg chewable tablet and placed it in a medication cup. MA G prepared 10 other oral medications and a nasal spray then walked into Resident #57's room. MA G administered all the medications. Resident #351 Review of Resident #351's undated face sheet reflected an [AGE] year-old female admitted to the facility 11/17/23 with diagnoses including diabetes mellitus with hyperglycemia (abnormal blood sugar levels), hypertension (high blood pressure), atherosclerotic heart disease (the arteries of the heart are thick and stiff), fracture of superior rim of left pubis (the lower front part of the hip bone), fracture of unspecified parts of lumbosacral spine and pelvis, and vitamin deficiency unspecified. Review of Resident #351's admission MDS assessment dated [DATE] reflected a BIMS [NAME] of 13 indicating intact cognition. Review of Resident #351's physician order dated 11/17/23 reflected, Calcium carbonate; 600mg calcium (1,500mg); amt: 1 tablet; oral once a day. Observation on 11/29/23 at 8:24 AM revealed, MA G prepared for administration of medications to Resident #351. MA G retrieved a Calcium Carbonate 500 mg chewable tablet and placed it in a medication cup. MA G prepared and gathered 14 other oral medications, eye drops, and topical patches then walked into Resident #351's room. MA G administered all the medications. During an interview on 11/29/23 at 1:43 PM with LVN E, she confirmed the order for Resident #88 was for multivitamin with folic acid. After LVN E reviewed the ingredients on the bottle of multivitamins with minerals she confirmed folic acid was not listed in the ingredients. She stated she had just missed it when she administered the medication. She stated giving the wrong medication could prevent the resident from getting the desired effect. During an interview on 11/29/23 at 1:54 PM the DON stated she would notify the provider about the medication errors. She stated a potential adverse outcome to getting the wrong medication was, Not getting what they need. During an interview on 11/30/23 at 8:46 AM the ADON stated calcium carbonate and calcium carbonate with vitamin D were two different things. She stated an adverse outcome if a resident received the wrong medication could have been lack of desired effect. During an interview on 11/30/23 at 9:26 AM with MA G, she stated there were multiple kinds of calcium she pulled several bottles out of the med cart. MA G stated she talked with a nurse before about clarification of calcium orders. She stated that she had given both Resident #57 and Resident #351 calcium carbonate 500 mg during medication administration on 11/29/23. Review of the facility's policy titled Medication Management Program revised 05/05/23 reflected in part, Preparing for the Medication Pass 4. Authorized staff must understand: D. The 8 Rights for administering medication: 1. The Right Patient/Resident 2. The right Drug 3. The right Dose . Administering the Medication Pass 6. The authorized staff member reads the label on the medication three (3) times. A. Before removing the medication from the drawer. B. Before dispensing the medication. C. After dispensing the medication.

Based on observation, interview, and record review, the facility failed to ensure storage of medications used in the facility was in accordance with currently accepted professional principles and include the appropriate expiration dates 3 of 4 medication carts (100 hall nurse cart, 200 hall nurse cart, and 300/400 hall med aide cart) reviewed for pharmacy services. -1. The facility failed to date a multi-use product (eye drops and inhalers) when the products were first opened according to manufacturer and professional standards. -2. The facility failed to ensure an expired insulin pen was removed from the medication cart. These failures could place residents at risk of not receiving the intended therapeutic effect of the medications or a contaminated medication. Findings Included: Observation on 11/29/23 at 8:51 AM revealed the 300/400 med aide cart had 2 bottles of latanoprost eye drops and 1 bottle of pilocarpine eye drops without open dates. Observation on 11/29/23 at 2:40 PM revealed the 100-hall nurse cart had a Fluticasone Propionate & Salmeterol inhaler without an open date. Observation on 11/29/23 at 2:42 PM revealed the 200-hall nurse cart had a Novolog insulin pen labeled Expires 28 days after opening, date opened 10/27/23, thus expired on 11/24/23. Observation on 11/29/23 at 2:42 PM revealed the 200-hall nurse cart with a Ventolin inhaler without an open date. During an interview on 11/29/23 at 8:53 AM, with MA G, she stated eye drop bottles should have been labeled with name and date when they were opened. During an interview on 11/29/23 at 3:45 PM., the DON stated multi-dose items should have been dated and expired medications should be removed from the medication carts. She stated the med aides and nurses were responsible for checking the expiration dates. The DON stated expired meds may not provide the desired effect. During an interview on 11/30/23 at 8:46 AM, the ADON stated the nurse or med aide labeled multi-dose items with the resident name and the date when opened. She stated insulin pens were good for 28 days once opened then needed to be discarded. During an interview on 11/30/23 at 9:35 AM, RN A stated multi-dose containers such as inhalers and insulin were dated when opened. She stated the person who opened the item was supposed to label it. If an opened undated multi-dose item was found in the med cart, it would be discarded. He stated insulin pens were good for 28 days once opened. RN A stated expired meds may not be effective. Review of the facility's policy titled Medication Management Program, revised 05/05/23 reflected in part: 7. H. Once any multi-dose packaged medication or biological is opened, nursing will mark multi-dose package with the date opened and follow guidelines for expiration dates. 15. Outdated medication is destroyed or returned to the pharmacy according to applicable state rules and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure menus were followed for 9 of 9 (Resident #8, Resident #18, Resident #24, Resident #29, Resident #46, Resident #52, Resident #60, Resident #73, Resident #91) residents reviewed for menus. 1. The facility failed to ensure CK N followed recipes when preparing pureed food items 2. The facility failed to ensure CK N served adequate portion sizes for residents on a pureed diet. These failures placed residents at risk of decreased intake, malnutrition, and weight loss. Findings included: A record review of Resident #8's face sheet dated 11/30/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease (dementia), hypertension (high blood pressure), neuralgia (nerve pain), deficiency of other vitamins, unspecified severe protein-calorie malnutrition, stage 2 pressure ulcer of sacral region, cachexia (unintentional weight loss), and dysphagia (difficulty swallowing). A record review of Resident #8's MDS assessment dated [DATE] reflected a BIMS score of 10, which indicated moderately impaired cognition. Resident #8's MDS assessment reflected she was on a mechanically altered diet. A record review of Resident #8's care plan last revised on 11/08/2023 reflected she was at risk for malnutrition. A record review of Resident #8's physician orders reflected an order dated 11/09/2023 for a pureed diet. A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #8 had not had significant weight loss in the past six months. A record review of Resident #18's face sheet dated 11/30/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Parkinson's disease, muscle wasting and atrophy (muscle loss), abnormal weight loss, hypertension (high blood pressure), hyperlipidemia (high cholesterol), and cerebral infarction (stroke). A record review of Resident #18's MDS assessment dated [DATE] reflected she was not assessed for BIMS due to rarely/never being understood. Resident #18's MDS assessment reflected she was on a mechanically altered diet. A record review of Resident #18's care plan last revised on 10/25/2023 reflected she was at risk for malnutrition. A record review of Resident #18's physician orders reflected an order dated 4/22/2023 for a pureed diet. A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #18 had not had significant weight loss in the past six months. A record review of Resident #24's face sheet dated 11/30/2023 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of cerebral infarction (stroke), stage 2 pressure ulcer of right heel, dysphagia (difficulty swallowing), muscle wasting and atrophy (muscle loss), hypertension (high blood pressure), vitamin deficiency, and history of nutritional and metabolic disease. A record review of Resident #24's MDS assessment dated [DATE] reflected a BIMS score of 11, which indicated moderately impaired cognition. Resident #24's MDS assessment reflected she was on a mechanically altered diet. A record review of Resident #24's care plan last revised on 10/30/2032 reflected she was at risk for malnutrition and received hospice services for her terminal illness of dementia. A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #24 had significant weight loss of 7.5% in 90 days. Resident #24 went from 135.2 lbs. on 8/01/2023 to 125 lbs. on 11/01/2023. A record review of Resident #29's face sheet dated 11/30/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of cerebral infarction (stroke), dysphagia (difficulty swallowing), muscle wasting and atrophy (muscles loss), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). A record review of Resident #29's MDS assessment dated [DATE] reflected a BIMS score of 9, which indicated moderately impaired cognition. Resident #29's MDS assessment reflected he was on a mechanically altered diet. A record review of Resident #29's care plan last revised on 10/20/2023 reflected he was at risk for malnutrition. A record review of Resident #29's physician orders reflected an order dated 8/03/2023 for a pureed diet. A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #29 had not had significant weight loss in the past six months. A record review of Resident #46's face sheet dated 11/30/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral infarction (stroke), hypertension (high blood pressure), hyperlipidemia (high cholesterol), nutritional deficiency, and dysphagia (difficulty swallowing). A record review of Resident #46's MDS assessment dated [DATE] reflected a BIMS score of 10, which indicated moderately impaired cognition. Resident #46's MDS assessment reflected she was on a mechanically altered diet. A record review of Resident #46's care plan last revised on 10/10/2023 reflected she was at risk for malnutrition. A record review of Resident #46's physician orders reflected an order dated 8/20/2021 for a pureed diet. A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #46 had not had significant weight loss in the past six months. A record review of Resident #52's face sheet dated 11/30/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of vascular dementia (dementia due to cerebral vascular disease), dysphagia (difficulty swallowing), hypertension (high blood pressure), anemia (deficiency of healthy red blood cells), hyperlipidemia (high cholesterol), and disorder of mineral metabolism. A record review of Resident #52's MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severely impaired cognition. Resident #52's MDS assessment reflected he was on a mechanically altered diet. A record review of Resident #52's care plan last revised on 11/08/2023 reflected he was at risk for malnutrition and received hospice services for sequela (pathological condition resulting from a prior disease) of cerebral infarction. A record review of Resident #52's physician orders reflected an order dated 11/08/2023 for a pureed diet. A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #52 had a severe weight loss of 9.4% in 90 days. Resident #52's weight went from 172 lbs. on 9/08/2023 to 155.7 lbs. on 11/01/2023. A record review of Resident #60's face sheet dated 11/30/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of dysphagia (difficulty swallowing), abnormal weight loss, hypertension (high blood pressure), hyperlipidemia (high cholesterol), unspecified dementia and repeated falls. A record review of Resident #60's MDS assessment dated [DATE] reflected a BIMS score of 7, which indicated moderately impaired cognition. Resident #60's MDS assessment reflected he was on a mechanically altered diet. A record review of Resident #60's MDS assessment dated [DATE] reflected he was not assessed for BIMS. A record review of Resident #60's care plan last revised on 10/31/2023 reflected he was at risk for malnutrition. A record review of Resident #60's physician orders reflected an order dated 10/05/2023 for a pureed diet. A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #60 had not had significant weight loss in the past six months. A record review of Resident #73's face sheet dated 11/30/2023 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of abnormal weight loss, Alzheimer's disease (type of dementia), hyperlipidemia (high cholesterol), and dysphagia (difficulty swallowing). A record review of Resident #73's MDS assessment dated [DATE] reflected a BIMS score of 7, which indicated moderately impaired cognition. Resident #73's MDS assessment reflected she was on a mechanically altered diet. A record review of Resident #73's care plan last revised on 11/28/2023 reflected she was at risk for malnutrition. A record review of Resident #73's physician orders reflected an order dated 8/16/2023 for a pureed diet A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #73 had not had significant weight loss in the past six months. A record review of Resident #91's face sheet dated 11/30/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of gastric ulcer, dysphagia (difficulty swallowing), muscle wasting and atrophy (muscles loss), hypertension (high blood pressure), moderate protein0calorie malnutrition, hyperlipidemia (high cholesterol) and gastro-esophageal reflux disease (acid reflux). A record review of Resident #91's MDS assessment dated [DATE] reflected a BIMS score of 14, which indicated minimally impaired cognition. This assessment also reflected Resident #91 received artificial nutrition. Resident #91's MDS assessment reflected he was on a mechanically altered diet. A record review of Resident #91's care plan last revised on 11/01/2023 reflected he was at risk for malnutrition and received artificial nutrition (Delivery of a patient's nutritional support without requiring the patient to chew and swallow). A record review of Resident #91's physician orders reflected an order dated 11/13/2023 for a pureed diet. Resident #91's order dated 10/26/2023 reflected he received enteral feedings (intake of food via the gastrointestinal tract). A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #91 had not had significant weight loss in the past six months. An observation on 11/28/2023 at 9:11 a.m. revealed Resident #18 was sitting in her bed. Resident #18 did not respond when spoken to by name. An observation on 11/28/2023 at 9:24 a.m. revealed Resident #52 was lying in bed. Resident #52 was non-interviewable. During an interview an observation on 11/28/2023 at 9:40 a.m., Resident #91 was observed lying in bed with his tube feeding connected. Resident #91 stated staff changed the dressing around his tube regularly. During an observation and interview on 11/28/2023 at 9:55 a.m., Resident #29 was observed sitting in his room and he said his breakfast was good. An observation on 11/28/2023 at 9:56 a.m. revealed Resident #60 was lying in his bed. Resident #60 was unable to be interviewed. During an observation and interview on 11/28/2023 at 11:29 a.m., Resident #46 was observed to be comfortable, and she stated she had no concerns. An observation on 11/28/2023 at 12:31 p.m. revealed Resident #73 was eating without assistance. Resident #73 was unable to be interviewed. During an observation and interview on 11/29/2023 at 8:57 a.m., Resident #24 was observed lying in bed. Resident #24 voiced no concerns but said she was a little hungry. During an observation and interview on 11/29/2023 at 10:03 a.m., Resident #8 was observed in the activity room. Resident #8 stated she stayed in the activity room most of the day. During an interview on 11/28/2023 at 10:13 a.m., CK N stated she started as a dietary aide 4-5 months prior and was promoted to cook 2-3 months ago. An observation of puree preparation on 11/28/2023 at 10:20 a.m. revealed CK N prepared pureed ham by adding six half cup measurements of mashed potatoes to the ham inside the food processor. During an interview on 11/28/2023 at 10:21 a.m., CK N stated she had added 1.5 lb. of ham to puree. CK O stated, you want it to look like pink mashed potatoes. During an interview on 11/28/2023 at 10:25 a.m., CK O stated adding mashed potatoes to the puree added flavor, nutrition, and it helps it puree. CK O stated, you just can't over do it with the mashed potatoes. During an interview on 11/28/2023 at 10:27 a.m., CK N stated that was her first time using mashed potatoes for puree. An observation on 11/28/23 at 10:29 a.m. revealed CK N added three half cups of mashed potatoes to the pureed green beans and blended it all together. CK N then added half a #10 can (12-13 cups) of green beans to the food processor plus six more half cup scoops of mashed potatoes-she then blended it all together and added some liquid from the green beans to the mix. During an observation and interview on 11/28/2023 at 10:33 a.m., CK O stated, we got to put the vegetable back in them. CK O then added 1/3 a can of green beans to the food processor and blended it again. CK N added two more scoops mashed potatoes. CK N stated, it tastes like green beans with mashed potatoes. An observation of tray line service on 11/28/2023 at 11:28 a.m. revealed CK N served pureed ham and pureed green beans using a blue #16 (2 oz./a quarter cup) scoop. An observation of puree preparation on 11/29/2023 at 10:40 a.m. revealed CK N pureed 7 6 oz. scoops of chicken with 4 scoops (unspecified in size) of mashed potatoes. During an interview and observation on 11/29/2023 at 10:45 a.m., CK N stated noodles was on the menu but residents on a pureed diet would receive mashed potatoes instead of noodles because noodles were harder to puree, and they wanted to make sure nobody chokes. An observation on 11/29/2023 at 11:54 a.m. revealed CK N served pureed greens and pureed chicken using a blue #16 (2 oz./a quarter cup). A record review of the facility's undated recipe titled Pineapple Glazed Ham reflected pureed ham was to be served using a #8 (4 oz./half cup) scoop. The recipe did not reflect mashed potatoes were to be added. A record review of the facility's undated recipe titled Italian [NAME] Beans reflected pureed green beans were to be served using a #10 (3.2 oz./a third cup) scoop. The recipe did not reflect mashed potatoes were to be added. A record review of the facility's undated recipe titled Seasoned Greens reflected pureed greens were to be served using a #8 (4 oz./half cup) scoop. A record review of the facility's undated recipe titled Baked Chicken Thigh did not reflect mashed potatoes were to be added. A record review of the diet spreadsheet titled Fall Winter '23-'24 Diet Guide Sheet dated 11/28/2023 reflected baked chicken was to be served in 3 oz. portions. During an interview on 11/29/2023 at 2:50 p.m., the RD stated she was not sure whether there was a written policy on following menus. The RD stated she could not speak specifically as to how cooks were trained on following menus, preparing pureed food items, and identifying correct scoop sizes. The RD stated there were recipe books and the cooks knew where to find recipes based on the recipe number. The RD stated staff knew which scoop size to use because it was on the recipes and menus. The RD stated the Dietary Manager trained cooks on finding recipes and using scoop sizes, but she was not sure whether the Dietary Manager had done that with CK N. When asked if the recipes for pureed ham, pureed green beans and pureed chicken called for mashed potatoes, the RD stated she did not know but usually it's food thickener. The RD stated her suspicion was that CK N added mashed potatoes to those food items to thicken them. When asked if CK N had used recipes the day prior (11/28/2023) and that day (11/29/2023), the RD stated she did not look. The RD stated she was not sure how, but that the Dietary Manager monitored staff to ensure they followed recipes, menus, and used correct scoops. The RD stated whenever possible, residents on a pureed diet should receive the same food item as residents on a regular diet-she stated she did not think there was any reason why residents on a pureed diet would receive mashed potatoes instead of pureed noodles. The RD stated it was not too difficult to puree rice or noodles. The RD stated adding mashed potatoes to food items could dilute the source of protein with meat and would also make food taste like mashed potatoes. The RD stated if residents received a smaller portion than the menu indicated as well as food thinned out with mashed potatoes, it could cause residents' needs to not be met. The RD stated, yes it would cause weight loss. During an interview on 11/30/2023 at 4:07 p.m., the DON stated residents on a pureed diet were at risk of nutrition deficits depending on ratio of food amounts. The DON stated receiving smaller portions and less protein would cause nutritional deficits and weight loss for sure. The DON stated Resident #24 had declined over the last year and her disease process had contributed to her weight loss. The DON stated Resident #24's dementia had caused her to lose the ability to eat as much. The DON stated Resident #52 had been admitted with a recently downgraded diet and wanted things outside of a pureed diet. The DON stated he had a history of choking and was admitted to hospice after being admitted to the facility. The DON stated Resident #52 struggled with dysphagia and did not want to eat at times. During an interview on 11/30/2023 at 4:30 p.m., the Administrator state she was sure there was a policy in the nutrition manual on following menus, but she expected that dietary staff followed recipes. The Administrator stated there was a book in the kitchen where recipes were, cooks were shown where recipes were, and CK N should have been trained. The Administrator stated cooks were not supposed to use mashed potatoes to puree food, it loses its nutritional value, and could cause weight loss. The Administrator stated yes if residents were not getting enough to eat, it could relate to some of the same issues. A record review of the facility's policy titles FOOD PREPARATION dated 6/20/2023 reflected the following: POLICY: Food will be prepared and attractively served using methods that conserve nutritive value, flavor, and appearance. PROCEDURES: 1. The cook is responsible for food preparation. Menu items are prepared according to the production count sheet. When Meal Tracker software is used, production count sheets are calculated automatically from the tray tickets. 3. Use the Recipe manual with standardized, yield-adjusted recipes. 6. Prepare altered consistency foods such as puree, minced-moist, and bite- size foods to meet the patient's/resident's individual needs and satisfaction. The facility will use the International Dysphagia Diet Standardization Initiative (IDDSI) as the foundation for texture modified foods and thickened drinks provided to the residents.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchens reviewed for food and nutrition services. 1. The facility failed to ensure all food items were covered, labeled, dated and discarded prior to their use-by date. 2. The facility failed to ensure CK N washed and sanitized the food processor between uses 3. The facility failed to ensure CK N wore gloves when handling ready-to-eat foods 4. The facility failed to ensure CK N washed her hands for 20 seconds after handling trash 5. The facility failed to ensure DA P removed his gloves and washed his hands after touching a contaminated object These failures could place residents at risk of foodborne illness. Findings included: An observation of the reach-in refrigerator on 11/28/2023 at 8:38 a.m. revealed a container of sliced cheddar cheese dated 11/21/2023 open to air and not sealed. There were also 12 2-oz. cups of salad dressing not labeled or dated. Observations of the walk-in refrigerator on 11/28/3034 from 8:40 a.m.-8:49 a.m. revealed the following: At 8:40 a.m., the walk-in refrigerator contained a container of chili dated 11/09/2023 with an illegible use-by date. At 8:43 a.m., the walk-in refrigerator contained a jug of pickles dated 7/20 and there were black, round, fuzzy spots on the lid, which was not tightly sealed. At 8:44 a.m., the walk-in refrigerator contained a jug of opened mayonnaise with a received date of 11/08/2023 and no opened date. At 8:45 a.m., the walk-in refrigerator contained a jug of coleslaw dressing dated 4/12/2023-the jug had black, round, fuzzy spots all over the lid and container. At 8:45 a.m., the walk-in refrigerator contained a jug of opened picante sauce with an opened date. At 8:46 a.m., the walk-in refrigerator contained an additional jug of picante sauce without and opened date. This container also had black-brown, round, fuzzy spots around the lid and container. At 8:47 a.m., the walk-in refrigerator contained a jug of opened Worcestershire sauce, covered with aluminum foil, and without an opened date. At 8:47 a.m., the walk-in refrigerator contained a plastic sealable bag of shredded cheddar cheese dated 11/23/2023. The bag was not sealed and was open to air. At 8:49 a.m., the walk-in refrigerator contained a raw round top roast dated 9/9. During an observation and interview on 11/28/2023 at 8:53 a.m., CK N stated she did not know if the round, black, fuzzy substance was mildew. CK N stated she was not sure what it could be but stated it could be oyster sauce or Worcestershire sauce. CK N stated she did not see anything that could have dripped. CK N stated she did not know when the round top was pulled from the freezer but said everything came in frozen. CK N stated all sealable bags should have been sealed shut and that was her first day back to work after being off for two days. CK N stated they kept leftovers for four days and said the chili needed to be taken out. Observed CK N remove, from the walk-in refrigerator, the items with the black unidentifiable substance-two jugs of picante sauce and one jug coleslaw sauce. An observation on 11/28/2023 at 10:11 a.m. revealed DA P was preparing toast in the kitchen. DA P touched his sweatshirt twice with gloved hands and continued to prepare toast without removing his gloves or washing his hands. During an interview on 11/28/2023 at 10:13 a.m., CK N stated she started as a dietary aide 4-5 months prior and was promoted to cook 2-3 months ago. Observations on 11/28/2023 from 10:25 a.m.-10:48 a.m. revealed CK N pureed ham, green beans, and pears consecutively without washing and sanitizing the food processor-she rinsed the food processor, blade, and lid under running water in the preparation sink in the kitchen. During an observation and interview on 11/28/2023 at 10:40 a.m., CK N was observed making pureed chicken-she pinched some chicken base with bare hands and dropped it into the food processor before blending it together. CK N stated she used the chicken base to add flavor. An observation on 11/28/2023 at 10:51 a.m. revealed CK N lifted the trash can lid up to throw away an empty can and then proceeded to pour the contents of the can into the food processor without washing her hands. During an interview on 11/29/2023 at 10:52 a.m., CK N stated she had not washed the food processor the day prior (11/28/2023) in between pureeing food items because the prep sink was right there and was easier. CK N stated she did not believe the food processor needed to be washed, rinsed and sanitized between pureeing each food item. During an interview on 11/29/2023 at 8:51 a.m., the RD stated the unlabeled salad dressing found in the reach-in refrigerator the day prior was ranch dressing and she thought dietary staff had just portioned it out prior to lunch. The RD stated the roast dated 9/9 had been frozen but since it had not been labeled with a pull date, they tossed it. During an interview on 11/29/2023 at 3:01 p.m., the RD stated yes everything should have a label and a date. The RD stated yes sealable bags needed to be sealed and everything should be covered, labeled, and dated. The RD stated yes items should be dated when opened and staff should follow best-if-used-by dates. The RD stated she expected staff to wash their hands and change gloves after touching part of their body during a food prep activity. The RD stated dietary staff should use a spoon when handling chicken base while preparing ready-to-eat items. The RD stated dietary staff should wash their hands for 20 seconds after handing a contaminated food item and before moving to a food prep activity. The RD stated staff should wash and sanitize the food processor in between pureeing different food items. The RD stated it was her first time seeing CK N cooking since the RD had been there. The RD stated she did not know how often staff cleaned food containers in the walk-in refrigerator, but she had never seen mildew and did not know what the black, circular, fuzzy spots on the condiment containers could be. The RD stated dietary staff were trained on food storage and sanitation by the Dietary Manager , who paired them with an experience employee for shadowing. The RD stated she trained staff in the form of in-services but not all staff had been trained by herself-she said CK N was new to her. The RD stated the Dietary Manager did some in-servicing as well. The RD stated the Dietary Manager monitored the kitchen for sanitation, but she was not sure how she monitored and handled her individual staff. The RD stated, we ask the Dietary Manager to check everything each day. The RD stated she monitored the kitchen by completing sanitation audits once a month. The RD stated if policies on food storage and sanitation were not followed, it could affect food quality and food safety. During an interview on 11/30/2023 at 4:30 p.m., the Administrator stated food should be covered and dated for whatever date they put it in the refrigerator. The Administrator stated leftovers should not be kept more than three days and the food processor should be washed between each use. The Administrator stated staff should wear gloves when handling ready to eat foods and if touching their body, staff should wash hands and change gloves. The Administrator stated she monitored the kitchen a lot and corrected things on the spot. The Administrator state she did a tray line audit every day she was in the facility and said she was constantly correcting dietary staff to wash their hands and not touch their body. The Administrator stated she did a sanitation audit once a week and when the RD was out for about six weeks, she did not find any audits from the dietitian who was covering. The Administrator stated the RD did a sanitation audit once a month and the Dietary Manager did the same things-she said the Dietary Manager should have completed a walk through every day. The Administrator stated dietary staff received skills check off for training and the Dietary Manager did side by side training with new staff for three days. The Administrator stated if kitchen sanitation policies were not followed, they could get sick or have foodborne illness. A record review of the facility's policy titled HAND HYGIENE/HAND WASHING dated6/20/2023 reflected the following: POLICY: Hand hygiene is the most important component for preventing the spread of infection. Proper hand washing technique will be used when hand washing is indicated. Employees keep their hands and exposed portions of arms clean. PROCEDURES: 1. Clean hands in a hand washing sink. Hands may not be cleaned in a sink used for food preparation or ware washing or in a service sink used for disposal of mop water. 2. Wash hands: C. Before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves D. Before handling or eating food J. After contact with soiled or contaminated articles, such as, dirty dishes K. After contact with an object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds RAIONALE Warm water helps to lather soap and also is more comfortable, thus increasing the chance [that] hands will be washed for at least 20 seconds. A record review of the facility's policy titled FOOD SAFETY IN RECEIVING AND STORAGE dated 6/20/2023 reflected the following: POLICY: Food will be received and stored by methods to minimize contamination and bacterial growth. General Food Storage Guidelines 2. Store food in its original packaging if the packaging is clean, dry, and intact. 3. Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. Label both the container and its lid with the common name of the contents, the date it was transferred to the new container, and the discard date. It is recommended that food stored in bins (e.g. flour or sugar) be removed from its original packaging. 12. Refrigerated, ready to eat Time/Temperature Control for Safety Foods (TCS) are properly covered, labeled, dated with a use-by date, and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1. Follow USDA guidelines for food storage. 14. Refrigerated condiments and salad dressings are properly covered, labeled, and clearly marked to indicate a use by date two months from the date opened. A record review of the facility's policy titled MANUAL CLEANING AND SANITIZING WITH A THREE-COMPARTMENT SINK dated 6/20/2023 reflected the following: POLICY: Equipment and utensils will be cleaned and sanitized appropriately after use. A three-compartment sink is used for manual washing, rinsing, and sanitizing utensils, and equipment. A high concentration of sanitation solution may be potentially hazardous. PROCEDURES: 1. Fixed equipment, utensils, and equipment too large to be cleaned in sink compartments are washed manually with detergent and hot water, rinsed, air-dried, and sprayed with a sanitizing solution. 2. Pre-flush or pre-scrape equipment and utensils and when necessary, pre-soak to remove large food particles and soil. 3. Conduct manual washing, rinsing, and sanitizing in sink compartments in the following sequence: NOTE: All methods will coincide with manufacturer's recommendations and/or state/local requirements. A. Clean the sink before each use. 8. Flush, scrape, or soak items before washing. C. 1st Sink: Equipment and utensils are thoroughly washed in the first sink in a detergent solution of at least 11 0 F. Wash water is kept clean and changed frequently. D. 2nd Sink: Equipment and utensils are rinsed free of detergent and abrasive with clean, clear water E. 3rd Sink: Equipment and utensils are sanitized in the third compartment according to one of the following methods: Facility uses method # ____ NOTE: If only a 2-compartment sink is available, follow A, B , C as written, rinse under running water and sanitize as per E or per state/local requirements. Method: 1. Immersion for at least 30 seconds in clean hot water at 171° F or hotter. (To prevent burns, use a basket, a rack or tongs to lower and remove items form the water). 2. Chemical sanitization following manufacturer's instructions. If explicit instructions are not provided, the recommended concentrations are as follows: Immersion for at least 10 seconds in a clean solution containing 50-100 ppm (parts per million) of chlorine at 75° For hotter but not exceeding 120° F. 4. Immersion for 30 seconds in a clean solution containing at least 12.5 ppm to 25 ppm of iodine and with a pH not higher than 5.0 and at 75° For hotter but not to exceed 120° F. A record review of the facility's policy titled WAREWASHING USING DISHWASHING MACHINE dated 6/20/2023 reflected the following: POLICY: Utensils and dishes washed by a mechanical dishwasher will be clean and sanitized. A record review of the 2017 FDA Food Code reflected the following: 4-702.11 Before Use After Cleaning. UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. 2-301.12 Cleaning Procedure. (A) Except as specified in (D) of this section, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under § 5-202.12 and Subpart 6-301. 2-301.14 When to Wash. 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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to be free from misappropriation of proper for 1 of 5 residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's Belsomra, a medication to help with sleeping. This failure could place residents at risk for not receiving prescribed medications. Findings included: Review of Resident #1's undated face sheet reflected the resident was admitted [DATE]. Her diagnoses included chronic respiratory failure (inability of the lungs to get enough oxygen to the body), sepsis (an infection in the blood), cognitive communication deficit (communication problem related to cognition rather than language or speech), hypertension (high blood pressure), cerebral infarction (stroke), type 2 diabetes mellitus (a problem with how the body regulates blood sugar), anxiety (intense feelings of fear or terror), and depression (persistent feeling of sadness and loss of interest). Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMs score of 14 indicating intact cognition. She was documented as receiving a hypnotic during the 7-day look back period. Review of Resident #1's physician orders dated 7/11/23 reflected an active order for Belsomra 10mg oral at bedtime. Review of Resident #1's Medication Administration Record (MAR) dated 11/1/23 through 11/21/23 reflected the Belsomra had not been administered the night of 11/13/23 because the medication was unavailable. Review of the facility's investigation of the missing Belsomra medication reflected on 11/14/23 at 6:12 AM, the DON was notified by LVN A of a med discrepancy for Resident #1. LVN A stated the narcotic count sheet reflected 10 tablets but there were only 6 on the medication cart. LVN A told the DON that MA C had counted the medications and told RN B there was a discrepancy. LVN A told the DON, RN B had already left the building. Review of the controlled drug receipt/record/disposition form reflected RN B signed the form on 11/13/23 with the quantity received marked as 10. During an interview on 11/21/23 at 12:55 PM with LVN A, she stated she had worked at the facility going on two years. She stated she had recent in-service on controlled medications and diversion. She stated the controlled meds were counted every time the keys change hands. She stated on her halls the med aides worked from 6:00 AM until 2:00 PM and then from 4 PM until 8:00 PM so the meds were counted multiple times throughout her shift. She stated if there was a med discrepancy, the DON was notified immediately. She stated she nor the other nurse or med aide could leave the building. During an interview on 11/21/23 at 1:00 PM with the DON, she stated she received a phone call in the morning reporting the narcotic count was off with four pills missing. She was informed the off-going nurse (RN B) had already left the building. She stated she called him, and he was loud and cursing and, all over the place. She stated that during the second call to RN B, he first said he could not remember if the medication was sealed and bagged but later, he stated it was sealed but he took it out of the bag when he locked it in his medication cart. The DON stated RN B admitted he had put the medication cart keys in the drawer at the nurse's station. She stated she was not able to determine who took the medications but, by leaving the keys in the drawer, he allowed everyone access to the medication cart. She stated RN B was suspended pending the investigation then after conversations with cooperate and human resources, RN B was terminated. She stated the facility did not have cameras, so she was not able to see who took the medications. During an interview on 11/21/23 at 1:10 PM with MA D, she stated she had worked at the facility full time since 2018. She stated she had recent training on counting controlled medications. She stated she had to count at the start of her shift and again before leaving. She stated if there was a discrepancy in the count that was not easily resolved, the charge nurse or DON was notified immediately. She stated staff could not leave the facility until the discrepancy was resolved. She stated the keys were kept in her pocket throughout the shift, but if she left the floor, she gave the keys to the nurse. During a telephone interview on 11/21/23 at 1:48 PM with the police detective assigned to the case, he stated he had not yet been in contact with RN B. During an interview on 11/21/23 at 3:26 PM with the DON, she stated it did not meet her expectations that controlled medications would be missing. She stated the suspected staff member was out of the building and there were systems in place to prevent it from happening again. Observation and interview on 11/21/23 at 2:50 PM revealed Resident #1 awake in a wheelchair in her room. She stated she slept well most nights but occasionally had trouble falling asleep. She stated she did not remember if she had missed any doses of the sleep medication recently. A telephone message was left on 11/21/23 at 3:25 PM for RN B requesting a return call. A return call was not received before close of business 11/21/23. Review of the facility's policy regarding Loss or Theft of Medications, revised 4/1/22 reflected in part, Staff should immediately report any discrepancies or a suspected theft or loss of drugs from an onsite store to a supervisor/manager or the Director of Nursing for appropriate investigation for possible diversion. Review of the facility's policy regarding storage and reconciliation of controlled substances revised 4/1/22 reflected in part, 1. Only authorized staff, licensed nurses and pharmacy personnel will have access to controlled medications. 3. All controlled medications must be maintained in separately locked, permanently affixed compartments. The access key to controlled medications is not the same key which gives access to other medications. Duplicate keys to all medication storage areas, including those for controlled medications, are kept by the Director of Nursing. A. The authorized staff member will have the controlled substance key(s) in his/her possession at all times while on duty. 4A. At the end of every shift the nurse/authorized staff member reporting on duty and the nurse/authorized staff member reporting off duty meet at the designated medication cart or storage area to count all controlled substance drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 2 residents review for advanced directives. (Resident #121) * The facility did not have a completed Out of Hospital-Do Not Resuscitate (OOH-DNR) for Resident #121. The form was missing required information. This failure could place residents at risk of lifesaving procedures performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. Findings included: Physician orders for [DATE] indicated Resident #121 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included stroke, high blood pressure, osteoporosis (weakened bones), and pathological fracture of the hip. An order dated [DATE] indicated she had a code status of DNR. A care plan dated [DATE] indicated Resident #121 was a DNR. An OOH-DNR dated [DATE] indicated no notary seal and no date for the physician signature. During an interview on [DATE] at 11:54 a.m., the DON said Resident #121's OOH-DNR was not valid and needed to be redone. She said Resident #121 was classified as a full code with an incomplete OOH-DNR. She said the SW was responsible for obtaining and ensuring the DNRs were completed. During an interview on [DATE] 12:17 a.m., the SW said Resident #121's OOH-DNR was missing the notary stamp and the date the physician signed the form. She said the missing information made the OOH-DNR invalid. She said she was responsible for ensuring the DNR forms were completed. A Do Not Resuscitate (DNR) policy revised [DATE] indicated the following: Policy: Facility staff will follow the resident's Advanced Directives in accordance with applicable law and regulation as well as the applicable Facility Policies and Procedures Absent any appropriate DNR Order/Identifier, Facility Staff will respond to medical emergencies with CPR measures and a FULL CODE will be instituted. Procedures: 1. At the time of admission and/or readmission to the Facility, Social Services or a Nursing Designee will review the resident's transfer summary, if any, for any documentation regarding the resident's code status, including but not limited to a valid DNR order and physician certifications regarding incapacity, terminal/incurable illness, persistent vegetative state, etc. per applicable state guidelines A Filling out the Out-of-Hospital Do-Not-Resuscitate Form accessed on [DATE] at http://dshs.texas.gov/emstraumasystems/dnr.shtm#form indicated the following: D. This box is used when a physician has evidenced that a patient has issued a previous directive to physician or observes a person issuing an OOH-DNR by non-written communication. The physician must check the appropriate box in this section, sign and date the form, print or type his/her name and provide his/her license number The Government Code for Notary Public accessed on [DATE] at https://statutes.capitol.texas.gov/Docs/GV/htm/GV.406.htm indicated the following: TITLE 4. EXECUTIVE BRANCH; SUBTITLE A. EXECUTIVE OFFICERS; CHAPTER 406. NOTARY PUBLIC; COMMISSIONER OF DEEDS; SUBCHAPTER A. NOTARY PUBLIC: Sec. 406.013. SEAL. (a) A notary public shall provide a seal of office that clearly shows, when embossed, stamped, or printed on a document, the words Notary Public, State of Texas around a star of five points, the notary public's name, the notary public's identifying number, and the date the notary public's commission expires. The notary public shall authenticate all official acts with the seal of office.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals identified with MD or ID have an accurate screening and/or are evaluated and receive care and services in the most integrated setting appropriate to their needs for 1 of 7 residents reviewed for Preadmission Screening and Resident Review (PASRR). (Resident #121) * The facility did not have a correct PASRR Screening for diagnoses including major depressive disorder and psychosis for Resident #121. *The facility did not complete a PASRR Evaluation for Resident #121. This failure could place the residents at risk for inappropriate placement in the nursing facility for long term care and not receiving needed care and services in accordance with individually assessed needs. Findings included: Physician orders for July 2021 indicated Resident #121 was admitted on [DATE]. Her diagnoses included major depressive disorder and anxiety disorder. An order dated 06/07/21 indicated she received mirtazapine (antidepressant) 15 mg at bedtime for depression and quetiapine (antipsychotic) 12.5 mg twice daily for anxiety. A PASRR Screening dated 06/07/21 indicated Resident #121 was negative for mental and was exempted hospital discharge with a physician indicating she was likely to require less than 30 days of nursing facility services. She had been at the facility for over the 30 days. There was no corrected PASRR Screening or PASRR Evaluation in Resident #121's EMR or in the PASRR portal. During an interview on 07/21/21 at 11:15 a.m., MDS Nurse D said the PASRR Screening for Resident #121 was negative. She said with Resident #121 having diagnoses of major depressive disorder and anxiety and taking medications the PASRR Screen should have been positive and a PASRR Evaluation should be done. She said she did not know what she needed to do to correct it, but she would find out. During an interview on 07/21/21 at 11:54 a.m., the DON said the MDS Nurses were responsible for reviewing the PASRR Screenings to ensure they were correct. A PASARR Documentation Policy revised 10/01/2020 indicated the following: This policy is intended as a general guide for the PASARR process. The facility develops a process for completion of the PASARR requirements per state-specific policy and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 24 residents reviewed for care plans. (Resident #115) * The facility did not have a care plan for Resident #115's surgical wound to the leg, her anticoagulant medication, or her antianxiety medication. This failure could place residents at risk for not receiving the proper care and services they needed. Findings included: Physician orders for July 2021 indicated Resident #115 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included narrowed and hardened arteries (atherosclerosis), progressive circulation disorder (peripheral vascular disease), anxiety disorder, and an irregular and rapid heart rate (atrial fibrillation). A physician order dated 07/08/21 indicated Resident #115 was to receive Eliquis (anticoagulant) twice daily for atrial fibrillation. A physician order dated 07/11/21 indicated Resident #115 was to receive clonazepam (medication to treat anxiety) twice daily for anxiety disorder. A physician order dated 07/16/21 indicated Resident #115 had a wound treatment to a wound located on the right leg. An admission MDS dated [DATE] indicated Resident #115 had an open lesion, she received antianxiety medication for 6 days of the 7 day look back period, and she received anticoagulant medication for 6 of the 7 day look back period. The care plan with the last care conference date of 06/24/21 had no indication of Resident #115's wound to her leg, her antianxiety medication, or her anticoagulant medication. During an observation and interview on 07/20/21 at 09:26 a.m. of Resident #115's wound care, she had an open wound to the right lower leg. ADON C said the wound was a failed vascular reconstruction surgical wound the resident had upon admission. She said the treatment was recently changed and the resident was being referred to a wound care center. During an interview on 07/21/21 at 11:15 a.m. the DON said she, the ADONs, or the MDS Nurses were responsible for updating care plan information. She said Resident #115's wound to her leg, antianxiety medication, and anticoagulant medication should have a care plan. She said she did not realize it was not discovered during the care conference. During an interview on 07/21/21 at 12:35 p.m. the MDS Nurse said care plans were to be updated with any new medication or treatment. A Person-Centered Care Plan policy revised on 07/01/2016 indicated Procedures: 3. Following RAI Guidelines develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment 10. Through ongoing assessment, the facility will initiate care plans when the resident's clinical status or change of condition dictates the need such as but not limited to falls and pressure ulcer development

Based on observation, interview and record review, the facility failed to provide food that was palatable and at an appetizing temperature for 1 of 1 meal observed and 2 of 19 residents reviewed for food palatability. * The facility did not serve food that was palatable. The vegetables were bland, and the sweet and sour pork had no flavor, and was not sweet or sour. * Resident #s 96 and 63 said the food was served bland without salt or seasonings. This failure could place residents who ate food from the kitchen at risk of weight loss, alternate nutritional status and diminished quality of life. Findings included: During an interview on 7/19/21 at 10:14 a.m., Resident # 96 said she Does not like the food, breakfast is fair, usually only eats half what they send her. Scrambled eggs are not good. The food has no seasoning or salt. She said at the hospital she received multiple seasonings. She said small packets of condiments would help the food so much. During an interview on 7/19/21 at 10:51 a.m., Resident #63 said the food had no seasoning in it. During an observation on 7/19/21 at 12:00 p.m., the administrator said the DM had been out for two weeks with COVID and was supposed to return today but did not and she could nptt get ahold of him. She said the one who was supposed to cook called in sick. She said that she had been in the kitchen helping. During an observation on 7/20/21 at 11:00 a.m., the RD said the truck did not come in this morning and they were having to add condiment size sweet and sour sauce to the pork to try and season it. During an interview on 7/20/21 at 11:30 a.m., [NAME] E said she had added some butter to the mixed vegetables to season them. During an observation on 7/20/21 at 12:45 p.m., a test tray consisted of sweet and sour pork over rice, oriental vegetable blend, a glass of unsweet tea and water with melted ice, pudding and they had forgot to put the bread on the tray. The sweet and sour pork was bland and was not sweet and sour. The vegetables tasted like frozen vegetables and had no salt or seasoning. The pureed tray was not appetizing nor appealing the sweet and sour pork over rice and the oriental mixed vegetables were running together on the plate. During an interview on 7/21/21 at 11:39 a.m., the RD said this was not their usual she hated we had to see this. She said the food was usually good. She said she expects the kitchen to serve good food, well-seasoned and on time. The RD said the condiments go up on top of the cart and it's up to the aide to put the condiments on the tray. During an interview on 7/21/21 at 12:00 p.m., the Administrator she said she expects the kitchen to serve food that is palatable and well-seasoned. A policy, Nutrition Policies and Procedures complete revision 8/1/20 indicates: A. The taste of the food should be palatable and pleasant tasting. B. Consider the seasoning of the food and determine if it is appropriate.