**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to attempt to use alternatives prior to installing a side or bed rail and assess the resident for risk of entrapment from bed rails prior to installation for 2 of 2 residents (Resident #4 and Resident #9) reviewed for bed rails. The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails for Resident #4 and Resident #9. These failures could place residents at risk for injury and restricted movement. The findings included: Resident #4 Record review of Resident #4's electronic face sheet dated 09/19/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, unsteadiness on feet, muscle weakness, reduced mobility, and need for assistance with personal care. Record review of Resident #4's annual MDS assessment dated [DATE] revealed: BIMS score of 03 meaning severe cognitive impairment; Section GG (Functional Abilities) revealed Resident #4 needed moderate assistance going from sitting to lying and maximal assistance going from lying to sitting on side of the bed; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #4's care plan reviewed on 09/19/2024 revealed Focus: ADL self-care performance deficit r/t confusion, dementia, impaired balance. Date Initiated: 05/14/2024. Interventions: SIDE RAILS MAY HAVE ½ RAILS UP X 2 AS ENABLER Date Initiated: 05/14/2024. Record review of Resident #4's electronic physician orders dated 09/19/2024 revealed physician's order dated 07/30/2023 with instructions MAY HAVE ½ SIDERAILS UP X 2 AS AN ENABLER. Record review of Resident #4's electronic records on 09/19/2024 revealed no evidence of an attempt to use alternatives to bed rails or an assessment for the risk of entrapment. During an observation on 09/17/2024 at 3:15 p.m., Resident #4's bed had half rails on both sides of the bed and were in the up position. During an observation on 09/19/2024 at 9:06 a.m., Resident #4 was lying in bed and had half rails on both sides of the bed and were in the up position. Resident #9 Record review of Resident #9's electronic face sheet dated 09/19/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, difficulty in walking, diabetes, and cerebral infarction (stroke). Record review of Resident #9's quarterly MDS dated [DATE] revealed BIMS score of 11 meaning moderate cognitive impairment; Section GG (Functional Status) revealed Resident #9 was independent with going from sitting to standing position; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #9's care plan reviewed on 09/19/2024 revealed Focus: ADL self-care performance deficit r/t abnormal gait and impaired mobility. Intervention: SIDE RAILS: MAY HAVE ½ SIDERAILS UP X 2 AN ENABLER. Record review of Resident #9's electronic physician orders dated 09/19/2024 revealed physician's order dated 07/28/2023 with instructions MAY HAVE ½ SIDERAILS UP X 2 AN ENABLER. Record review of Resident #9's electronic records on 09/19/2024 revealed no evidence of an attempt to use alternatives to bed rails or an assessment for the risk of entrapment. During an observation and interview on 09/18/2024 at 10:02 a.m., Resident #9 was lying in her bed with half rail on left side of the bed in up position. Resident #9 stated she used the rail for mobility when she exited the bed. During an observation on 09/19/2024 at 9:06 a.m., Resident #9 was lying in bed and had half rail on left side of the bed in the up position. During an interview on 09/19/2024 at 8:56 a.m., LVN C stated she did not do risk for entrapment or bed rail assessments. She stated she did not know who performs those assessments . During an interview on 09/19/2024 at 9:00 a.m., the ADON stated she guessed she was who was responsible to perform the risk of entrapment assessments on the residents who had bed rails. She stated both Resident #4 and Resident #9 used bed rails for mobility. She stated no risk of entrapment assessment had been performed. She stated not performing assessment could lead to facility not ensuring safety of residents when using bed rails. During an interview on 09/19/2024 at 9:02 a.m., the DON stated the facility had not performed a risk of entrapment on residents who had bed rails. She stated for safety reasons, assessments should have been performed. The DON stated no negative outcome had occurred from the assessments not being performed . Review of the facility policy titled Bed Safety and Bed Rails dated August 2022 revealed: The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent .Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include: a. roll guards; b. foam bumpers; c. lowering the bed; and/or d. use of concave mattresses to reduce rolling off the bed .The resident assessment to determine risk of entrapment includes, but is not limited to: a. medical diagnosis, conditions, symptoms, and/or behavioral symptoms; b. size and weight; c. sleep habits; d. medication(s); e. acute medical or surgical interventions; f. underlying medical conditions; g. existence of delirium; h. ability to toilet self safely; i. cognition; j. communication; k. mobility (in and out of bed); and l. risk of falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 8 residents (Resident #1, Resident #32, and Resident #57) reviewed for comprehensive care plans. The facility failed to ensure Resident #1 had a care plan to address an indwelling urinary catheter, a continuous blood glucose monitoring device (a sensor worn by the resident that continuously provides real-time blood sugar, or glucose, levels), and weight loss. The facility failed to ensure Resident #32 had a care plan to address a physician's order for a fall mat. The facility failed to ensure Resident #57 had a care plan to address a physician's order for hospice services. These failures could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: Resident #1 Record review of Resident #1's electronic face sheet revealed a [AGE] year-old male, admitted [DATE] with medical diagnoses of pressure wounds on the left buttock and left heel, high blood pressure, chronic migraine headaches, diabetes, and parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors). Record review of Resident #1's admission MDS dated [DATE] revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed a BIMS score of 15 on a 0-15 scale, indicating intact cognition . Record review of Resident #1's physician orders dated 09/12/2024 revealed an order for [brand name] device (Continuous Glucose System Receiver ). Record review of Resident #1's weights revealed he weighed 158 pounds on 07/29/2024 and 136 pounds on 09/10/2024 indicating a 13.92% weight loss. Review of Resident #1's care plan revised on 08/02/2024 revealed no evidence addressing weight loss, catheters, or glucose monitoring. During an on observation on 09/19/24 at 9:50 AM, Resident #1 had an indwelling urinary catheter with the collection bag hanging on the right side of the bed draining by gravity . Resident #32 Record review of Resident #32's electronic face sheet revealed an [AGE] year-old male admitted [DATE] with medical diagnoses of dementia, heart disease, enlarged prostate, and high blood pressure. Record review of Resident #32's Quarterly MDS dated [DATE] in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed a BIMS score of 3 on a 0-15 scale, indicating severe cognitive impairment. Record review of Resident #32's physician's order dated 08/10/2024 revealed Fall mat at bedside every day and night shift for falls. Record review of Resident #32's care plan dated initiated and revised 06/19/2024, indicated the resident was at risk for falls. Utilizing a fall mat was not included in the interventions. Focus: [Resident] is at risk for falls d/t Confusion, Gait/balance problems, Incontinence, Poor communication/comprehension, Unaware of safety needs, Vision/hearing problems. Goal: The resident will be free of falls throughout the review date. Target date 08/26/2024. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that the resident is wearing appropriate footwear WHEN UP mobilizing in w/c. Follow facility fall protocol. Record review of Resident #32's Quarterly MDS dated [DATE] in Section J - Health Conditions, subsection J1900 Number of Falls Since Admission/Entry or Reentry or Prior Assessment. revealed Resident #32 experienced 2 falls without injury and one fall with injury (skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall related injury that causes the resident to complain of pain). During an observation on 09/17/24 at 10:43 AM, Resident #32 was in his room with a visitor. No fall mat was seen in the room. Resident #57 Record review of Resident #57's electronic face sheet revealed an [AGE] year-old female admitted [DATE] with medical diagnoses of lung cancer, liver cancer, high blood pressure, and chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breathe). Record review of Resident #57's admission MDS dated [DATE], Section C - Cognitive Patterns, subsection C0500. BIMS Summary Score revealed a score of 4 on a 0-15 scale indicating severe cognitive impairment. Section O-Special Treatments, Procedures, and Programs, subsection K1 revealed the resident was receiving Hospice care. Record review of Resident #57's physician's order dated 08/05/2024 revealed an order to Admit to [provider] hospice. Record review of Resident #57's Comprehensive Care Plan dated 08/14/2024 revealed hospice care services were not addressed. During an interview on 09/19/24 at 2:10 PM, CNA E stated she only looked at care plans when she had a question about a resident. She stated the nurse would pull the care plan up on the computer and show her the information she needed. CNA E stated the nurses were responsible for making the care plans . During an interview on 09/19/24 at 2:15 PM, LVN D stated the DON was responsible for the care plans. LVN D stated catheters should be included on the care plan. She stated not including catheters on a resident's care plan may cause the resident to not receive the care needed. LVN D stated a continuous blood glucose monitor device also should be included on the care plan. During an interview on 09/19/24 at 2:22 PM, with the DON and the MDS Coordinator, the DON stated the MDS Coordinator was responsible for creating the care plan, but the DON was ultimately responsible. The DON stated catheters should be addressed on the care plan. The DON stated she did not think the effect on the resident would be consequential and stated, we still know it's there and have orders for it. The DON stated hospice services should be addressed on the care plan. She stated care plans were reviewed and updated on admission, annually, and when needed. The DON stated her expectations for completing care plans was for all information on how to best assist the residents was included. The MDS Coordinator stated she was new to do doing care plans. She stated she had years of experience with completing the MDS. Training on how to complete care plans was by learning on the job. During an interview on 09/19/24 at 2:41 PM, LVN D stated the continuous glucose monitoring device used by Resident #1 should be addressed on the care plan. She stated the DON made changes to the care plans when needed. LVN D stated the resident could possibly not receive the care needed if the information was not included on the care plan. During an interview on 09/19/24 at 2:43 PM, the DON stated an indwelling urinary catheter should be addressed on the care plan. The DON stated the continuous glucose monitoring device should be addressed on the care plan. The DON stated weight loss experienced by Resident #1 should be addressed on the care plan. She stated the care plan included interventions to prevent further weight loss. She stated the issues would not have a negative effect on residents because the staff had physician's orders for care and the staff were aware the resident had the monitoring system. The DON stated she did not know why these failures occurred. She explained the MDS coordinator was responsible for the care plans and the DON was responsible for monitoring the review and revision of the care plans. Record review of facility policy dated March 2022, Care Plans, Comprehensive Person-Centered, Item 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, . Item 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to conduct regular inspections of all bed frames and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 2 of 2 (Residents #4 and #9) residents reviewed for bed rails. The facility did not conduct regular inspections of bed rails, including Residents #4 and #9's beds. This failure could place residents who have bed rails at risk for injury related to poor maintenance of the bed rails. The findings included: Resident #4 Record review of Resident #4's electronic face sheet dated 09/19/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, unsteadiness on feet, muscle weakness, reduced mobility, and need for assistance with personal care. Record review of Resident #4's annual MDS assessment dated [DATE] revealed: BIMS score of 03 meaning severe cognitive impairment; Section GG (Functional Abilities) revealed Resident #4 needed moderate assistance going from sitting to lying and maximal assistance going from lying to sitting on side of bed; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #4's care plan reviewed on 09/19/2024 revealed Focus: ADL self-care performance deficit r/t confusion, dementia, impaired balance. Date Initiated: 05/14/2024. Interventions: SIDE RAILS MMAY HAVE ½ RAILS UP X 2 AS ENABLER Date Initiated: 05/14/2024. Record review of Resident #4's electronic physician orders dated 09/19/2024 revealed physician's order dated 07/30/2023 with instructions MAY HAVE ½ SIDERAILS UP X 2 AS AN ENABLER. Record review of Resident #4's electronic records on 09/19/2024 revealed no evidence of regular inspections of bed rails. During an observation on 09/17/2024 at 3:15 p.m., Resident #4's bed had half rails on both sides of the bed in the up position. During an observation on 09/19/2024 at 9:06 a.m., Resident #4 was lying in bed and had half rails on both sides of the bed in the up position. Resident #9 Record review of Resident #9's electronic face sheet dated 09/19/2024 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, difficulty in walking, diabetes, and cerebral infarction (stroke). Record review of Resident #9's quarterly MDS dated [DATE] revealed BIMS score of 11 meaning moderate cognitive impairment; Section GG (Functional Status) revealed Resident #9 was independent with going from sitting to standing position; and Section P (Restraints and Alarms) revealed physical restraints bed rail not used. Record review of Resident #9's care plan reviewed on 09/19/2024 revealed Focus: ADL self-care performance deficit r/t abnormal gait and impaired mobility. Intervention: SIDE RAILS: MAY HAVE ½ SIDERAILS UP X 2 AN ENABLER. Record review of Resident #9's electronic physician orders dated 09/19/2024 revealed physician's order dated 07/28/2023 with instructions MAY HAVE ½ SIDERAILS UP X 2 AN ENABLER. Record review of Resident #9's electronic records on 09/19/2024 revealed no evidence of regular inspections of bed rails. During an observation and interview on 09/18/2024 at 10:02 a.m., Resident #9 lying in her bed with half rail on the left side of the bed in an up position. Resident #9 stated she used the rail for mobility when she exited the bed. During an observation on 09/19/2024 at 9:06 a.m., Resident #9 was lying in bed and had half rail on the left side of the bed in the up position. During an interview on 09/19/2024 at 8:24 a.m., the MD stated he installed the bed rails to bed frames. He stated he did not perform routine bed rail, mattress, or bed frame assessments for risk of entrapment. He stated he would inspect the bed rail if he had been told rails were loose by housekeeping or the nursing staff. He stated he did not keep a log of those inspections. He stated he did not know who monitored that those inspections had been performed. The MD stated he had not performed inspections because he had not known to routinely inspect bed frames, mattresses, or bed rails . During an interview on 09/19/2024 at 8:31 a.m., the ADMN stated the MD would check bed rails if he had been told by a CNA that something was wrong with bed rails. She stated she did not know who monitored inspections were done but would get the facility policy to review. During a follow up interview on 09/19/2024 at 10:40 a.m., the ADMN stated the facility ensured the inspection of all bed frames, mattresses, and bed rails by the maintenance director who would correct any issues when staff brought issues to his attention. She stated the CNAs knew when a bed rail was not working appropriately and could monitor the equipment was working appropriately. She stated the equipment was inspected and maintained according to manufacturer's recommendations since no regular inspections were listed in Medline's instructions for installing rail. The ADMN stated she did not know if inspections were documented but would look in the maintenance log. She stated no negative effect had occurred to residents. She stated the maintenance director would report that he had repaired a bed rail in some of the morning meetings, but no documentation could be given to show what bed or room he had performed the repair . Review of facility policy titled Bed Safety and Bed Rails dated August 2022 revealed: Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail, and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA. Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. The maintenance department provides a copy of inspections to the administrator and report results to the QAPI committee for appropriate action. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee.

Based on observations, interviews, and record review 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 heated to a temperature of 165 degrees F and held at least 15 seconds when food temperature was below 140 degrees F. 2. The facility failed to ensure temperature logs were completed for all meal services. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an interview on 09/17/2024 at 10:30 a.m., [NAME] B stated she pureed beef taco meat with cold milk in the blender until it reached appropriate texture. She then placed pureed beef taco meat into a pan and into the steam table. During an observation on 09/17/2024 at 10:33 a.m., beef taco puree was in aluminum pan sitting in the steam table. [NAME] B pureed charro bean soup. She added prepared charro bean soup and cold milk to blender. She blended both together until food reached pudding texture. She then placed pureed charro bean soup into oiled aluminum pan and placed pan into the steam table. During an interview on 09/17/2024 at 10:52 a.m., [NAME] B stated she had performed all steps of pureeing beef and beans. She stated she was done with pureed foods. During an interview on 09/17/2024 at 10:53 a.m., [NAME] A stated she would place food in the oven after pureeing to make sure the food temperature reached a temperature of 140 degrees F. During an observation and interview on 09/17/2024 at 10:54 a.m., [NAME] B stated she forgot to place pureed foods in the oven after pureeing them. [NAME] B obtained the temperature of 110 degrees F of pureed beans from the pan sitting on the steam table. [NAME] B obtained the temperature of 95 degrees F of pureed meat from the pan sitting on the steam table. [NAME] B covered both pans with foil and placed pans into oven. During an observation on 09/17/2024 at 11:30 a.m., binders of food temperature logs in the kitchen revealed: March 25, 2024, no logged food temperatures for items served during supper. March 26, 2024, no logged food temperatures for items served during supper. March 27, 2024, no logged food temperatures for items served during supper. March 31, 2024, no logged food temperatures for items served during supper. April 17, 2024, no logged food temperatures for items served during breakfast or lunch. April 18, 2024, no logged food temperatures for items served during breakfast or lunch. May 1, 2024, no logged food temperatures for items served during lunch except Meat 1. May 2, 2024, no logged food temperatures for items served during lunch except Meat 1. June 3, 2024, no logged food temperatures for items served during supper. June 4, 2024, no logged food temperatures for items served during supper. June 18, 2024, no logged food temperatures for items served during lunch. June 19, 2024, no logged food temperatures for items served during lunch and only cereal oats temperature logged for breakfast. June 24, 2024, no logged food temperatures for items served during breakfast or lunch. June 25, 2024, no logged food temperatures for items served during breakfast or lunch. June 26, 2024, no logged food temperatures for items served during breakfast or lunch. July 1, 2024, no logged food temperatures for items served during breakfast or lunch. July 2, 2024, no logged food temperatures for items served during breakfast or lunch. September 16, 2024, no logged food temperatures for items served during supper. September 17, 2024, no logged food temperatures for items served during supper. September 18, 2024, no logged food temperatures for items served during supper. September 19, 2024, no logged food temperatures for items served during supper. September 20, 2024, no logged food temperatures for items served during supper. September 21, 2024, no logged food temperatures for items served during supper. September 22, 2024, no logged food temperatures for items served during supper. September 23, 2024, no logged food temperatures for items served during supper. September 24, 2024, no logged food temperatures for items served during supper. September 25, 2024, no logged food temperatures for items served during supper. September 26, 2024, no logged food temperatures for items served during supper. September 27, 2024, no logged food temperatures for items served during supper. September 28, 2024, no logged food temperatures for items served during supper. During an observation on 09/17/2024 at 11:36 a.m., [NAME] B obtained temperature of 148 degrees F of pureed beans in the pan taken out of the oven. She placed the pan of beans onto the steam table. [NAME] B obtained temperature of 127 degrees F of pureed meat. She placed the pan back into the oven. During an observation on 09/17/2024 at 11:45 a.m., [NAME] A obtained temperature of 151.7 degrees F of pureed meat. She placed the pan of meat onto the steam table. During an interview on 09/17/2024 at 10:42 a.m., the ADMN stated all residents eat out of the kitchen. During an interview on 09/17/2024 at 12:31 p.m., the DM stated she expected for food recipes to be followed. She stated if a recipe stated to bring up food temperature to 165 degrees F, then the kitchen staff should have heated food to 165 degrees F. She did not state any negative effects on the residents. The DM would not comment on if food had been in danger zone or what effect not reheating to 165 degrees F could have on the residents. She stated she monitored that food temperatures were logged, and the recipes were followed. She stated she expected for temperature logs to be filled out with the temperatures for all meals. She stated the kitchen staff may have forgotten to fill in the log and staff turnover may have led to failure of temperature logs to be completed. She stated not filling out temperature logs could lead to infections in residents . During a telephone interview on 09/19/2024 at 8:13 a.m., the Dietitian stated the kitchen staff could add cold milk into the food to be pureed but the food would need to be reheated to 165 °F for 15 seconds after it was pureed. She stated if the recipe stated to heat food to 165 °F she expected for the kitchen staff to follow the recipe. She stated the guidelines state, the goal was for food to be heated to 165 °F for 15 seconds for food safety. After food had been heated to 165 °F it could be maintained at 135 °F. The Dietitian stated she expected for food temperature logs to be completed with temperatures of the food that was obtained prior to serving. She stated failing to log food temperatures could lead to the DM not knowing temperatures of food for that meal service. She stated the DM monitored the food temperature logs were completed. She did not know why the food temperature logs had not been completed for all meal services or why the Cooks did not heat the food to 165 °F during preparing steps . During an interview on 09/19/2024 at 8:29 a.m., the ADMN stated she expected for kitchen staff to heat the food to 165 °F if the recipe stated to. She stated not heating food to appropriate temperatures could lead to food not being safe to eat. She stated she expected for the food temperature binder to be filled out every meal. She stated the food temperature log was proof that the temperature of the food had been correct for the safety of serving out to residents. She stated the DM monitored recipes were followed and the temperature of foods were appropriate. The ADMN stated the DM monitored that the food temperature logs were filled out every meal. She stated she did not know why foods were not heated to 165 °F for 15 seconds after food temperature dropped below 140 °F or why the temperature logs were not completed. Record review of policy titled, Daily Food Temperature Control with no date revealed: We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges .Prior to meal service, the cook shall take the temperature of all hot and cold foods .Temperatures are recorded on the Temperature Log form .All hot foods shall be cooked and held for service at temperatures of 140 degrees F or above. Any hot or cold food which does not meet the minimum acceptable temperature shall be heated to a temperature of 165 degrees F and held at least 15 seconds. Record review of pureed charro bean soup recipe dated June 3, 2024, revealed: Reheat to an internal temperature of >165F held for 15 seconds .Maintain at an internal temperature of >140F for only 4 hours. Record review of pureed soft beef taco recipe dated June 3, 2024, revealed: Reheat to an internal temperature of >165F held for 15 seconds .Maintain at an internal temperature of 140F for only 4 hours. According to the FDA (Food and Drug Administration) Food Code (https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 09/19/2024), revealed: 3-403.11 Reheating for Hot Holding. (A) Except as specified under (B) and (C) and in (E) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74°C (165°F) for 15 seconds. (B) Except as specified under (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD reheated in a microwave oven for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74°C (165°F) and the FOOD is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. (C) READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that has been commercially processed and PACKAGED in a FOOD PROCESSING PLANT that is inspected by the REGULATORY AUTHORITY that has jurisdiction over the plant, shall be heated to a temperature of at least 57°C (135°F) when being reheated for hot holding. (D) Reheating for hot holding as specified under (A) - (C) of this section shall be done rapidly and the time the food is between 5ºC (41ºF) and the temperatures specified under (A) - (C) of this section may not exceed 2 hours. (E) Remaining unsliced portions of MEAT roasts that are cooked as specified under 3-401.11(B) may be reheated for hot holding using the oven parameters and minimum time and temperature conditions specified under 3-401.11(B).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 2 residents reviewed for quality of care. The facility failed to ensure the nurses initialed and dated wound dressings when wound care was performed on Resident #1 This failure could result in residents with wounds not having their treatments performed as ordered, wounds becoming infected, and decreased wound healing. Findings include. Record review of face sheet dated 6/11/24 indicated Resident #1 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including Hemiplegia (weakness caused by brain or spinal cord problems) and Hemiparesis (weakness on one side) following Cerebral Infarction (blood in the brain) affecting left non-dominant side, Cerebellar Stroke Syndrome, unsteadiness on feet, muscle weakness, reduced mobility, depression, Hyperlipidemia (high levels of fat) and disorder of the Autonomic Nervous system. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS of 1 which indicates severe cognitive impairment. Record review of the physician orders dated 6/10/24 indicated Resident #1, left thigh had an order to cleanse, pat dry, apply Xeroform (non-adherent, occlusive wound dressing) and super absorbent dressing every Tuesday, Thursday, and Saturday until healed. Record review of the TAR dated 6/1/24 through 6/11/24 indicated Resident #1's wound care treatment was being performed on Resident #1's left thigh by the facility. During an observation on 6/11/24 at 2:15pm, Resident #1 was sitting in his wheelchair in the dining room listening to music being played. Resident #1 was wearing shorts and the dressing to his thigh was visible. The dressing was clean and did not look old. The dressing did not have a date or initials. Interview on 6/11/24 at 2:45pm RN B stated she performed wound care on Resident #1 on 6/11/24 at 8:00 AM. RN stated she does wound care Tuesday, Thursday, and Saturday. Surveyor and RN looked at Resident #1's dressing, and the dressing was not dated or initialed. RN stated she did not have a marker at the time of treatment and forgot to go back and date/initial. During an interview on 6/12/24 at 1:20pm, LVN A stated it is important to date and initial wound care bandages because, if different nurses were working the hall, or the nurse was not going to be there the next day, the dressing should be initialed and dated to show wound care has been performed. Interview on 6/12/24 at 2:45pm DON stated her expectations for wound care were do wound care as ordered, follow infection control, let DON know if there is a change or question about the wound and/or wound care, document in the TAR, do a skin report, initial and date on the dressing, and follow policy. Review of facility's (No date) Wound Care policy Steps in the Procedure, Step #13 reflected 'Dress wound, mark wound dressing with initials and date'.

Based on observation, interview, and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident, for 1 of 1 lunch meal reviewed. The facility failed to follow the recipe when preparing the puree bread. This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake. Findings included: During an observation on 08/07/2023 at 10:45 AM, [NAME] did not follow the recipe while she pureed sliced bread . [NAME] placed sliced bread into processor and added milk and pancake syrup to the processor. During an interview on 08/09/2023 at 2:25 PM, the DM stated her expectation was cooks follow the recipes. The DM stated staff have always added the pancake to the puree bread. The DM stated residents' diets could have been affected by adding the syrup because it was not calculated in their calorie count. The DM stated what led to failure was that cooks did what they always did and did not follow the menu. During an interview on 08/09/2023 at 5:35 PM, the ADMN stated her expectation was the cooks should have followed the recipe for puree. The ADMN stated the DM was responsible for ensuring cooks followed recipes. The ADMN stated effect on residents could have been residents' calorie intake could have been altered. The ADMN stated cooks not reading and following recipes led to failure. Record review of facility recipe titled roll, revealed May add liquid to reach desired consistency. Ex[example] reserved liquid/juice, milk. Record review of facility policy titled, Food and Nutrition Services dated October 2017 revealed Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property by failing to conduct a criminal history/EMR/NAR verification on employees prior to employment and/or annually for 13 of 14 (ADMN, DON, SW, AD, DM, DE, RN-A, RN-B, LVN-C, LVN-D, CNA-E, CNA-F, CNA-G) employees reviewed for employability. Facility staff did not have criminal history check and/or an EMR/NAR check prior to offering employment to the facility and/or annually for employees. These findings placed residents at risk of receiving care by someone that was unemployable. The findings included: Record review of the ADMN the personnel file revealed a hire date of 09/08/2014. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the DON the personnel file revealed a hire date of 09/13/2021. There was no documentation evidence of an annual EMR/NAR found in the file Record review of the SW the personnel file revealed a hire date of 09/05/2022. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the AD the personnel file revealed a hire date of 08/30/2021. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the DM the personnel file revealed a hire date of 11/08/2011. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the DE the personnel file revealed a hire date of 12/19/2020. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of the personnel file revealed a hire date of 12/19/2020. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of RN-A the personnel file revealed a hire date of 08/15/2011. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the RN-B the personnel file revealed a hire date of 07/13/2022. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of LVN-C the personnel file revealed a hire date of 11/12/2014. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of LVN-D the personnel file revealed a hire date of 04/23/2014. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the CNA-E the personnel file revealed a hire date of 03/21/2016. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the CNA-F the personnel file revealed a hire date of 12/16/2021. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the CNA-G personnel file revealed a hire date of 07/21/2017. There was no documented evidence of a Criminal History check prior to employment. There also was no annual EMR/NAR check found in the file. An interview on 08/09/23 at 6:37 PM the ADMN stated the facility had not had a steady HR in the past year. The HR the facility had previously had not kept up with the EMR's or criminal background checks of employee staff. She stated the responsibility of this should have been HR, but being they had no one at that time, the responsibility fell on her as ADMN. She stated the negative impact to residents was, there was not one, as she felt the EMR's, and background checks were somewhere in the facility with management not able to find them. She stated the failure was not having a steady HR and not having a corporate lifeline to guide the upper management on what was needed to run the facility correctly. The ADMN stated her expectations were for the EMR's and background checks to be completed on every facility staff member and expecting the new HR coming in to be trained to her full extent following policies and guidelines. Review of facility policy Background Screening Investigations dated 2001 and revised 2019 revealed: Policy Statement Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants four positions with direct access to residents (direct access employees). Policy Interpretation and Implementation 1. For purposes of this policy direct access employee means any individual who has access to a resident or patient of a long-term care (LTC) facility or provider through employment or through a contract and has duties that involve (or may involve) one-on-one contact with the patient or resident of the facility or provider, as determined by the state for purposes of the national background check program. 2. The director of personnel, or designee, conducts background checks, reference checks and criminal conviction check (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment. 3. 3. For any individual applying for a position, the state EMR search is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or have the property have been entered into the applicants file. Review of the New Hire Application for Employment revealed: the included document DPS Computerized Criminal History (CCH) Verification with the revised date of 09/2015.

Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for one of one facility. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 10 days of the second quarter of year 2023. This failure placed the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings included: Review of facility's RN nursing schedule for RN for 01/2023-02/2023, 10 of the 59 days (01/07/2023, 01/08/2023, 01/14/2023, 0115/2023, 01/21/2023, 01/22/2023, 02/04/2023, 02/05/2023, 02/18/2023, and 02/19/2023) reflected there was no RN coverage. An interview on 08/09/23 at 6:26 PM the Admn stated it was the DON who was responsible and monitored the RN coverage. She stated when someone calls in, the DON would usually come in and if not, the on-call RN should had been called. The ADMN stated the negative impact for residents was there could possibly be a crisis with a resident requiring the care of an RN, which could have possibly led to an increased risk of possible illness or worse. She stated the failure occurred when the facility tragically lost an RN and at that time, they were searching for another RN leaving them down two RN's. The ADMN stated she was not sure why the DON did not come into the facility to cover for those days previously missed. The ADMN expectations were to have the required RN coverage, following the facility policy and procedures. An interview on 08/09/2023 at 6:40 PM, the DON stated they should follow the protocols, having an RN on a rotation. She stated the protocols were to have an RN or DON. She stated they were down two RN's during that time. The DON stated it would have been herself who was responsible in this being monitored. She stated she felt there were no negative impact as she was confident and trusts in her staff being LVN's. The DON stated her expectations from now on were for the facility to have the proper RN coverage. Record review of facility policy titled, Staffing, Sufficient and Competent Nursing dated 2001, revised August 2022, revealed the following: Policy Statement Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in according with resident care plans and the facility assessment. Policy Interpretation and Implementation: Sufficient Staff . .3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RN's may be scheduled more than eight hours depending on the acuity needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days for 3 (Resident #18, Resident #41, and Resident #2) of 8 residents reviewed for unnecessary medications. 1. The facility failed to ensure Resident #18's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. 2. The facility failed to ensure Resident #41's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. 3. The facility failed to ensure Resident #2's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. These failures place residents at risk for psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: Resident # 18 Review of Resident #18's electronic face sheet revealed resident was an [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Anxiety, Depression, and Cerebral Infarction (brain stroke). Review of Resident #18's Annual MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score not performed; Section N- Medication's resident received Antianxiety medication 0 days out of the last 7 days of review period. Review of Resident #18's electronic physician orders revealed: Lorazepam Oral tablet 0.5mg give 1 tablet by mouth every 4 hours as needed for anxiety with a start date of 06/28/2022 and no end date. Review of Resident #18's physician progress notes from January 2023- August 2023 revealed no documented rationale for the continued provision of lorazepam. Review of Resident #18's electronic MAR for August 2023 revealed no doses of Lorazepam had been administered. Record review of Drugs.com for Lorazepam accessed on 08/10/2023 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Resident #41 Review of Resident #41's electronic face sheet revealed resident was an [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Anxiety, Depression, Insomnia, and Dementia. Review of Resident #41's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 10 (moderate cognitive impairment); Section N- Medication's resident received Antianxiety medication 0 days out of the last 7 days of review period. Review of Resident #41's electronic physician orders revealed: Lorazepam Oral Concentrate 2MG/ML give 1 ml by mouth every 4 hours as needed for Anxiety with a start date of 03/15/2022 and no end date. Review of Resident #41's physician progress notes from January 2023- August 2023 revealed no documented rationale for the continued provision of lorazepam. Review of Resident #41's electronic MAR for August 2023 revealed no doses of Lorazepam had been administered. Record review of Drugs.com for Lorazepam accessed on 08/10/2023 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Resident #2 Record review of Resident #2's electronic face sheet revealed resident was a [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Dementia, Anxiety, and high blood pressure. Review of Resident #2's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 99 (indicating resident was unable to complete the interview); Section N- Medication's resident received Antianxiety medication 0 days out of the last 7 days of review period. Review of Resident #2's electronic physician orders revealed: Lorazepam Oral Tablet 0.5mg give 1 tablet by mouth every 6 hours as needed for Anxiety with a start date of 06/28/2023 and no end date. Review of Resident #2's physician progress notes from January 2023- August 2023 revealed no documented rationale for the continued provision of lorazepam. Review of Resident #2's electronic MAR for August 2023 revealed no doses of Lorazepam had been administered. Record review of Drugs.com for Lorazepam accessed on 08/10/2023 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. During an interview on 08/09/2023 at 3:40 PM, the ADON stated her, and the facility staff were unaware that PRN psychotropic medications could only be ordered for 14 days. She stated the pharmacist had not mentioned anything about this to the facility. During an interview on 08/09/2023 at 5:58 PM, the DON stated she was not aware of the regulation on PRN psychotropic medications. She stated it was her responsibility to be current and up to date on regulations. She stated she had not seen it on the pharmacy consult review. She stated the harm to the resident could be receiving medication not needed or being over medicated. Review of document titled, Consult Pharmacist Report, dated 04/13/2023 revealed: Recommendations and Additional Comments: .3. PRN psychoactive medication orders should indicate how long the order is to be in effect, otherwise they are only good for 14 days. The physician can indicate a longer duration for the order and hospice can indicate that it is good for the duration of hospice services. The duration must be indicated on the order itself for easy reference. Review of facility policy titled, Nursing Services Policy and Procedure Manual for Long-Term Care, revised July 2022 revealed: Behavior, Mood, and Cognition: .12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. A. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order .

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerator. The facility failed to ensure all food was not kept past expiration date. These failures could place residents that eat from the kitchen at risk for food borne illnesses. Findings included: During an observation on 08/07/2023 between 10:20 AM and 11:00 AM revealed: Refrigerator #1 1. One open container of cottage cheese without an open date, labeled with a use by date of 07/02/2023. 2. Two containers of sour cream labeled with a use by date of 07/28/2023. 3.One opened container of sour cream without an open date, labeled with a use by date of 07/07/2023. 4.One bag with a seal contained celery that had brown spots on celery with and open date of 07/02/2023. Freezer #1 1.An open package of chicken strips not labeled with an item description or an open date. During an interview on 08/09/2023 at 2:25 PM, the DM stated her expectation was that food was labeled when received and again when opened and that items be discarded after 5 days of being opened. The DM stated effect on residents could have been residents had gotten food poisoning. The DM stated staff not paying attention to dates led to failure of items not being discarded. The DM stated the cooks, dietary aides and the DM were responsible to ensure items were thrown out. The DM stated they did not have a policy. During an interview on 08/09/2023 at 5:35 PM, the ADMN stated her expectation was that food items were labeled correctly and were discarded when past the use by date. The ADMN stated receiving food past the 'use by date could have caused residents not to receive flavorful food or could have gotten sick. The ADMN stated staff being confused about not knowing policy was what led to failure. The ADMN stated the DM was responsible for monitoring to ensure food was stored and labeled correctly and not kept past use by date. Review of Food Code 2022 accessed https://www.fda.gov/media/164194/download 08/16/2023 revealed in annex 3 page 17: the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind.

Based on observations, interviews and record reviews, the facility failed to ensure that the quality assessment and assurance committee developed and implemented appropriate plans of actions to correct identified quality deficiencies for the failing to conduct criminal history/EMR/NAR verifications on employees prior to employment and/or annually for 13 of 14 (ADMN, DON, SW, AD, DM, DE, RN-A, RN-B, LVN-C, LVN-D, CNA-E, CNA-F, CNA-G) employees reviewed for employability reviewed in that: The Facility HR failed to correct and monitor a quality deficiency identified on the previous survey, regarding employee criminal history, and EMR/NAR checks had been performed since previous past noncompliance. These findings placed residents at risk of receiving care by someone that was unemployable due to abuse/neglect charges in the past. Findings Include: Record review of the ADMN the personnel file revealed a hire date of 09/08/2014. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the DON the personnel file revealed a hire date of 09/13/2021. There was no documentation evidence of an annual EMR/NAR found in the file Record review of the SW the personnel file revealed a hire date of 09/05/2022. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the AD the personnel file revealed a hire date of 08/30/2021. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the DM the personnel file revealed a hire date of 11/08/2011. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the DE the personnel file revealed a hire date of 12/19/2020. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of the personnel file revealed a hire date of 12/19/2020. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of RN-A the personnel file revealed a hire date of 08/15/2011. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the RN-B the personnel file revealed a hire date of 07/13/2022. There was no documented evidence of an initial or annual EMR/NAR check found in the file. Record review of LVN-C the personnel file revealed a hire date of 11/12/2014. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of LVN-D the personnel file revealed a hire date of 04/23/2014. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the CNA-E the personnel file revealed a hire date of 03/21/2016. There was no documented evidence of a Criminal History check prior to employment. There also was no initial or annual EMR/NAR check found in the file. Record review of the CNA-F the personnel file revealed a hire date of 12/16/2021. There was no documented evidence of an annual EMR/NAR check found in the file. Record review of the CNA-G personnel file revealed a hire date of 07/21/2017. There was no documented evidence of a Criminal History check prior to employment. There also was no annual EMR/NAR check found in the file. Review of the facility's CMS 2567/facility-submitted Plan of Correction dated 07/27/2022 which was submitted in response to the 07/14/2022 SSA recertification survey revealed: Facility failed to conduct a criminal history/EMR/NAR verification on employees prior to employment and/or annually for 9 of 13 (DON, AD, DM, LVN-JB, LVN-MM, Cook-A, NA-NC, CNA-AL, RN-WA) employees reviewed for employability. Identification of other residents having the potential to be affected include: All resident that resides in the facility have a potential to be affected. Actions taken/systems put into place to reduce the risk of further occurrences include: Staff reeducated on the requirement from proper background checks in relation to the hiring process, annual checks, and as needed. An interview on 08/15/2023 at 7:10 PM, the ADMN stated previous deficiencies were to be monitored and followed up by the Department Heads and ADMN staff as well as the MD. She stated previous deficiencies of personnel files not being followed up should have been discussed and addressed in the QAPI. She stated they were only discussed in the morning meetings, but remembered them being discussed with HR. The ADMN stated she had not been in the position of ADMN and was not sure how to address previous issues with QAPI and stated she was unaware of these deficiencies previously cited. The ADMN stated it was her responsibility to monitor as well as Department Heads to follow up on previous deficiencies cited. The ADMN stated the negative impact for residents were that it could have interfered with safety and health or their well-being if not addressed in a timely manner. She stated what lead to the failure was, there was no ADMN at that time after the previous survey as well as no leader to oversee or correct those situations. The ADMN's expectations were for those matters of previous citations to be addressed in a timely manner for those issues and not to arise in upcoming surveys. There was no POC policy provided during survey time while in facility prior to exit.

Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 6 of 12 meetings reviewed for QAPI. The facility did not ensure the MD, or a representative attended QAPI meetings in January 2023, February 2023, March 2023, April 2023, May 2023, June 2023 and July 2023. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings included: Record review of sign in sheets for QAPI meetings in January 2023, February 2023, March 2023, April 2023, May 2023, June 2023 and July 2023 revealed no evidence that the MD attended QAPI meeting. During an interview on 08/09/2023 at 4:38 PM the ADMN stated the only way to verify that MD attended meetings was his signature on the sign in sheets. The ADMN stated that the MD was a required member of the QAPI team but did not attend the meetings. Record review of facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program- Analysis and Action dated March 2023 revealed: Quality deficiencies that are identified with feedback and data and will undergo appropriate corrective action. Corrective actions are monitored against established goals and benchmarks by the QAPI committee. The QAPI program overseen by the QAPI committee, is designed to identify and address quality deficiencies through the analysis of the underlying cause and actions targeted at correcting systems and comprehensive level. Record review of document titled Quality Assurance Committee Members , without a date, revealed MD was a member of the committee. Record review of Medical Director Agreement signed 04/17/2012 and renewed on 11/1/2015 revealed: The agreement addresses the medical director's responsibilities for the following: Serving as a member of the organized medical staff, attending its meetings, and helping to ensure adherence to the medical staff bylaws, rules, and regulations. Participating in establishing policies, procedures and guidelines designed to ensure the provision of adequate comprehensive services. Participation in the resident care management system.

Based on interviews and record reviews, the facility failed to maintain an infection control program for identifying and reporting a communicable disease for 2 of 75 employees and 1 of 56 residents reviewed for mitigation of Covid-19. 1 staff member tested positive for Covid 19 on 6/30/22 and the facility did not report the case to HHSC until 7/12/22. 1 staff member tested positive for Covid 19 on 7/3/22 and the facility did not report the case to HHSC until 7/12/22 1 resident tested positive for Covid 19 on 7/8/22 and the facility did not report the case to HHSC until 7/12/22. These failures placed all residents and staff at risk of adverse effects of Covid 19 infections. Findings included: During an interview on 7/12/22 at 10:00AM with DON and ADON, the DON said they had 1 resident on transmission-based precautions due to testing positive for Covid 19. ADON said they had a staff member test positive for Covid 19 on 6/30/22. They began doing outbreak testing and then another employee tested positive on 7/3/22, then they had 1 resident test positive for Covid 19 on 7/8/22. ADON said the facility did not report the positive cases to HHSC because she was unaware the facility was supposed to report the cases to HHSC. ADON said the administrator usually handled reporting things to HHSC, but the facility did not have an administrator at the time of the first positive case. DON said she was not aware that Covid 19 was a reportable illness. ADON said she had looked online, and it did not show Covid 19 as an illness that was reportable, so she thought it was fine. The ADON said she reported to NHIS weekly for illnesses and vaccination status and thought that was how HHSC found out about the facility cases and not through facility doing their own self-reporting to HHSC. Record review of TULIP intake 363488 accessed on 7/20/22 at https://txhhs.lightning.force.com/lightning/r/RS_Case__c/a2e8y0000002QTTAA2/view revealed: Date Received: 7/12/2022 4:03 PM . Facility First Learned of Incident 6/30/2022 3:00 PM . Date and Time of the Incident 6/30/2022 3:00 PM . NOTE 07/14/22: THE FACILITY IS ON THE 07/11/22 RECOVERED COVID-19 SPREADSHEET. NO OTHER COVID-19 INCIDENTS FOUND IN TULIP WITHIN THE PAST 14 DAYS . Narrative of the incident: This employee began to feel ill during work, congestion, and fatigue. We at the facility tested this employee and he showed positive for COVID 19. Actions and notifications: Employee was removed from facility and placed on 10-day quarantine, He is fully vaccinated Record review of facility policy labeled Covid-19 Novel Coronavirus dated 7/14/2021 revealed: Positive Staff . Immediate Action (0-24 hours) . Complete Self Report to HHSC . within 2 hours . If a resident receives a positive test result . Self-Report to state within 2 hours via TULIP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property by failing to conduct a criminal history/EMR/NAR verification on employees prior to employment and/or annually for 9 of 13 (DON, AD, DM, LVN-JB, LVN-MM, Cook-A, NA-NC, CNA-AL, RN-WA) employees reviewed for employability. HR staff did not have run criminal history check and/or an EMR/NAR check prior to offering employment to the facility and or annually for long term employees. These findings placed residents at risk of receiving care by someone that was unemployable due to abuse/neglect charges in the past. Findings included: During an interview with HR on 7/13/22 at 2:30PM, she said that while she was getting requested personnel records ready for surveyor review, she was not able to find that some of the employees had a criminal history check and/or an EMR/NAR run prior to their employment or annually. She said she had been working as HR for a short time and those employees were hired prior to her assuming the responsibilities of HR. During an interview with HR on 7/14/22 at 9:30AM, she said that the facility was not in compliance with the criminal history/EMR/NAR checks prior to 7/12/22. During an interview with DON on 7/14/22 at 3:30PM, she said that she did not realize that employees did not have their criminal history/EMR/NAR ran prior to employment or annually until HR was reviewing the personnel files requested for survey. She felt that the failure occurred because the former HR was not running the checks and she did not properly train the new HR. Record review of Personnel Files on 7/13/22 revealed: DON with a hire date of 9/18/14. Last criminal history was run 7/13/22 with HR unable to determine when previous criminal history was run, and last EMR/NAR date was 5/25/21. DM with a hire date of 11/8/11 with a last EMR/NAR date of 7/13/22 with HR unable to determine when previous EMR/NAR had been run. Cook-A with a hire date of 1/11/22 with a criminal history and EMR/NAR date of 1/13/22. AD with a hire date of 1/17/13 with a last EMR/NAR date of 7/13/22 with HR unable to determine when previous EMR/NAR had been run. LVN-JB with a hire date of 1/25/16 with no previous criminal history run date and EMR/NAR date of 7/13/22, HR unable to determine last annual criminal history/EMR/NAR run date. LVN-MM with a hire date of 5/2/22 with an EMR/NAR date of 7/13/22, HR unable to determine previous EMR/NAR run date. RN-WA with a hire date of 3/20/18 with no previous criminal history/EMR/NAR run date, HR unable to determine previous criminal history/EMR/NAR run date. NA-NC with a hire date of 8/13/21 with criminal history/EMR/NAR run date of 7/13/22, HR unable to determine previous criminal history/EMR/NAR run date. CNA-AL with a hire date of 3/28/22 with criminal history/EMR/NAR run date of 7/13/22, HR unable to determine previous criminal history/EMR/NAR run date. Record review of facility Resident Abuse Policy revised March 2017 revealed: Our policy is based on the October 3rd in 2006 provider letter number O6-32 regarding guidelines for reporting abuse and the [NAME] abuse prevention program manual published in 2000. In order to prevent and reduce potential for abuse, every new employee's background and criminal history is investigated before they are hired. The human resource manager, or their designee, will conduct a search through the DPS criminal background history and a check is run through the sex offender registry to see if they have any records. Certain offenses will prevent them from being hired. Also, the employee misconduct registry and nurse aide registry is searched for recorded violations before they are allowed to have any contact with our residents. Record review of Employee Handbook undated revealed: Background checks will be performed prior to employment and annually by Human Resources Coordinator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide, based on the comprehensive assessment and care plan, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 3 of 3 residents reviewed for activities (Residents #28, #58, #38). The facility failed to provide activities to Residents #28, #58, and #38 and to the rest of the residents who resided on the Alzheimer's unit. This failure could place residents at risk for decline in social and mental psychosocial wellbeing. Findings included: Review of the face sheet on 07/14/2022 for Resident #28 revealed he was [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Paralysis of right dominant side, Cognitive communication deficit, Anxiety Disorder, and Loss of expressive speech. Review of Resident #28's MDS dated [DATE] revealed Section C BIMS score was 00 which indicated he had severe cognitive Impairment. Review of Resident #28's Care Plan dated 04/21/2022 for activities revealed: Remind/encourage to attend, assist to activities as needed. Provide for in-room activities as needed and required. Review of Resident #28's Physician's Orders dated 07/01/2022 revealed the resident may participate in activities as tolerated. Review of the face sheet on 07/14/2022 for Resident #58 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Unspecified dementia (impaired ability to remember) with behaviors, Osteoarthritis, and High blood pressure. Review of Resident #58's MDS dated [DATE] revealed Section C BIMS score was 00 which indicated she had severe cognitive impairment. Review of Resident #58's Care Plan dated 06/23/2022 for activities revealed: Remind/encourage to attend, assist to activities as needed. Provide for in-room activities as needed and required. Review of Resident #58's Physician's Orders dated 07/01/2022 resident may participate in activities as tolerated. Review of the face sheet on 07/14/2022 for Resident #38 revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Unspecified dementia (impaired ability to remember) with behaviors, High blood pressure, and Unsteadiness on feet. Review of Resident #38's MDS dated [DATE] revealed Section C BIMS score 03 which indicated severe cognitive impairment. Review of Resident #38's Care Plan dated 05/26/2022 revealed: Remind/encourage to attend, assist to activities as needed. Provide for in-room activities as needed and required. Review of Resident #38's Physician's Orders dated 07/01/2022 resident may participate in activities as tolerated. Observed on 07/12/2022 at 2:23 PM the activities calendar had dominoes scheduled at 3:30 PM. Observed on 07/12/2022 at 3:30 PM there were no activities being conducted with the residents on the certified Alzheimer's unit. Review of the July 2022 activities calendar revealed at 9:30 AM puzzles was scheduled. Observed on 07/13/2022 at 9:30 AM there were no activities being conducted with the residents on the certified Alzheimer's unit. Review of July 2022 activities calendar revealed craft time was scheduled for 03:30 PM. Observed on 07/13/2022 at 3:30 PM there were no activities being conducted with the residents on the certified Alzheimer's unit. Review of July 2022 activities calendar revealed at 9:30 AM revealed building was scheduled. Observed on 07/14/2022 at 9:30 AM there were no activities being conducted with the residents on the certified Alzheimer's unit. Review of July 2022 activities calendar Memory Game was scheduled for 03:30 PM. Observed on 07/14/2022 at 3:30 PM there were no activities being conducted with the residents on the certified Alzheimer's unit. Interview with the AD on 07/14/2022 at 10:16 AM she stated she comes over to the certified Alzheimer's unit two times a day. She stated only one resident that participates with her in the activity for that day. She stated there is a calendar with scheduled activities for the residents. She stated yesterday (07/13/2022) she had an appointment, and she did not make it over to certified Alzheimer's unit. She stated usually the staff will engage the residents in activities if she was not available. Interview with the DON on 07/14/2022 at 2:20 PM she stated that there should be activities for the residents on the certified Alzheimer's unit. The DON stated they try to have the aides do puzzles and coloring with the residents. The DON stated she was am not sure why the AD was not over there Tuesday (07/12/2022) and Wednesday 07/13/2022. She stated that most of the residents on that unit were not able to do activities due to their cognitive status. The DON stated the residents should have activities at least daily. She stated their activity schedule has at least 2 activities a day. She stated she was responsible for overseeing the AD and her schedule. Review of facility's Activity Programs policy dated Revised August 2006: Policy statement: Activity programs designed to meet the needs of each resident are available on a daily basis. 1. Our activity programs are designed to encourage and maximum individual participation and are geared to the individual's needs. 2. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs. 3. Our activity programs consist of individual and small and large group activities that are designed to meet the need and interests of each resident. Review of facility's policy titled: Individual Activities and Room Visit Program dated Revised August 2006 Policy Statement: Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities, and for those residents who do not wish to attend group activities. Residents who are able to maintain an independent program will have supplies available to them. 1. Individual activities are provided for individuals who have conditions or situations that prevent them from participating in group activities, or who do not wish to do so. 2. For those residents whose condition or situation prevents participation in group activities, and for those who do not wish to participate in group activities, the activities. The activities offered are reflective of the resident's individual activity interests, as identified in the Activity Assessment, progress notes and the resident's Comprehensive Care Plan.

Based on interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 3 (DM, [NAME] A and Dietary Aide A) of 9 dietary staff did not have Food Handler's certificates. The facility failed to ensure that dietary staff (DM, [NAME] A and Dietary Aide A) serving in the kitchen were working with a current Food Handler Certificate. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses due to lack of dietary staff training. Findings include: Record review of the DM's employee file revealed no evidence of Food Handler certificate. Record review of [NAME] A's employee file revealed no evidence of Food Handler certificate. Record review of Dietary Aide A's employee file revealed no evidence of Food Handler certificate. Record review of CMS Form 672 dated 7/12/2022 revealed all residents ate from the kitchen. During an interview on 07/14/22 at 2:00 PM with the DM, she stated she did not have her food handlers certificate up to date. The DM stated [NAME] A and Dietary Aide A did not have current food handler's certificates, that they had expired. During an interview on 07/14/22 at 2:21 PM with the DON, she stated all dietary staff should have a food handler certification upon hire and keep their certification updated. The DON stated staff not having a current food handlers certification can affect residents by residents not receiving food prepared properly which could make residents sick. The DON stated the DM was responsible for ensuring food handlers certificates were up to date. The DON stated she was not sure what lead to the failure of dietary staff not having current food handler certificates. Record review of Job Description for Food Service Worker, not dated, revealed: Job Qualifications . Licensure, Registry or certification: Texas Food Handlers Certification.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. The facility failed to ensure all food was not past expiration date. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: Observation of the kitchen on 07/12/2022 between 10:15 AM and 11:00 AM revealed: Dry Storage 1. One 28 oz can of diced tomatoes that was dented. 2. One 10.5 oz can of chicken broth that was dented. 3. One can 104 oz can of apple slices that was dented. 4. Two 115 oz cans of ketchup that were dented. 5. One open 50 lb bag of flour that was not sealed and exposed to air. Fridge #1 1. One opened 5lb container of cottage cheese with a use by date of 6/24/22. 2. One opened 5lb container of cottage cheese with a use by date of 6/11/22. 3. Two unopened bags of coleslaw with a use by date of 7/10/22. 4. One unopened bag of lettuce with a use by 7/11/2022. 5. One open bag of lettuce with a use by date of 7/11/22. 6. One open bag of carrots with a use by date of 6/27/22. 7. One unopened bag of carrots with a use by date of 6/27/22. Fridge #2 1. One 10 lb tube of defrosted hamburger meat not in original container was not labeled with a date or item written on the tube. The hamburger meat was in a container labeled ground meat with a date of 7/7/22. 2. Five single serving tubs containing ranch dressing that were not labeled with item or an open date. 3. One container (previously purposed for cottage cheese) containing apple crisp that was not sealed. 4. One cool whip container containing chocolate pudding not in original packaging. During an interview on 07/12/2022 between 10:15 AM and 11:00 AM with the DM, she stated that she was the DM and started in June 2022. The DM stated the dented cans should not have been in the storeroom, that they are taken to a separate room down the hall. The DM stated dented cans should not be used, they need to be thrown out or sent back to supply company. The DM stated the hamburger meat should be defrosted in the fridge and used within 24 hours or thrown out. The DM did not know why the hamburger meat was not dated or how long it had been in the fridge to defrost. The DM stated that everyone was responsible for dating and throwing out expired items. The DM stated it was her responsibility to go behind kitchen staff to ensure they were doing what needed to be done. The DM stated leftovers should have been thrown out after 3 days. The DM stated that leftovers should have been stored in clear plastic containers not reusing cool whip or cottage cheese containers. The DM stated she had told staff not to reuse cool whip or cottage cheese containers to store leftovers. The DM stated the cool whip and cottage cheese containers to do not seal properly and containers not sealing properly could cause food to spoil, loose flavor, take on flavors from the fridge, and could develop bacteria. The DM stated these failures could lead to residents becoming sick with food poisoning from salmonella or other bacteria. DM stated what lead to the failures in kitchen was that she was new and is trying to get everything in order. During interview on 07/14/22 at 2:21 PM with the DON, she stated her expectation in the kitchen was food needs to be labeled with date opened and item description. The DON stated food should be thrown out when the expiration date is met. The DON stated leftovers should be stored in appropriate containers, not in reused cool whip or cottage cheese containers because the reused containers do not seal properly. The DON stated hamburger meat should have been used or discarded within 24 hours, after setting out for defrosting. The DON stated the failures in the kitchen could affect residents by residents becoming sick from food born illness. The DON stated what led to failures in kitchen was staff refusing to follow the policy and the DM not going back and checking. DON stated the DM was responsible for the kitchen. During interview on 07/14/22 at 3:38 PM with the DM, she stated staff were trained when hired on proper storage and labeling and thinks there was a check off list but does not know where to find the check off list. The DM also stated they have had some in-services but does not know where previous DM stored them. During interview on 07/14/22 at 3:39 PM with HR, she stated she has not seen any type of check off list or trainings on food handling, storage, or labeling. Record review of CMS Form 672 dated 7/12/2022 revealed all residents ate from the kitchen. Record review of the policy titled, Refrigerators and Freezers, dated December 2014 revealed: All food should be appropriately dated to ensure proper rotation by expiration dates. 'Received' dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. 'Use by' date will be completed with expiration dates on all prepared food and refrigerators. Expiration dates on unopened food will be observed and 'used by' dates indicated once food is opened. Supervisors will be responsible for ensuring food items and pantry, refrigerators, and freezers are not expired or past perish dates. Supervisor should contact vendors or manufacturers when expiration dates are in question or to decipher codes. Record review of policy titled, Food Receiving and Storage, dated July 2014 revealed: Dry foods that are stored in bins will be removed from original packaging, labeled and dated (used by date). Such foods will be rotated using a 'first in- first out' system. All foods stored in the refrigerator or freezer will be covered, labeled, and dated ('use by' date).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 facility reviewed for administration. There was no active licensed administrator in the facility from [DATE] to [DATE]. The facility did not report the 3 new active positive cases of Covid 19 that began on [DATE]. The facility had not been doing criminal history, EMR/NAR checks prior to employment and/or annually for 9 of 13 staff reviewed. The facility was not ensuring employees had dementia training for employees that included staff for the certified Alzheimer's unit of the facility for 3 of 13 staff reviewed. These findings placed all residents at risk of not achieving their highest practicable physical, mental, psychosocial well-being. Findings included: During an interview with DON and ADON on [DATE] at 10:00AM, DON said the facility did not have an ADM at the moment for the facility. ADON said ADM-A left in mid-April of 2022 or May of 2022 and the facility had a consultant in the building as acting ADM-B, but he had a Louisiana license, and he could not get it transferred to Texas, so he left in mid -[DATE]. DON said she was the acting ADM as well as the DON for the facility at that time. DON said she did not have an active ADM license. ADON said the ADM was who usually reported Covid-19 cases to HHSC and did a spreadsheet that tracked the positive Covid-19 cases to the HHSC program manager of the facility. ADON said she had looked online and did not find that Covid-19 was a reportable illness. During an interview with HR on [DATE] at 2:30PM, she said the former HR person had removed a lot of the computerized training, and HR did not realize the staff was not completing the orientation or annual training prior to the review of personnel files. HR said she was working on getting the computerized training added back for the staff to be able to complete all required trainings. She said that while she was getting requested personnel records ready for surveyor review, she was not able to find that some of the employees had a criminal history check and/or an EMR/NAR run prior to their employment or annually. She said she had been working as HR for a short time and those employees were hired prior to her assuming the responsibilities of HR. During an interview with HR on [DATE] at 9:30AM, she said the facility was not in compliance with employee background checks or trainings prior to [DATE]. During an interview with DON and ADON on [DATE] at 3:11PM, DON said she was the acting ADM, DON, and abuse coordinator for the facility. DON said the former HR person was not doing criminal history checks and/or EMR/NAR checks prior to new staff employment and the DON did not realize they were not being completed. DON said the former HR person was not sure about which staff needed what trainings, so she removed a lot of the trainings from the facility's computerized training system and DON did not realize they were not being completed by new staff on orientation or annually. DON said the facility had an active licensed certified Alzheimer's unit in the facility. ADON said the HR department sent out a weekly delinquent training schedule for the staff of each department to each of the department managers that they followed, but if it was not in the system then it would not show that it was delinquent anyway. DON said she felt that the reason for the failure of the trainings and background checks were in part, because of the changing of the former to the new HR personnel and the new HR personnel not being properly trained. DON said that some of the failures with the reporting of Covid 19 were due to no actual ADM at that time and the DON and ADON not knowing that it was reportable. DON said the facility did not notify HHS about either administrator leaving and the facility not having an administrator. Record review of ADM hire dates on [DATE] were as follows: ADM-A with an active NFA license with expiration date of [DATE] with last renewal of [DATE]. Hired [DATE] and a termination date of [DATE]. ADM-B with an expired NFA license as of [DATE] with a hire date of [DATE] and a termination date of [DATE]. Record review of Administrator Job Description dated February 2017 revealed: Plans, organizes and directs the operations of the center home. Takes all reasonable steps to assure that quality long term care services are provided through the center home. Coordinates long term care activities with outside agencies and offices . Licensure, Registry or Certification: Current licensure by the Texas Board of Licensure for Nursing Home Administrator . Adopts and enforces rules and regulations relative to the level of health care and safety of the residents, and others, and for the protection of their personal property and civil rights ensures that a person in authority is designated if the facility does not have an administrator and ensures that the designated person notifies the Texas Department of Human Resources. Assures that in the absence of an administrator another employee of the facility is authorized, in writing, to act on the administrator's behalf. Record review of facility policy labeled Covid-19 Novel Coronavirus dated [DATE] revealed: Positive Staff . Immediate Action (0-24 hours) . Complete Self Report to HHSC . within 2 hours . If a resident receives a positive test result . Self-Report to state within 2 hours via TULIP. Record review of TULIP intake 363488 accessed on [DATE] at https://txhhs.lightning.force.com/lightning/r/RS_Case__c/a2e8y0000002QTTAA2/view revealed: Date Received: [DATE] 4:03 PM . Facility First Learned of Incident [DATE] 3:00 PM . Date and Time of the Incident [DATE] 3:00 PM . NOTE [DATE]: THE FACILITY IS ON THE [DATE] RECOVERED COVID-19 SPREADSHEET. NO OTHER COVID-19 INCIDENTS FOUND IN TULIP WITHIN THE PAST 14 DAYS . Narrative of the incident: This employee began to feel ill during work, congestion, and fatigue. We at the facility tested this employee and he showed positive for COVID 19. Actions and notifications: Employee was removed from facility and placed on 10-day quarantine, He is fully vaccinated Record review of Personnel Files on [DATE] revealed: DON with a hire date of [DATE]. Last criminal history was run [DATE] with HR unable to determine when previous criminal history was run, and last EMR/NAR date was [DATE]. DM with a hire date of [DATE] with a last EMR/NAR date of [DATE] with HR unable to determine when previous EMR/NAR had been run. Cook-A with a hire date of [DATE] with a criminal history and EMR/NAR date of [DATE]. AD with a hire date of [DATE] with a last EMR/NAR date of [DATE] with HR unable to determine when previous EMR/NAR had been run. LVN-JB with a hire date of [DATE] with no previous criminal history run date and EMR/NAR date of [DATE], HR unable to determine last annual criminal history/EMR/NAR run date. LVN-MM with a hire date of [DATE] with an EMR/NAR date of [DATE], HR unable to determine previous EMR/NAR run date, no dementia training. RN-WA with a hire date of [DATE] with no previous criminal history/EMR/NAR run date, HR unable to determine previous criminal history/EMR/NAR run date. NA-NC with a hire date of [DATE] with criminal history/EMR/NAR run date of [DATE], HR unable to determine previous criminal history/EMR/NAR run date, no dementia training. CNA-AL with a hire date of [DATE] with criminal history/EMR/NAR run date of [DATE], HR unable to determine previous criminal history/EMR/NAR run date. CNA-SJ with a hire date of [DATE] with no dementia training. Record review of facility Resident Abuse Policy revised [DATE] revealed: Our policy is based on the [DATE]rd in 2006 provider letter number O6-32 regarding guidelines for reporting abuse and the [NAME] abuse prevention program manual published in 2000. In order to prevent and reduce potential for abuse, every new employee's background and criminal history is investigated before they are hired. The human resource manager, or their designee, will conduct a search through the DPS criminal background history and a check is run through the sex offender registry to see if they have any records. Certain offenses will prevent them from being hired. Also, the employee misconduct registry and nurse aide registry is searched for recorded violations before they are allowed to have any contact with our residents. Record review of Employee Handbook undated revealed: Background checks will be performed prior to employment and annually by Human Resources Coordinator. Record review of Employee Handbook undated revealed: Education and Training. All employees are required to fulfill regulatory training requirements per Long Term Care/Skilled Nursing Facility license mandates per Texas Department of Health and Human Services Commission .All employees . will have monthly and/or annual training assigned . It is requirement of successful employment . Human Resources assigns and tracks completion of all online training . In-service training is provided as needed, in an effort to improve and maintain knowledge of ever-changing health care and Long-Term requirements.