Based on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of the review for 1 (SNA A) of 6 SNAs and CNAs whose records were reviewed, by failing to ensure: SNA A had an annual performance review and completed 12 hours annual in-service education in 2024 and 2025 which was based on a performance review. This facility failure could affect the residents by placing them at risk for a physical decline in their health status. The findings included: In an interview with the Administrator on 3/13/2025 at 12:30 PM she stated it was her expectation that employees were responsible for taking monthly scheduled training in a program on the computer -based program She stated it was the responsibility of each department head to monitor to see that the employees kept their trainings requirements current and their certification current. She stated failure to complete required training could result in residents not receiving adequate care In an interview on 3/12/2025 at 2:30 PM, the DON stated she could only provide documentation of one new employee orientation in-service training was held. It was dated 4/18/23. She also stated that SNA A did not have a performance review every 12 months or 12 hours of annual training based on her performance review. She stated it was the responsibility of each department head to monitor to see that the employees kept their trainings requirements current and their certification current. She stated failure to complete required training could result in residents not receiving adequate care. She stated she would be monitoring to see that inservices were completed in a timely manner in the future. During an interview on 03/12/2025 at 6:30 PM , SNA A stated she had been working continuously at the facility since April of 2023. She stated she performed the duties of a CNA on the 6 PM to 6 AM shift. She stated that she had taken her certification test and failed the skills test about 2 months ago. She stated she had not completed her 12 hours of Inservice education that is required annually in the Brand XXX training program. She stated she did not realize that it was a state or federal requirement . She stated she did not really know of a negative outcome that could affect the resident due to her not completing her monthly inservices. Review of the facility employee list with hire dates and positions, and the staff in-service sign in sheets for SNA A provided by the DON, revealed documented annual in-service hours, during the last 12 months, as follow: SNA A - date of hire 4/18/2023, - 0 hours of documented in-service since 4/18/2 and no performance evaluation since 4/18/23 Record review of the document provided by the DON titled Job Description for a CNA dated 2014, and signed on 4/ 18/23 by SNA A stated the following [in part] : Knowledge Base - Ability to perform technical procedures and record information, Ability to comply with employee responsibilities, ability to comply with facility safety policies and procedures . Record review of the document provided by the DON titled Job Description for a SNA dated 2010, and signed on 4/ 18/23 by SNA A stated the following [in part] : Knowledge Base - Only perform patient care areas that they have been trained for, accountable for personal care (grooming, dressing, personal care, catheter care, peri care, and dressing), basic computer knowledge, identifies and reports any condition requiring management attention, ambulate and transfer residents utilizing appropriate assistive devices and body mechanics Record review of an Inservice which was given by the DON and Administrator. dated 3/12/25 at 2 PM reflected the following: Brand XXX Inservice training program used by the facility) is mandatory. Continuing education is required by the state and federal government. Training is not optional The trainings must be completed by the due dates. There are new in-services assigned monthly and occasionally inservices are assigned as needed. Get with your department supervisor to discuss how you will get these completed if you are having issues. Each staff member is responsible for their training. Working on this a little every day (10-15 minutes per day) while you are at work will keep your continuing education up to date. This is your education on completing Inservice training in Brand XXX. This is a required task . disciplinary action will be the next step if the training is not completed.

Based on interview and record review the facility failed to not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual has completed a training and competency evaluation program for 1 (SNA A) of 3 student nurse aides reviewed. The facility failed to ensure SNA A was certified within the required time. This failure place residents at risk for receiving inappropriate care from an individual whose skill level was not known. Findings include: Review of the facility's employee files revealed: -SNA A had a hire date of 4/18/2023 and worked full time. - An employability status check dated 8/27/24 indicated SNA A had a CNA certification expiration date of 5/22/15. During an interview on 03/12/2025 at 6:30 PM , SNA A stated she had been working continuously at the facility since April of 2023. She stated she performed the duties of a CNA on the 6 PM to 6 AM shift. She stated that she had taken her certification test and failed the skills test about 2 months ago. She stated she felt like she failed the test because she would ask the ADON (no longer employed at the facility) to help her with her skills and she didn't want to help her. She stated she did not tell the DON or Administrator that she needed assistance. She stated the adverse outcome that could result from her failure to be certified would be the resident might not get the care that they should receive, and that might affect their health and overall wellbeing. She stated she had not registered to take the test again because she had to pay for it herself . She stated the facility paid for the first attempt at passing the CNA certification , but if the SNA failed on the first attempt, it was the responsibility of the SNA to pay for the certification retesting. During an interview on 3/13/2025 at 2:47 p.m., the DON stated that her expectation would be for the facility to have certified nurse assistants. She stated that she recently took on the responsibility of monitoring and ensuring the CNAs tested and became certified. She stated she was aware that SNA A was working without certification but didn't know there was a limit on how long she could work before becoming certified. She stated she knew that SNA A would have to pay for the retesting for the skills portion of her test. She stated the company would only pay for the first test. She stated SNA A had not requested her assistance to prepare for the test. She stated no negative effect had occurred to residents due to care received from a non- certified NA, but an adverse outcome could be that a resident could not receive appropriate care. She stated it was the responsibility of the prior ADON to monitor training and certifications, but going forward it was her responsibility. Record review of a document titled How To Become a Certified Nurse Aide (CNA) in Texas not dated stated in part: - Complete NATCEP Training (Nurses aide Certification and Evaluation Training program) - Submit an application through TULIP (Texas Unified Licensure Portal) - NATCEP approval - based on successful completion of training; Successful background check Student not listed on the EMR - Schedule and pass the exam : Student schedules and passes both the written and skills exams Record review of the document provided by the DON titled Job Description For A SNA dated 2010, and signed on 4/ 18/23 by SNA A stated the following [in part] : Knowledge Base - Must provide written proof of a completion of 16-hour ADL training by authorized school instructor. Only perform patient care areas that they have been trained for, accountable for personal care (grooming, dressing, personal care, catheter care, peri care, and dressing), basic computer knowledge, identifies and reports any condition requiring management attention, ambulate and transfer residents utilizing appropriate assistive devices and body mechanics . Applicant declaration: I have read the qualifications and requirements of the position of student nurses aide; I understand this position is not permanent but limited to 120 days in which I am required to test and obtain certification. I understand and certify that the foregoing is a non-exhaustive criterion that is consistent with the needs of this facility and is a legitimate measure of the qualifications for a Certified Nursing assistant and relates to the functions essential to a certified nursing assistant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 2 residents (Residents #38 and #61) reviewed for respiratory care. The facility failed to ensure Residents #38 and #61's nasal cannula and nebulizer were kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. The findings included: 1. Record review of Resident #38's face sheet, dated 09/06/2024, reflected a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included Hypertension (high blood pressure), Shortness of breath, Depression, Anxiety , chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe). Record review of Resident #38's MDS admission assessment, dated 05/17/2024, reflected a BIMS score of 06, which indicated severe cognitive impairment. Section I: Active diagnosis reflected chronic pulmonary disease, or chronic lung disease. Section O: Respiratory Treatments was marked for Oxygen Therapy. Record review of Resident #38's Physician Orders, dated 05/17/2024, reflected an order for Oxygen at 3 - 4 liters per minute via nasal cannula and nebulizer treatments two times daily. Change oxygen and nebulizer tubing weekly on Sunday. Record review of Resident #38's quarterly Care Plan, 06/24/2024, reflected a care plan for has COPD (obstructive pulmonary disease) - Oxygen at 2- 4 liters per minute continuously. The Care Plan did not have an intervention regarding when oxygen tubing needed to be changed. In an observation on 09/04/2024 at 10:30 AM, revealed Resident #38 was lying in bed her nasal cannula was uncovered and hanging over the bed rail in her room with the nasal prongs lying on floor . 2. Record review of Resident # 61's face sheet, dated 08/06/2024, reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #61 had diagnoses which included dementia (memory loss), Hypertension (high blood pressure), Pneumonia (Inflammation of the air sacs in the lungs), Muscle wasting, Shortness of breath, chronic obstructive pulmonary disease (a lung disease that block airflow and make it difficult to breathe). Record review of Resident #61's MDS admission assessment, dated 07/29/2024, reflected a BIMS score of 12, which moderate cognitive impairment. Section I: Active diagnosis reflected chronic pulmonary disease, or chronic lung disease. Section O: Respiratory Treatments was marked for Oxygen Therapy. Record review of Resident #61's Physician Orders dated 08/07/2024 revealed an order for Oxygen at 3 liters per minute via nasal cannula and nebulizer treatments every six hours as needed. Change oxygen and nebulizer tubing as needed. Record review of Resident #61's admission Care Plan, dated 08/14/2024, reflected a care plan for [Shortness of Breath #61] has COPD (obstructive pulmonary disease) - Oxygen at 3 liters per minute continuously. The Care Plan did not have an intervention regarding when oxygen tubing needed to be changed. In an observation and interview on 09/04/2024 at 09:45 AM, during initial rounds, Resident #61 was lying in his bed receiving oxygen via nasal cannula at 3 liters per minute. His nebulizer was sitting on the nightstand uncovered. In an interview on 09/06/2024 at 2:06 p.m., the administrator stated, she expects the nebulizer mouth pieces and oxygen nasal cannulas to be stored in a plastic bag when not in use. She further stated, by not cleaning and storing the nebulizers and oxygen nasal cannulas in a plastic bag could cause cross contamination and make the resident sick. In an interview on 09/06/2024 at 3:06 p.m., the DON stated, it is her expectation that the nebulizer tubing and mouthpiece be kept in a plastic bag when not in use and that it is the charge nurses responsibility to ensure that this is done. She further stated, if the nebulizers and oxygen tubing is not kept in plastic bag this could cause cross contamination and the resident could become ill. Record review of the facility policy Respiratory Therapy -Prevention of Infection, dated 2001 revised November 2011, revealed the following [in part]: Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Procedure: Product: Oxygen delivery devices (no-aerosol producing) Ex: venturi masks, nasal cannulas, oxygen supply tubing. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag between uses. 9. Discard the administration set-up every seven (7) days as needed.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with current accepted professional principles for 2 (Hall A and Hall E ) of 5 medication carts observed for medication storage. The facility did not ensure Hall A and Hall E Medication Carts was locked and secure. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them. Findings include: Observation on 9/5/2024 at 11:36 AM, revealed the Hall E medication cart was unlocked and unattended, the cart was parked in hall and nurse was in resident room. Nurse was not in line of sight of medication cart. Present in medication cart included over the counter medications, prescription medications, insulin, breathing treatment medication, narcotic drawer was locked by one lock. During an observation and interview on 09/05/24 at 4:30 PM , the medication cart was observed to be unlocked and unattended on Hall A with a resident within 6 feet away of open cart. In an interview on 09/05/2024 at 4:30 PM, LVN B stated that she did not know anyone had been close to the medication cart and knew she was to have it within eyesight if left unlocked. LVN B further stated if residents was to obtain medications from the medication carts that was not theirs, they could have an allergic reaction. Interview with LVN A on 9/5/2024 at 11:40 AM, revealed Normally I would have turned the cart away in the door way so I let go of my cart and went to her. I didn't think correctly. LVN A further stated the medication cart was not in her line of sight and it was not locked. LVN A stated the medication cart should be locked if not in use or line of sight and that lack of locking medication cart could lead to resident getting into cart causing drug diversion. Interview with DON on 9/5/24 at 11:38 AM revealed her expectation is for medication carts to be locked when nurse is not in front of cart or utilizing cart for medication pass. The DON also stated if cart is not locked residents could get into cart and have a possibility of drug diversion. In an interview on 9/5/24 at 12:28 PM the ADM stated should be locked according to our guidelines regarding expectation for medication cart security. ADM continued stating that lack of securing medication carts could potentially allow the wrong person to get in cart and get medications. Record review of policy Medication Carts from Pharmacy Policy and Procedure Manual 2003 revealed the following [in-part]: 1. The medication carts shall be maintained by the facility. 2. The carts are to be locked when not in use or under the direct supervision of the designated nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility did not make sure that resdients withloss of bladder control received treatment or services to prevent infections and help get normal bladder control for 1 of 18 resident (Residents #30) reviewed in that: CNA-A failed to provide incontinent care in a manner to prevent potential spread of infection. This failure could place residents at risk for the spread of infection and skin complications. Findings include: Record review of Resident #30 Annual MDS, dated [DATE], revealed a [AGE] year-old male who was admitted to the facility on [DATE] with an active DX list that included: CAD (CAD Acronym or abbreviation to medical concept or diagnosis of coronary artery disease - common type of heart disease), Hypertension (High Blood Pressure), Hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), Neurogenic Bladder (the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem) and MS (a long-lasting [chronic] disease of the central nervous system). Resident #30 had a BIMS of 15, which meant the resident was cognitively intact. Resident #30 required ADL care needs of 2-person physical assistance. He had always been incontinent of bowel and bladder During observation on 07/10/2023 at 10:18 AM of peri care, the CNA-A performed peri care for Resident #30. While resident was on his side for peri care, CNA-A wiped the resident from back to front with a sanitary wipe. During interview on 07/10/2023 at 1:10 PM, CNA-A stated the procedures for peri care were to wipe the resident with sanitary wipes from front to back with one swipe and throw away. She stated when performing resident care, she should have never cleaned a resident from back to front with not being taught any other way. She stated it was a habit to perform perineal care the way she did. CNA-A stated if the resident was not wiped in the right direction it could cause the resident harm such as infection. During interview on 07/10/2023 at 1:17 PM, the DON stated while performing peri care on a resident, the staff member should wipe with a sanitary wipe once and throw away and definitely did not teach to wipe from back to front. She stated she did not teach her staff those procedures any other way. She stated best procedure for perineal care would be to wipe front to back. The DON stated there could be a negative impact to a resident of possible contamination. She stated the failures were that her CNA was nervous. Her expectation was to do perineal care correctly the first time as well as every time. She stated her trainings were done by observing her staff as well as having one on one, telling them they should carry out completely with each resident the right way, every time. Record review of the facility policy titled Perineal Care, dated 04/27/2022, revealed: .male Resident . 21. Gently perform care to the buttocks and anal area working from front to back without contaminating the perineal area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility did not make sure that residents receive adequate dialysis care for for 2 (Resident #25 and Resident # 43) of 3 residents in that: The facility failed to ensure physician orders were written for Resident #25 and Resident #43. This failure could place residents at risk of having errors in care and treatment. Findings include: Review of Resident # 25's face sheet dated 07/11/2023 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of which included chronic kidney disease. Review of Resident #25's Quarterly MDS, dated [DATE], revealed Section C - Cognitive behavior a BIMS score of 9, which meant she had moderate cognitive impairment. Review of Resident #25's physician orders revealed no evidence of orders for dialysis. Review of Resident #43's face sheet, dated 07/11/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease and dependence on renal dialysis. Review of Resident #43's Quarterly MDS, dated [DATE], revealed in Section C - Cognitive Behavior, a BIMS score of 13, which meant she was cognitively intact. Review of Resident #43's physician orders revealed no evidence of orders for dialysis. During an interview on 07/09/23 at 3:44 PM, Resident # 25 stated she received dialysis three days per week. During an interview on 07/11/23 at 1:56 PM, the DON stated she did not think there should have been an order for dialysis but was not sure what the policy stated. After the DON reviewed the policy she stated there should have been an order for dialysis per their policy. The DON stated her expectation was staff followed the policy. The DON stated what led to failure was the lack of knowledge on the DON's part. The DON stated there was no negative impact on the residents. The DON stated she was responsible for monitoring resident charts for accuracy. The DON confirmed that Resident #25 and Resident #43 had been receiving dialysis weekly. Review of the facility MDS Resident Matrix, dated 07/09/2023, revealed Resident #25 and Resident #43 received dialysis. Review of the facility policy titled, Dialysis, dated November 2013, revealed, Procedure 1. Review and confirm the physician's order for dialysis. Follow the specifications of the medical regiment including dietary restrictions and medical management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 2 (Resident #25 and Resident # 43) of 3 residents reviewed for resident records. The facility failed to ensure physician orders were written for Resident #25 and Resident #43. This failure could place residents at risk of having errors in care and treatment. Findings include: Review of Resident # 25's face sheet dated 07/11/2023 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of which included chronic kidney disease. Review of Resident #25's Quarterly MDS, dated [DATE], revealed Section C - Cognitive behavior a BIMS score of 9, which meant she had moderate cognitive impairment. Review of Resident #25's physician orders revealed no evidence of orders for dialysis. Review of Resident #43's face sheet, dated 07/11/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease and dependence on renal dialysis. Review of Resident #43's Quarterly MDS, dated [DATE], revealed in Section C - Cognitive Behavior, a BIMS score of 13, which meant she was cognitively intact. Review of Resident #43's physician orders revealed no evidence of orders for dialysis. During an interview on 07/09/23 at 3:44 PM, Resident # 25 stated she received dialysis three days per week. During an interview on 07/11/23 at 1:56 PM, the DON stated she did not think there should have been an order for dialysis but was not sure what the policy stated. After the DON reviewed the policy she stated there should have been an order for dialysis per their policy. The DON stated her expectation was staff followed the policy. The DON stated what led to failure was the lack of knowledge on the DON's part. The DON stated there was no negative impact on the residents. The DON stated she was responsible for monitoring resident charts for accuracy. The DON confirmed that Resident #25 and Resident #43 had been receiving dialysis weekly. Review of the facility MDS Resident Matrix, dated 07/09/2023, revealed Resident #25 and Resident #43 received dialysis. Review of the facility policy titled, Dialysis, dated November 2013, revealed, Procedure 1. Review and confirm the physician's order for dialysis. Follow the specifications of the medical regiment including dietary restrictions and medical management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received necessary respiratory care and services that was in accordance with professional standards of practice for 3 of 6, (Resident # 61, 34, 53) residents reviewed for respiratory services. Resident #61 did not have signage on doorway indicating oxygen use, oxygen tubing and humidifier bottle undated, tubing laying in floor while not in use. Resident #34 did not have signage on doorway indicating oxygen use, oxygen tubing was dated 5/28. Resident #53 did not have signage on doorway indicating oxygen use, oxygen tubing and/or humidifier bottle was dated 5/29. These failures could place residents that used oxygen at risk of respiratory distress. Findings included: Resident #61 Record review of Resident #61's Facesheet dated 6/16/22 revealed an [AGE] year-old female admitted to the facility on [DATE], with a diagnosis list that included: Personal history of Covid-19, Acute pulmonary edema, COPD, Acute bronchitis, Cough, SOB, Acute on chronic combined systolic and diastolic congestive heart failure. Record review of Resident #61's MDS dated [DATE] revealed a BIMS score of 7 meaning severely impaired cognition. Active diagnosis list included Pulmonary: Asthma, COPD, or chronic lung disease, Respiratory failure. SOB: SOB with exertion, SOB when lying flat. Special treatments: Oxygen therapy while a resident. Record review of Resident #61's Care plan revised 6/13/22 revealed: The resident has oxygen therapy. The resident will have no signs or symptoms of poor oxygen absorption through the review that. Oxygen per NC. Notify the nurse if the oxygen is off the resident. Record review of Resident #61's Physician Orders dated 6/16/22 revealed: May use oxygen at 1LPM via nasal canula every shift, start date of 1/20/22. Change respiratory tubing, mask, bottled water, clean filter every 7 days, every night shift every Sunday, start date of 1/23/22. Check O2 every shift and PRN as needed, start date of 1/20/22. Record review of Resident #61's TAR for June 2022 revealed: Oxygen saturation levels ranging from 97% to 93% in the daytime to 97% to 92% in the evening time. Change respiratory tubing, mask, bottled water, clean filter every 7 days, every night shift every Sunday, with a staff signature for 6/5/22 and 6/12/22. During an observation on 6/14/22 at 11:18AM of Resident #61's room revealed, Resident did not have signage on doorway identifying oxygen use. Resident was not wearing oxygen at that time. The oxygen tubing with NC was laying on the floor near oxygen concentrator. There was no date on resident's humidifier bottle and/or tubing. There was not a bag present to place oxygen tubing inside while not in use. During an observation on 6/15/22 at 9:43AM of Resident #61, she was not wearing O2 at that time. The oxygen tubing was in a bag and the humidifier bottle had a date of 6/12/22. Resident #34 Record review of Resident #34's Face sheet dated 6/16/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis list that included: Pulmonary hypertension, Congestive heart failure, COPD, Nonspecific abnormal finding of the lung field, Dependency on supplemental oxygen. Record review of Resident #34's MDS dated [DATE] revealed a BIMS of 14 meaning no cognitive deficits. Active diagnosis list that included: Pulmonary: asthma, chronic obstructive pulmonary disease (copd), or chronic lung disease. Special Treatments: Oxygen therapy not selected while or while not a resident of the facility. Record review of Resident #34's Physician Orders dated 6/16/22 revealed: Change or clean the filter of the nebulizer machine every nightshift every Sun with a start date of 12/30/2021. Change respiratory tubing, mask, bottled water, clean filter q7d every nightshift every Sun with a start date of 12/30/2021. Check O2 sat Q shift and PRN as needed with a start date of 12/30/2021. Record review of Resident #34's TAR for June 2022 revealed: change respiratory tubing, mask, bottled water, clean filter q7d every nightshift every sun. Nurse signed off 6/5/22 and 6/12/22. During an observation and interview with Resident #34 on 6/14/22 at 11:22AM, she had O2 via NC at 3LPM. Her oxygen tubing had a date of 5/28/22. Resident #34 said she wore O2 on a continuous basis and did not know when the facility staff last changed her O2 tubing. Resident #34 did not have signage on her doorway to indicate that she used O2. During an observation and interview with Resident #34 on 6/15/22 at 10:03AM, her O2 tubing was dated 5/28/22. She said the facility staff had not been in to change her O2 recently. During an observation and interview with Resident #34 on 6/16/22 at 9:41AM, her O2 tubing was dated 5/28/22. She said facility staff had not changed her O2 tubing recently. Resident #53 Record review of Resident #53's Facesheet dated 6/16/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis list that included: Obstructive sleep apnea and COPD. Record review of Resident #53's MDS dated [DATE] revealed a BIMS of 15, meaning no cognitive deficits. Active diagnosis list that included: Pulmonary: asthma, chronic obstructive pulmonary disease (copd), or chronic lung disease. Special Treatments: Oxygen therapy while a resident of the facility. Record review of Resident #53's Care plan last revised 1/12/22 revealed: Resident has O2 therapy. The resident will have no signs of poor O2 absorption. O2 per NC. Record review of Resident #53's Physician Orders dated 6/16/22 revealed: May use O2 at 2 LMP via NC, with a revision date of 3/6/22. During an observation and interview with Resident #53 on 6/14/22 at 10:57am, her humidifier bottle on her O2 concentrator was dated 5/29/22, with no date on the O2 tubing. Resident did not have signage on her doorway to indicate O2 usage. She said it was about time to change her tubing. During an interview with LVN M on 6/16/22 at 8:55AM, he said night shift changed O2 equipment weekly, and both the tubing and bottle should be dated with a bag for the tubing when not in use. He said there should have been O2 signs on all doors that O2 was being used. LVN M said nurses and administration were responsible for ensuring signs were in place. He said the failure of not changing O2 equipment weekly could hibernate bacteria, cause discomfort for the resident if water ran out of the humidifier out and cause potential nose bleeds. He said the signs were meant to help staff and EMS know who had O2. During an interview with the DON on 06/16/22 at 10:31 AM, she said it was a standard nursing practice that the equipment, tubing, and bottle would be changed out weekly. She said it would also be a standard that it all got changed out at the same time, so the date on 1 item such as the bottle would be the date that the bottle and tubing was replaced. She said that differences could have been the night nurse was changing all residents O2 and missed Resident #61 and then when they came back from their day off, seen the equipment together in their cart and changed it all out, not changing the dates they already had prepared originally. During an interview with DON on 06/16/22 at 10:40 AM, she said the O2 policy addressed changing O2 equipment weekly but not specifically that an order to change the O2 equipment was needed. She said, she might have the nurses put a date all equipment including tubing and bottle to avoid that type of confusion again. DON said Resident #34 and #53 both wore continuous oxygen, so she wondered why they especially did not have recent dates. She said Resident #34 had a lot of nasal drainage routinely. During an interview with LVN E on 6/16/22 at 10:55AM, she said night shift staff changed out O2 equipment weekly. She said the resident should have a sign outside the door to indicate that O2 was in use in the room and to not smoke. Failure to change the O2 equipment weekly could cause their nose to get dry, cause distress, and the water in the humidifier to become stagnant. During an interview with ADM on 06/16/22 at 11:21 AM, she thought all the residents that used O2 had signs up on their doorway prior to survey entrance. She said she used to go through the facility and audit and make sure the signs were there. Record review of facility policy labeled Oxygen Administration last revised 2/13/07 revealed: Oxygenation administration disposable equipment should be changed weekly and PRN . Place NO SMOKING signs in area when oxygen is administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts (Hall A med cart, Hall B med cart) reviewed for medication labeling and storage. The A Hall medication cart contained one vial of Humulin R insulin for Resident #62 with an open date of 05/01/2022. The A Hall medication cart contained one Tresiba flex pen insulin for Resident #52 with no open date. The B Hall medication cart contained one Tresiba flex pen insulin with an open date of 04/29/2022 and one Humalog flex pen insulin with no open date for Resident #75. The B Hall medication cart contained one vial of Novolin R insulin for Resident #67 with an open date of 05/01/2022. The B Hall medication cart contained one vial of Insulin Lispro for Resident #229 with no open date. These failures could place residents who receive insulin at risk of exposure to medications and/or biologicals that are expired and/or contaminated. Findings Included: Record review of the electronic face sheet for Resident #62 reveled admission date 02/20/2017. Resident was [AGE] years old female with a diagnosis of diabetes. Record review of electronic physician's orders dated 06/14/2022 for Resident #62 revealed orders for Humulin R Inj U-100 Inject as Per Sliding Scale: If 201 - 250 = 2u; 251 - 300 = 4u; 301 - 350 = 6u; 351 - 400 = 7u, Subcutaneously Four Times A Day. Record review of the electronic face sheet for Resident #52 reveled admission date 02/10/2022. Resident was [AGE] years old male with a diagnosis of diabetes. Record review of electronic physician's orders dated 06/14/2022 for Resident #52 revealed orders for Tresiba FlexTouch Solution Pen-Injector 100 Unit/Ml Inject 15 Unit Subcutaneously One Time A Day. Record review of the electronic face sheet for Resident #75 reveled admission date 09/02/2021. Resident was [AGE] years old male with a diagnose of diabetes. Record review of electronic physician's orders dated 06/14/2022 for Resident #75 revealed orders for Tresiba Flex Inj 100unit Inject 6 Unit Subcutaneously One Time A Day for Dm And Humalog Kwik Inj 100/Ml Inject as Per Sliding Scale: If 151 - 200 = 2 U; 201 - 250 = 4u; 251 - 300 = 6u; 301 - 350 = 8u; 351 - 400 = 10u, Subcutaneously. Record review of the electronic face sheet for Resident #67 reveled admission date 02/29/2016. Resident was [AGE] years old female with a diagnose of diabetes. Record review of electronic physician's orders dated 06/14/2022 for Resident #67 revealed orders for NovoLIN R Solution 100 UNIT/ML Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 unit; 401 - 450 = 12 units, subcutaneously before meals for DM AND Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units, subcutaneously at bedtime for DM. Record review of the electronic face sheet for Resident #229 reveled admission date 05/13/2022. Resident was [AGE] years old female with a diagnosis of diabetes. Record review of electronic physician's orders dated 06/14/2022 for Resident #229 revealed orders for Insulin Lisp Inj 100/Ml Inject as per sliding scale: if 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401+ = 10 units, subcutaneously two times a day for diabetes. During on observation on 06/14/2022 at 10:10 AM of the B Hall medication cart with LVN A, a Tresiba flex pen insulin with an open date of 04/29/2022 and one Humalog flex pen insulin with no open date for Resident #75 was found. Further observation revealed one vial of Novolin R insulin for Resident #67 with an open date of 05/01/2022 and one vial of Insulin Lispro for Resident #229 with no open date. During on observation on 06/14/2022 at 10:20 AM of the A Hall medication cart with LVN A, a vial of Humulin R insulin for Resident #62 with an open date of 05/01/2022 and a Tresiba flex pen insulin for Resident #52 with no open date was found. During an interview on 06/14/22 at 10:50 AM, LVN A stated insulin should be dated upon opening or breaking the seal because Insulin was only good for 28 days after opening. He stated a lot of the outdated insulins were PRN and were hardly ever given was why it was missed. He stated nurses check the dates when giving the medication. During an interview on 06/14/22 at 03:36 PM the DON stated all insulins must be dated when opening and Insulins must be discarded within 28 days of opening. She was unsure why the failure occurred. She stated it was the nurse's responsibility to check dates prior to administration. She stated the nurses should audit the med carts weekly. She stated negative harm could be residents receiving expired medications and not receiving the desired effect of the medication. Record review of policy titled, Medication Storage and Labeling, last revised 02/2017 read in part . Multi-dose vials which have been opened or accessed (e.g., needle-punctured) should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial .

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1.The facility failed to ensure foods were sealed and/or labeled properly in refrigerators. 2.The facility failed to ensure areas in the kitchen were clean, exposing food and equipment to unsanitary conditions. 3.The facility failed to ensure food was cooled in a manner that prevents the growth of pathogenic microorganisms. 4.The facility failed to ensure that staff utilized proper personal hygiene practices. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: During observation and interview on 6/14/22 between 9:45AM and 10:30 AM of the Kitchen revealed: Cook A was standing at the stove cooking, wearing mask revealing both his nose and mouth. The only Hand washing station in kitchen was next to the plate warming cart. The plates in the warming cart were not covered which exposed plates for water to be splashed on top of them when staff were washing their hands . The trash can next to the hand wash station was not able to be opened by using the foot press, because there were large plastic lids sitting on top of the trash can Dry Storage: 1.An opened bottle of lemonade dated 2/16 that stated refrigerate after opening 2.One bottle of Worcestershire had a manufactured date 9/8/20 and had an open date of 9/9 . The outside of the bottle was grimy to touch, and the outside of bottle was soiled with dark brown stains. 3.Cajun Hot sauce dated 4/8/20, the DM stated bottle had expired 4. 22 plastic storage containers containing food . The tops were soiled with food crumbs and grimy to touch. 5.One plastic storage container filled with croutons and the lid was not sealed. 6.One plastic Container of bowtie pasta the and the lid was not sealed. 7.One plastic bag with a seal containing stuffing mix, not sealed. 8.One open bottle of BBQ sauce that was opened. The label stated it needed to be refrigerated after opening. 9.One plastic container with flour, the edge under the lid had a yellow substance that was greasy to touch. 10.One plastic container containing cheerios cereal did not have a lid. 11.One plastic container containing fruit loop cereal was not sealed. 12.Two opened bags of bread were noted with an open date and were not sealed. 13.Two packages of tortillas, out of original packaging, were not dated or labeled. 14.One plastic bag with seal containing tortilla chips was not sealed. Refrigerator 1: 1.One plastic container containing ketchup that was not sealed. 2.One plastic container containing gravy was warm to touch. 3.One plastic container of cream of mushroom soup dated 5/19/22. 4.One plastic container containing hash brown potatoes was not sealed. 5.One plastic container of Cherries revealed the outside of container was sticky to touch and there was a green/black fuzzy substance on the jar. Refrigerator 2: 1. Two bags of lettuce with use by date of 6/8/22. 2. One box containing 60 health shakes that were dated 5/29. The label read: do not leave thawed for more than 14 days. 3. One plastic container of Ham Salad dated 6/4/22. During observation of Kitchen on 6/14/22 between 11:00AM and 12:15 PM revealed : 1. [NAME] B walking around kitchen wearing mask with nose exposed while washing dishes and walking around kitchen putting up dishes. 2. [NAME] B touched mask and did not wash hands before putting lids on resident tea glasses. 3. [NAME] A after he washed hands, he threw the paper towels on table where he was preparing lunch puree. [NAME] A used the dirty paper towels to wipe hands during the puree process. [NAME] A washed hands several times and each time added the dirty paper towels on the table instead of the trash. 4. [NAME] A dropped the oven mitt on the floor and picked it up and put on countertop and then reused the oven mitt to remove pans with food from the warmer to the serving line. During observation of Kitchen on 6/14/22 at 1:45 PM revealed, [NAME] A and [NAME] B standing beside each with their mask work below their nose and mouth, while getting dishes out of the dishwasher. During interview on 06/14/2022 between 9:45 AM and 10:30 AM with DM, she stated the plate warming cart has always been next to the sink. DM stated she never thought to move it. DM stated that the plates sitting next to the sink could be contaminated while staff were washing their hands. DM stated the gravy should not have been in the refrigerator. DM stated that the gravy had not been cooled properly before placing it in the fridge, it should not be warm to touch. DM stated food items were dated when received and that open food items were labeled with date opened. DM stated food items not in original packaging should be labeled with an item description. DM stated leftovers should be thrown out after 7 days. DM stated the plastic containers used for storing food should be sealed and cleaned. DM stated when looking at the plastic containers they were not clean and needed to be cleaned. During interview on 06/15/2022 at 1:30 PM with DM, she stated staff should not have their mask off any time they were in the kitchen and mask should always cover their nose and mouth. DM stated staff had been trained on how to wear mask and the proper way to wash hands. DM stated soiled paper towels should be thrown in the trash can after they were used, they do not belong on counter where staff were working. DM stated if you drop an oven mitt on the floor it should go in the dirty laundry, it should not be used again. DM stated when new staff were hired, she trains on how to label, date and store food, that there was not a checklist or training they take. DM stated what lead to the failures that occurred in the Kitchen was that she just returned leave and trying to get things back in order from being on leave. During interview on 06/16/22 at 9:32 AM with ADM, she stated her expectation for labeling and storage of food was everything needs to be labeled and dated when comes in labeled and then when it was opened, and items should be thrown out after 7 days. ADM stated her expectation was that staff wear mask always covering their mouth and nose while in building. ADM stated staff have been trained on hand hygiene and mask wearing. ADM stated what led to failures in the kitchen was the DM has been off on maternity leave and other staff had to work on keeping kitchen going. ADM stated there had been a lot of confusion with cooperate coming to work and other staff covering in kitchen. During interview on 06/16/22 at 10:30 AM with [NAME] A, he stated he had been trained on wearing mask and washing hands. [NAME] A stated used paper towels should be thrown in the trash can after washing hands. [NAME] A stated he was in a hurry and didn't think about his mask being down or throwing paper towels away. During interview on 06/16/22 at 10:35 AM with [NAME] B, she stated she received training on how to wear mask and proper hand washing. [NAME] B stated she cannot breathe in her mask and that she was in a hurry. Record review of PPE and Hand Hygiene Checkoff dated May 22, 2022, revealed that [NAME] A and [NAME] B had completed and criteria met for the PPE and Hand Hygiene Checkoffs. Record review of policy titled, To Guide the use of Masks, dated September 2010 revealed: To prevent transmission and infectious agents through the air. Be sure that face mask covers the nose and mouth while performing services for the patient . Never touch the mask while it is in use . Follow established handwashing techniques. Record review of policy titled, Hand Washing, dated 2012 revealed: Discard used paper towels in trash receptacle. Record review of policy titled, Left-Over Foods, dated 2012 revealed: Leftover food shall be refrigerated, dated labeled and properly covered promptly after meal service. When cooling large quantities of food, divide into shallow pans and place on ice in the refrigerator. It must reach 70 degrees within two hours, and 41 degrees or below within four additional hours . Food that is spoiled, contaminated, or suspect shall not be served and shall be discarded immediately.

Based on observation, interviews, and record review the facility failed to maintain and test the automated external defibrillator (AED) device on B Hall according to the manufacturer's guidelines. The facility failed to ensure that AED on B hall had working batteries. This failure could affect the residents who did not have advanced directives and could cause delay in treatment and even death if the AED device was not working properly. The Findings included: Observation on 06/15/22 at 9:58 AM revealed one AED device located on the wall at the front of Hall B in a glass and metal covered cabinet in which the indicator on upper right side of unit was flashing red. During an observation and interview on 06/15/22 at 1:12 PM the DON inspected the AED device on B Hall and agreed the indicator light was flashing red. The DON stated the device had been used recently and that possibly depleted the battery. The DON stated the pads were replaced after use. The DON stated the check marks and initials on the daily form did not clearly answer the questions. The DON stated the night nurse was responsible for checking the active status. The device was checked daily and the nurse checking the device initialed the form titled Defibtech DDU-100 Operator Checklist The DON stated consequences of not having an AED functioning properly would be a delay in resident care response. She stated there was a second AED device in the locked unit. She stated she did not feel that one unit not working was an issue with a second unit available. The DON stated, with EMS so close to the facility, EMS could probably be at the facility before the AED was done analyzing for use. The DON stated when the AED was used recently, staff applied the pads and EMS arrived, removed the pads, and used their own equipment. During an interview on 06/16/22 at 9:08 AM CNA C stated the AED device was located on B hall but did not know where the second AED was located. The CNA stated if the AED device did not work, she would find the 2nd device. During an interview on 06/16/22 at 9:10 AM RN C stated she knew the night shift staff checked the AED device on B Hall. RN C stated the AED was used 4 days ago, and it was working then. During an interview on 06/16/22 at 10:12 AM the Admin stated she was not surprised that staff may not know there were 2 AED devices in the facility because they try to keep staff on locked unit separate from other staff, so it does not confuse the residents. The Admin stated consequences of an AED not working could be death of a resident. New hires were oriented to the location of the AED devices and were checked off on using it. The Admin stated she was aware having a second AED device behind a door that requires a code to enter and was in a closet at the end of the locked unit hall is not ideal but at least there was a backup device in the facility. Record review of Resident #6 progress notes dated 06/12/22 revealed the AED pads were applied to R #6, analysis was performed, and no shock advised was announced by the AED device. Review of the form titled Defibtech DDU-100 Operator Checklist for B Hall and D Hall dated 6/2022 revealed initials and check marks for the daily questions of Check the Active Status Indicator. Is it flashing green? Yes or No, and Unit is clean and without visible defects? Yes or No under dates 1 through 14. Review of facility policy, no date, titled Automatic External Defibrillator, Use and Care of under Maintaining the AED, item 2 stated Check the device and perform maintenance tasks, as directed. Review of the Operating Guide stored with the AED device on B Hall dated 06/08/2018 stated, in part, on page 17 an LED indicator located in the corner of the unit actively indicates unit status. If the unit is fully operational, the Activity Status Indicator (ASI) will blink green and if the unit needs attention, the ASI will blink red