**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (LVN B) staff members and 2 of 4 residents (Residents #6 and Resident #22) reviewed for infection control procedures. LVN B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #6 and Resident #22 was observed using blood pressure cuffs on two other unknown residents. LVN B failed to cleanse his hands following using blood pressure machine and prior to administering medications for Resident #6 and Resident #22. The failures could place residents at risk for cross contamination and infections. Findings included: Record review of Resident #6's quarterly MDS assessment, dated 05/07/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included: Cerebrovascular Accident (stroke), hemiplegia (paralysis)and hypertension with multiple sites. Resident #6 was a BIMS of 3 indicating cognitive impaired and required assistance of one staff for activities of daily living. Record review of Resident #6's physician's orders dated 05/01/2025 reflected, amlodipine (high blood pressure) tablet 5 mg one tab by mouth once a day, atorvastatin tablet 10 mg (high blood pressure) tablet give one tab at bedtime. Record review of Resident #22's Quarterly MDS dated , dated 05/23/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #22 had diagnosis with included: hypertension (high blood pressure), Cerebral Vascular Accident (stroke), and paraplegia (loss of lower extremities). Record review of Resident #22's physician's orders dated 05/01/2025 reflected, Norvasc (high blood pressure) tablet 25 mg one tab by mouth once a day, metoprolol 100 mg (high blood pressure) one tablet by mouth two times a day. Observation on 06/16/2025 at 9:48 a.m., revealed LVN B taking the blood pressure machine into Resident #6's room to check her blood pressure. LVN B placed on gloves used the blood pressure cuff on Resident #6 to check her blood pressure. LVN B then removed his gloves, placing them in the trash and walked out of the room without washing his hands or using hand sanitizer. LVN B then prepared Resident #6's medications and returned to Resident #6's room. LVN B proceeded to give Resident #6 her medications. LVN B removed the blood pressure machine out of the room, did not wipe the machine down with Sani wipes. LVN did not clean his hands prior to moving to the next resident to administer medications Observation on 06/16/2025 at 10:21 a.m., revealed LVN B taking the blood pressure machine into Resident #22's room to check her blood pressure. LVN B used the blood pressure cuff on Resident #22 to check her blood pressure. LVN B then prepared Resident #22's medications and returned to Resident #22's room. LVN B proceeded to give Resident #22 her medications. LVN B removed the blood pressure machine out of the room, did not wipe the machine down with Sani wipes. LVN B did not wash his hands or use hand sanitizer prior to or after administering resident's medications. An interview on 06/16/2025 at 10:30 a.m., LVN B stated if they did not wash their hands or use a hand sanitizer it could spread germs to other residents. LVN B stated the equipment, like the blood pressures machine should be cleaned between every resident, with Sani Wipes. LVN B stated that if the blood pressure cuffs were not cleaned appropriately then it could spread germs to the other residents. LVN B stated he was busy using new blood pressure machine and did not think about infection control. An interview with the DON, who was the infection control preventionist, on 06/17/2025 at 1:20 p.m., revealed the DON stated that all direct care staff must clean equipment, including blood pressure cuffs after having contact with each resident, and Sani-wipes were available. The staff should be washing their hands or using hand sanitizer after direct care contact with any resident. The DON stated when giving medications they should be cleaning their hands before and after and in between each resident. The DON stated, the staff had available the disinfectant wipes that would kill all germs. The DON stated the staff would be in-serviced on infection control and she would perform teaching concerning infection control. If they did not clean the blood pressure cuffs appropriately, they could spread germs to themselves and the residents. Record review of an in-service records with the DON reflected: dated 05/01/2025, revealed LVN B had received cleaning and properly storing equipment after each use, standard infection control precautions, and hand hygiene. Record review of the Facility's Policy titled Infection Control dated revised 2015, reflected: To ensure training is provided to all staff that outlines the definition of Infection control as it relates to the work place and utilized for ongoing in-service. Procedure: Standard precaution: . treat all materials, instruments, and surfaces as if they are infected .Handwashing: . wash hands after each direct contact as accepted by professional practice. After removing gloves or any other personal protective equipment such as gloves, 1. Infection control Practices: A. Infection control includes all those activities carried out to prevent or limit the spread of daises. Infection control measures are safety measures Record review of the Facility's Policy titled Routine Procedures Handwashing revised dated July 2014 reflected: It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff. Purpose: hand washing/hand hygiene is generally considered the most important singe procedure for preventing the transmission. Record review of the Facility's Policy titled Cleaning and Disinfecting of Resident-Care Items and Equipment revised dated July 2014 reflected: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected .d. reusable items are cleaned and disinfected or sterilized between residents .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's main kitchen. 1. The facility failed to ensure food items in the refrigerator were stored sealed and not exposed to air in accordance with the professional standards for food service. 2. The facility failed to ensure dented cans were placed in a separate storage area. These failures could place residents at risk for food-borne illness and cross contamination. Findings Include: Observation of the walk-in refrigerator on 06/16/2025 at 9:26 am revealed the following: - 1 tub of grated parmesan cheese, 5 lbs., packed on 02/26/2025 open date 05/29/2025 was exposed to the air. - 1 - 7 lb. can of chocolate pudding received 03/22/2025, with no best by date, was dented on the bottom rear of can. - 1 - 6 lb. 39 oz can of cut baby corn received by date 03/13/2025, with no best by date, dented on the top and bottom right side seal. Interview with DM on 06/16/2025 at 9:45 am, said he looks at the cans when they come off the delivery truck to check for dented cans and will return them to the delivery driver for a refund or he will put the can on the dented can shelf. He stated if the cooking staff find a dented can they are responsible for putting the dented can on the dented can shelf. He said a dent is considered a dent no matter the size. Interview with DM on 06/18/2025 at 09:13 am said if dented canned food or food that is left opened and not sealed in the refrigerator is served to residents they could get sick. 06/18/25 09:26 AM Interview with [NAME] A said if she finds dented cans she removes them and puts them on the dented can shelf. She said if dented cans or food that is left opened in the refrigerator is served to residents the residents could possibly get sick. She said when staff takes food out of the refrigerator, they are supposed to make sure there is an in and out date label on it and it's sealed. Record review of the facility's Food Storage Policy, dated October 2017, bullet point 8 states, All food stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). There was nothing pertaining to can storage. Review of the U.S. FDA Food Code 2022 reflected: Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. Review of the U.S. FDA Food Code Chapter 3 FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's main kitchen reviewed for food safety. 1. The facility failed to ensure the ice machine filter and vent was free from dirt and dust. 2.The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 4. The handwashing sink garbage receptacle had items other than paper towels. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of the Kitchen on 06/11/24 at 09:25 AM revealed the following: -Handwashing sink garbage receptacle had items other than paper towels, there were product packaging, a foam cup with red liquid, pieces of strawberries and gloves. -On a storage shelf across from a prep table, on a 2nd row there was a box of iodized salt dated 06/06/24 with manufacturer recommended best by date 3 years from opening. There was no received by date and the container was left open to air (not cover on the opening). -2-5 lbs. Original buttermilk pancake & waffle mix dated 10/24/23 and 04/18/24, unopened, manufacturer's expiration date 08/23/23. -1-Extra-large storage bin with lid labeled flour, no received by date, no opened date, manufacturer's expiration date 06/03/24. -Floor was dirty, had a slippery/greasy residue noted and bits of paper and trash on it. -1- Extra-large white bin with lid, labeled flour dated 06/03/24. No opened date and no consume or discard date. Observations of Reach-in refrigerator on 06/11/24 at 09:50 AM revealed the following: -Top row: -1 Large zip top bag with sliced yellow cheese labeled cheese dated 06/06/24, no end by or consume by date. Observations of Walk-in refrigerator on 06/11/24 at 09:54 AM revealed the following: -1 medium zip top bag of table grapes dated 06/10/24 no end or consume by date, left opened to air. -4-1 lb. clear containers of whole strawberries with dated 06/10/24, 3 of the 4 containers were dated 06/11/24, they contained soft, darkened, dried appeared strawberries in containers, there were no consume by or discard by date. -1-1 lb. clear container of strawberries with 2 strawberries in the container had mold on them, 1 strawberry that was split open or inside of it was exposed as if had been sliced opened. Observations of Walk-in Freezer on 06/11/24 at 10:16 AM revealed the following: -1 extra-large tri-tip beef/brisket on bottom of shelf, date smeared, no label of item description. -1 box of plant-based patties with 20 or more patties (40 servings per nutrition label) in a bag left open to air. Observations of Kitchen on 06/11/24 at 10:25 AM revealed the following: -1-large rack with a plastic cover over it labeled desserts dated 06/11/24. There were several different items on the rack but not labeled. The top row had approximately 20-24 small bowls of salads, two rows down, approximately 16-20 slices of cheesecake with red sauce on top, a few rows down, were 2 rows of approximately 36-40 small bowls of sliced strawberries covered with plastic wrap and under that was a medium shallow pan with salad mix inside, covered in plastic wrap, not on ice. Observations of Dry Storage Room on 06/11/24 at 10:28 AM revealed the following: -1-box (12 pies) of Oatmeal Crème Pies (7 remaining) dated 05/07/24 opened, there was no opened date, no end by or consume by date. -1 large zip top bag labeled fish fry mix dated 06/04/24, no end by or consume by date. -1- extra-large zip top bag of uncooked rice dated 06/04/24 no end by or consume by date. -1-6.63 lbs. can of beef stew dated 05/31/24 with dented can on center bottom of can manufactured expiration date 01/11/26. -1-6 lbs. 9 oz can of diced tomato in juice dated 04/15/24 with dented top left. -1-6 lbs. 8 oz can of spaghetti sauce with tomato bits dated 06/11/24, dented top right. Observations of the Ice Machine Closet on 06/12/24 at 09:42 AM revealed the following: - Ice Machine plastic vent, located on the right side of the machine, the vent slats had dust on them. In an interview on 06/11/24 at 10:47 AM with the Cook, she stated we do inventory of dry storage and labeling. She stated we also can do inventory of the refrigerator. The cook stated they use FIFO (first in-first out) system. She stated she tried to put older stuff up front so staff can see the date to pick the older date first. In an interview on 06/11/23 at 03:17 PM, with the Dietary Manager, revealed the facility kept dry goods that were opened for 72 hours. He stated he was the one who checked the truck when it comes in with food deliveries. The Dietary Manager stated the covered rack sitting in the kitchen with different food items marked dessert the top row was going to one floor and the next set was going to another floor and the last three rows were for a different floor. DM stated the rack had only been sitting out for about 15-20 minutes. He stated the ice machine was not working, the one they normally use but the water had been turned back on to the ice machine on the 1st floor of the building #3 and that was the one they were using for now. The Dietary Manager stated the kitchen managed the ice machine on the 3rd floor, but maintenance maintained this one. He stated the concern regarding the dirty vent and filter was cross contamination. Review of the facility's Food Receiving and Storage Policy dated March 2001: Revision October 2017, version 1.3, reflected Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 1. Food services, or other designated staff, will maintain clean food storage areas at all times. 2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. 3.The food and nutrition services manager shall verify the latest approved inspection and also monitor the food quality of the supplier. 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in - first out system. 8.All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 11. Wrappers of frozen foods must stay intact until thawing. Review of the U.S. FDA Food Code 2022 reflected: Chapter 2 . section 2-301 Hands and Arms. 2-301.11 Clean Condition. Food Employees shall keep their hand and exposed portions of their arms clean. 2-301.12 Cleaning Procedure. (C). To avoid recontaminating their hands or surrogate prosthetic devices, food employees may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a Handwashing Sink or the handle of a restroom door. 2-201.14 When to Wash. Food Employees shall clean their hands and exposed portions of their arms as specified under section 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles. and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling service animals or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw food and working with ready-to-eat food; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. Section 2-301.15 Where to Wash. Food Employees shall clean their hands in a Handwashing Sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or ware washing, or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid waste. Chapter 3 . section 3-201.11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in LAW, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. Section 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. Chapter 5 . Section 5-205.11 Using a Handwashing Sink (A) A Handwashing Sink shall be maintained so that it is accessible at all times for Employee use. Section 5-501.16 Storage Areas, Rooms, and Receptacles, Capacity and Availability . (B) A receptacle shall be provided in each area of the Food establishment or premises where refuse is generated or commonly discarded, or where recyclables or returnables are placed. (C) If disposable towels are used at handwashing lavatories, a waste receptacle shall be located at each lavatory or group of adjacent lavatories. Section 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: . www.fda.gov eCFR- Code of Federal Regulations are indicating within the text by an *- www.ecfr.gov

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents had the right to be free of misappropriation of resident property for 15 residents (Residents #1, #2, #3, #4, #5, #6 #7, #8, #9, #10, #11, #12, #13, #14, #15) of 18 residents reviewed for financial exploitation. The facility failed to prevent Former BOM A from diverting the rental payments of 15 residents to her LLC Company which totaled $328,061.11. It was determined a past non-compliance existed from 12/20/22 to 03/14/24, because the facility staff were unaware the Former BOM A told the RP's and/or Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15's to stop sending the checks to [The Facility] and to write out their checks to the LLC Company she owned. The Past Non-compliance was determined to have been removed on 04/02/24 due to the facility's implemented actions that corrected the non-compliance. The facility re-educated the staff on Misappropriation of funds and implemented a Rent Checks policy and Cash/Check Handling Policy and procedure, notified LE, conducted an AD Hoc Quality Assurance Meeting, prior to the beginning of the HHSC investigation on 04/16/24. The Staff confirmed when interviewed they were adequately trained to report immediately to the Associate ED, if they heard or suspected Misappropriation of property. This failure could place residents at risk of undue hardship and accelerated depletion of the financial resources causing them an inability to stay at the facility and pay other bills which could result in eviction, distress, and decreased psycho-social well-being. Findings included: 1)Record review of Resident #1's admission MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted [DATE] with a BIMS score of 07 (severe cognitive impairment), used a wheelchair, diagnosed with medically complex conditions and cognitive communicative deficit. (He discharged [DATE]). 2)Record review of Resident #2's Significant Change MDS assessment dated [DATE] revealed a [AGE] year-old female who admitted [DATE] with a BIMS score of 04 (Severe cognitive impairment), used a wheelchair, and diagnosed with medically complex conditions, Alzheimer's disease and non- Alzheimer's Dementia, metabolic encephalopathy, dysphagia, and cognitive communicative deficit. (She discharged [DATE]). 3)Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed an [AGE] year-old female who admitted on [DATE] with a BIMS score of 09 (Moderately cognitively impaired), used a wheelchair, diagnosed with a stroke, Non-Alzheimer's Dementia, vascular dementia, and non-traumatic subarachnoid hemorrhage. 4) Record review of Resident #4's Quarterly assessment dated [DATE] revealed and [AGE] year-old male who admitted on [DATE] with a BIMS score of 06 (Severely cognitive impaired), used a wheelchair, diagnosed with non-traumatic brain dysfunction, Alzheimer's disease, and Non-Alzheimer's Dementia. 5) Record review of Resident #5's Significant Change MDS dated [DATE] revealed an [AGE] year-old female who admitted on [DATE] with a BIMS score of 06 (Severe cognitive impairment), used a walker, and diagnosed with medically complex conditions, Alzheimer's Disease and Non-Alzheimer's Dementia. (She discharged [DATE]). 6) Record review of Resident #6's admission MDS assessment dated [DATE] revealed an [AGE] year-old female who admitted on [DATE], with a BIMS score of 15 (no cognitive impairment), used a wheelchair, Schizophrenia, encephalopathy, and unspecified dementia. (She discharged [DATE]). 7) Record review of Resident #7's admission MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted on [DATE] with a BIMS score of 15 (No cognitive impairment), used a wheelchair, and diagnosed with fractures and other multiple trauma. 8) Record review of Resident #8's admission MDS assessment dated [DATE] revealed an [AGE] year-old male who admitted [DATE] with a BIMS score of 14 (no cognitive impairment), used a wheelchair, diagnosed with medically complex conditions. (He discharged [DATE]). 9)Record review of Resident #9's Quarterly MDS assessment dated [DATE] revealed an [AGE] year-old female who admitted [DATE] with a BIMS score of 03 (Severe Cognitive impairment), used a wheelchair, diagnosed with fractures and other multiple trauma, Alzheimer's Disease, dizziness, giddiness, and dysphagia following cerebral infarction. 10) Record review of Resident #10's admission MDS assessment dated [DATE] revealed a 95-year female who admitted on [DATE] with a BIMS score of 09 (Moderate cognitive Impairment), used a walker, diagnosed with medically complex conditions such as frontal lobe and executive function deficit and cognitive communicative deficit. (She discharged [DATE]). 11) Record review of Resident #11's Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted [DATE] with a BIMS score of 12 (cognitively intact), diagnosed with debility, cardiovascular conditions. 12) Record review of Resident #12's admission MDS assessment dated [DATE] revealed an [AGE] year-old male who admitted on [DATE] with a BIMS score of 15 (cognitively intact), diagnosed with medical complex conditions. (He discharged [DATE]). 13) Record review of Resident #13's Quarterly MDS assessment dated [DATE] revealed an [AGE] year-old male who admitted [DATE], with a BIMS score of 11 (Moderate cognitive impairment), used a wheelchair, diagnosed with traumatic brain dysfunction, including Non-Alzheimer's Dementia and Parkinson's disease. 14) Record review of Resident #14's admission MDS assessment dated [DATE] revealed a [AGE] year-old male who admitted [DATE], with a BIMS score of 05 (Severe cognitive impairment), used a wheelchair, diagnosed with medically complex conditions, including stroke. (He discharged [DATE]). 15) Record review of Resident #15's admission MDS assessment dated [DATE] revealed an [AGE] year-old female who admitted [DATE] with a BIMS score of 10 (moderate cognitive impaired), used a wheelchair, diagnosed with non-traumatic brain dysfunction. (She discharged [DATE]). Interview on 04/16/24 at 10:35 am, the Facility Volunteer stated the Former BOM A created invoices making it appear the residents owed the facility money even though the residents had paid their rent and were up to date. They stated Former BOM A fabricated a few of the resident's debt and said she first heard about it when the facility tried to evict an independent living resident but found out he had not missed any rent payments. They stated now the facility had discovered ALF and Nursing residents' rent money was also given to Former BOM A. They stated Former BOM A had a Limited Liability Company she asked the residents and responsible parties to send money to. They stated there was so many things Former BOM A did and added a police detective was now involved. They stated the administrative staff should have been aware of what Former BOM A was doing with the resident's rental payments. Interview on 04/17/24 at 9:48 am, the Associate ED stated after he found out about the IL and Assisted Living residents' money being diverted, they spoke to Former BOM A and she denied the allegation of rerouting the residents' rental payments to herself. He stated she was immediately suspended and her keys and computer access was disabled then they started their investigatory stage. He stated he was not aware of any issues with the nursing home resident's money being diverted until 03/14/24. He stated Resident #3's FM provided cashed checks showing the checks were written out to the LLC Company with Former BOM A signature on them. He stated he reported the exploitation intake on 03/15/24 to HHSC and contacted the police detective and was told he would add the nursing home residents to the case he already had opened. Interview on 04/17/24 at 12:22 pm, the LE Detective stated the case involving the nursing home residents and Former BOM A was referred to the embezzlement special unit department. He stated for financial theft cases, he had to get all the evidence and documents before taking any further actions and was still currently investigating this case. Interview on 04/17/24 at 1:42 pm, ABOM K stated she just recently started working at [This Facility] and heard about the misappropriation of funds of the residents. She stated she asked the residents and RP's if they had any discrepancies with their rental payments and who were they sending payments to. She stated a few of them said they sent rental payments to another business the Former BOM A told them to send payments to. She stated the Former BOM A targeted the wrong person, because a family member said they paid rent but received a collection letter. She stated they found out the family member wrote the check out to another business and not [The Facility]. She stated the Former BOM A called the RP's and told them the corporate name changed and to start making the resident's payments to an LLC Company. She stated they were also dealing with figuring out if the Resident's Medicaid applied incomes were affected. She stated going forward once she received the rental payments; she scanned the checks to be deposited to their internal banking system then she sent the scanned copies to BOM B who then uploaded copies of the checks to the resident's EMR records. She stated BOM B then sent the cashed receipts journal to upper management to show what was all put into the resident's EMR's. She stated they reviewed the journal and payment reports of each deposit to ensure it matched with what was scanned and if it did not, they would seek to figure out why. She stated they were doing mid-month reports to check which residents had not paid then BOM B would contact the RPs to determine why and document that information. She stated then close to the end of the month a second collection notice would go out and then around the 45th day the Associate ED would contact any late payments still pending to determine cause and document that information. She stated from her understanding prior to this point it was a one-person system of checks and balances. She stated the Former BOM A did the bank processing, sent out the collection notices and documented fake information to the resident's records as to them being behind on payments. She stated the last known amount of the nursing home resident's money that was diverted to Former BOM A was $328,061. Interview on 04/17/24 at 3:29 pm, BOM B stated she used to be the ABOM when Former BOM A worked at this facility. She stated honestly, she did not have firsthand knowledge of how the Former BOM A was able to get the residents funds. She stated this situation with the Former BOM A just blew her away that she could do this and said although she (BOM B) mostly worked remotely, she never heard the Former BOM A asking residents/RP to pay to this LLC Company and if she did, she would have said something to the Associate ED immediately. She stated she never heard of this LLC Company owned by Former BOM A until just recently. She stated what Former BOM A did was just plain old wrong to take the residents money. She stated Former BOM A created narratives for the residents with late payment collections accounts and would say some residents had an identity theft issue and their funds were on hold. She stated they just recently found out there were no letters from the bank about that happening. She stated the prior checks and balances in place was that Former BOM A received and deposited the checks and accounted for any money not received, then she documented the updated collection efforts into the resident's records. She stated she trusted Former BOM A and after she reviewed the residents' notes, she took what Former BOM A said and documented it at face value. She stated Former BOM A always had a direct answer when she asked about the residents past due collections amounts and felt she should not have believed what Former BOM A said. She stated she felt really foolish but added none of the residents or banks notified her about any issues. She stated the collection letters the Former BOM A sent out referenced the residents/RP to contact the Former BOM A and said in hindsight she did not see any red flags or issues during that time. She stated since this happened, the facility hired ABOM K who would be responsible for scanning all of the residents' payments to the inhouse banking system, then she was to document each and every payment onto a report log sheet. She stated after that she was responsible for checking to ensure the copies of what was deposited, was also on the log sheets and then she documented the payments to the residents EMR. She stated when the ABOM K made her 1st collection calls she documented it into the resident's records then at the end of the month if there were still collection accounts, she (BOM B) would call the resident/RP and then after 2 weeks the Associate ED called if there was still delinquent collection accounts. She stated before this there was only a one-point system of the Former BOM A did all of the collecting of the checks, deposits, and collections. She stated she had weekly collection meetings with the ED and Former BOM A to review what was received and not received and efforts to collect. She stated she was not sure who was overseeing Former BOM A at the corporate level. She stated they sent letters to the residents/RP about not writing checks to no other companies than [This Facility]. She stated she was responsible for reviewing the front and back of the checks and posting it in the residents' EMR. She stated she was also responsible for sending out the monthly statements to the Residents/RP. She stated misappropriation of funds could cause the residents/RPs to lose trust in the facility staff. She stated it could have put the Residents into a financial strain and at risk of evictions and could have snowballed into all types of things. Interview on 04/17/24 at 5:12 pm, the ED stated, That was a really good question as to how the Former BOM A got away with getting all this money from the residents. He stated the Associate ED first discovered the diverted funds on 02/26/24 with an independent living resident saying he paid his rent-on time, but his account showed he owed $30,000. He stated then they found out the ALF residents had their payments going to the Former BOM A's LLC company. He stated they reviewed the copies of the cashed checks and noticed the Former BOM A's signature was on the backs of them. He stated they also discovered the LLC company was set up in the Former BOM A's name and her home address was listed on the company name. He stated on 02/29/24 he spoke to the facility's Senior [NAME] President about the matter then the next day on 03/01/24 at 9:00 am, he, the HR Director, Corporate CEO, and the Associate ED met to discuss this matter then at 11:00 am on 03/01/24, they all spoke to the Former BOM A. He said the Former BOM A denied it all and had no idea about the LLC Company, even after he showed her the copies of the checks with LLC Company on it with her name on them. He stated, at that time they just had three of the resident's checks, then they suspended Former BOM A and took all her access and keys away. He stated they called the Ombudsman, LE, submitted a 5-day HHSC PIR about the ALF residents. He stated Former BOM A was terminated permanently from ever working at any of their facility's and without pay on 03/06/24. He stated on 03/08/24 they sent letters out to everyone about the misappropriation and on 03/14/24 he received confirmation that a Nursing Home resident sent checks to this LLC Company. He stated Resident #3's RP provided bank copies of this resident's checks being sent to the LLC Company. He stated they reported this incident to HHSC and since then they updated their investigating and log sheet and continued with identifying if any other residents were affected. He stated prior to this they were doing AR calls weekly with Former BOM A and BOM B to review the collection efforts but again they were trusting what the Former BOM A said and documented. He stated Former BOM A did a very [NAME] job hiding what she did because she picked and chose which residents to target. He stated Former BOM A collected some of the residents checks in their rooms and they wrote the checks to her LLC company name. He stated from what they gathered, Former BOM A took those checks and mobile deposited them to the banks to go to her. He stated they had a New Rents policy for all checks have to be written to [The Facility], hired an ABOM K, had an Ad Hoc QA meeting. He stated the Medical Director expressed his support and said he did not have an idea how this could have happened and who was the person doing checks and balances prior but as of now the Associate ED was responsible for ensuring the collections were done accurately, timely and appropriately. He stated the Associate ED was also responsible for ensuring the resident's money was posted to the resident's accounts and monthly statements were sent out to the residents. He stated he believed Former BOM A fabricated statements in the EMR system which showed collection notes of made up stories why the residents had not paid their rent. He stated Former BOM A documented the collection residents were not paying due to identity theft, family member stealing money and bank issues. He stated prior to this incident the Associate ED was responsible for ensuring checks and balances were in place to prevent misappropriation. He stated from what [The Facility] gathered Former BOM A had redirected the residents rental payments that went back to April 2022 for the Nursing home residents. He stated his plan to prevent this from happening again was to monitor the Associate ED to ensure the rent check policy was followed. He stated he felt the Former BOM A did not steal money from the 15 residents since they were giving the 15 residents credit for the diverted money paid to Former BOM A. Interview on 04/17/24 at 6:17 pm, MDS Coordinator H stated Resident #3's cognition was off and, on her MDS BIMS score, showed she had a cognitive impairment, but she was pleasant. She stated Resident #7 had some cognitive impairment and Resident #9 was confused and was a hospice resident and her cognition was kind of high. She stated Resident #13 was cognitively impaired with Parkinson's Disease. Interview on 04/17/24 at 6:56 pm, the Associate ED stated the plan to prevent this from re-occurring was to have weekly meetings to review past due balances with BOM B and ABOM K. He stated around the 10th or 12th of the month the BOM B was to post the resident's rental payments and run the balances to see who was past due. He stated the ABOM K then was responsible for making the collection calls to the RP's/Residents and documenting the collection in the resident's records. He stated the next step was for BOM B to run the balance reports between the 3rd or 4th week of the month to see who still had not paid. He stated BOM B was responsible for making the collection calls and documented in the resident's records and after that if the resident still had a balance from the previous month, he was responsible for making a collection call to the RP/Residents. He stated between the three of them calling and checking the statuses of the past due accounts they should not have any issues. He stated the Former BOM A was crafty and created speaking to the Residents/RP's and advising them to write the checks to her LLC Company. He stated he was responsible for ensuring the BOM processed and posted the payments accurately. He stated they were very caught off guard and said the Corporate Office were doing financial audits, but the diversion of funds was not caught because the collection notes appeared to be real as to why the residents had not paid. He stated the payments and collections procedures no longer fell on one person any longer. He stated his expectations of BOM B and ABOM K was for them to have full transparency with the payment transactions and clear statements of any payments made. He stated they needed to protect the residents by properly posting it and providing any kind of statements the residents needed. He stated if the residents' funds was diverted and not properly posting their payments to their accounts could cause the residents to be evicted from the facility and emotionally affect them. He stated they have determined 15 residents were affected and were currently cooperating with LE with any items they needed, and all staff had been trained on Misappropriation of property. Interview on 04/17/24 at 7:51 pm, the ED stated what Former BOM A did was an embezzlement of the company's funds and not the resident's funds, because the money was supposed to be sent to [This Facility]. He stated the 15 residents were not out of any money and their company planned to give the residents credit for all the money that was diverted to Former BOM A. Interview on 04/18/24 at 2:10 PM, CNA C stated a few weeks ago she heard there was a resident in the dining room saying someone stole her money, then another lady said let me go check my bank statements. She stated she reported to the Associate ED what she heard in the dining room. She stated she later saw the Associate ED going to the nursing home floor passing out letters about the situation and if they knew of any misappropriation of property to let him know immediately. They had training about misappropriation of property 3/10/24 and 03/17/24. Interview on 04/18/24 at 10:31 am, FM #16 stated they just found out about what Former BOM A did a week ago when BOM B called and asked if they wrote payments to [This facility] and they said No. They stated the Former BOM A told them to write three months' worth of rental payments. They stated the Former BOM A told them the facility had a new company to write the checks out to and said approximately $25,000 in checks were written to the LLC Company. They stated when the second payment was made Resident #2 was on hospice and they should not have paid room and board because hospice paid for her stay at that point. They stated [The facility] was still working on seeing if they were going to get a refund or not for the months she was a hospice patient. Interview on 04/18/24 at 10:43 am, FM #17 stated the Former BOM A asked her to make the rental payment checks out to the LLC Company in June 2022. They stated writing checks out to the LLC Company in the amounts of approximately $2220.00 in June 2022 and then in December 2023 it went up to approximately $3570.00 then January 2024 they sent a payment of approximately $3440.00. They stated come to find out Former BOM A was redirecting Resident #5's payments to her own personal account. After reviewing the back statements and giving them to Associate ED they were able to see Former BOM's signatures on the back of the checks. They stated not understanding how the Former BOM A felt she was entitled to the resident's money and added they hoped she was arrested for stealing the resident's money. They stated there were just shocked when they found out about this and felt betrayed, deceived basically lied to. Interview on 04/18/24 at 11:25 am, FM #18 stated Resident #6 was admitted on [DATE] and there was a crazy mix-up on her bill over and above what her Medicare insurance covered. Former BOM A said Resident #6 owed rent and that she preferred cash because she could give them a discount. They stated paying $2800.00 supposedly thinking they were getting a discount then later found out Resident #6's rent was only $2300.00. They stated they received another bill for $2300.00 in [DATE] or February saying he owed $2300.00 but they told the [The Facility] the rent had already been paid. They stated they were refunded $500.00. They stated not being sure what the deal was with the billing processes at [This Facility] but they just went by the statements and what the Former BOM A told him to pay, and everything looked okay to them at the time. Interview on 04/18/24 at 11:49 am, FM #19 stated they were informed by the Associate ED last month about the misappropriation of funds. They stated speaking to Resident #10 about it and the resident said the Former BOM personally went to her room in July 2023 and asked her to start making her rental payments to the fraudulent LLC Company. They stated after getting the copies of the cashed checks from the bank there had been a total of 8 checks written to the LLC Company totaling approximately $24,000. They stated the copies showed the Former BOM A signed the cashed the checks. They stated Resident #10 told them she did not really think anything about the name change because she trusted the Former BOM A because she worked there over the past years. They stated Former BOM A worked at the [This Facility] for so long and knew how [The Facility] ran and how much money to siphon, a little money here and there not to alarm any red flags. They stated [The Facility] had so many changes in the administrative staff, but the Former BOM A was always there. They stated Former BOM A went one by one to certain residents, and no one questioned it. They stated this was such a shame because it was the elderly people she took from. They stated they never physically met Former BOM A because she was always out on leave when they visited Resident #10. They stated the Associate ED told them they were investigating this matter and LE was involved. They stated things slipped through the cracks and the facility lost money and now it had trickled down to cutting costs to care for the residents. They stated Resident #10 was doing okay but added they were more incensed about it because they were not keeping the appearance of the facility up. They stated the Associate ED explained the issue with payments and asked them to get the check copies so that he could give to LE. They stated Resident #10 was not going to owe anything but hoped they could recoup that money. Interview on 04/18/24 at 1:17 pm, FM #20 stated they were told to stop sending checks to the LLC Company last month. They stated the Former BOM A said six months ago [The Facility] sold out to another company and to start making Resident #11's payments to the LLC Company so they started mailing checks to [This Facility] but wrote the checks out to the LLC Company. They stated after this was discovered he looked at the cashed checks and saw the ones with [The Facility] stamp but then saw the ones Former BOM signed. They stated they requested monthly statements from the Former BOM A, and she always said she would send them out, but she did not do it. They stated they never talked to anyone else about Resident #11's financials because they thought everything was on the up and up and the Former BOM A seemed to be a very nice person and great. They stated being confused when they received a statement a few weeks ago saying the Resident #11 owed [The Facility] $44,000 so they gave copies of the cancelled checks last Thursday 4/10/24 to [This facility]. They stated feeling a little ticked off for paying $7000.00 a month to take care of their family member for this to happen. They stated they were waiting for a response from the facility on what they planned to do about this matter. They stated the [The Facility's] management team must had trusted the Former BOM just like they did. Interview on 04/18/24 at 2:54 pm, FM #21 stated they received a call from BOM A two weeks ago and she told them to provide all of Resident #9's cashed checks and had not heard from anyone there since. They stated Former BOM A was getting the rental payments sent to an LLC Company and that should not have been done. They stated they paid Resident #9's rent in person, but the Former BOM A always said they were paying late and had a $34,000 balance but would never send them monthly statements. They stated the Former BOM A always said she was trying to get Resident #9's Medicaid eligible. They said just recently BOM B told them the Former BOM A documented an attorney was working on Resident #9's Medicaid application, but that was not true. They stated the Former BOM A was devious because of what she had done. They stated at times of asking Former BOM A about these charges and she would just say she would get back to them. They stated not being sure what [The Facility] planned to do about this situation because they had not received any confirmation from anyone. They stated they stopped writing checks out to the LLC Company and added their only concern was could Resident #9 been getting better care and had the Medicaid benefit at this point. They stated Former BOM A asked for three months over the past year as if she was helping with the Medicaid process. They stated for the past two years they did not ever get a monthly statement and after verifying their address with BOM B the address on file was off by one digit and added they were not sure if the address mix-up was intentional or not. They stated the Former BOM A tried to isolate him from talking to anyone else because she always said to go to her for any questions. They stated not getting the monthly statements was a red flag, but they just did not think it was an issue but wished they would have said something to the Associate ED before now. They stated BOM B was very apologetic and said it was kind of embarrassing for them for this to have happened. They stated calculating over two years they wrote approximately $106,000 worth of checks to the LLC Company. Interview on 04/18/24 at 4:22 PM, FM #22 stated discovering what Former BOM A did about a month ago and she was fired. They stated after looking back at Resident #3's account they found a substantial number of checks had been signed by Former BOM A. They stated calling the Associate ED to let him know about it and stated prior to this they had not spoken to anyone about anything concerns. They stated in February 2023 the Former BOM A told them Resident #3 was behind on rent and the payments needed to be written to the LLC Company. They stated dropping the checks off to the nursing home lock box at the Business office and never received monthly financial statements. They stated approximately $5175.00 in checks was written to the LLC Company regretted they did not think to verify this change. They stated they would credit the resident's account with what was misappropriated by Former BOM. They stated [The Facility] should have looked closely and asked questions about what Former BOM A did. They stated after what the Former BOM A did they had no clue how the facility was going to recover from this. Interview on 04/19/24 at 2:18 pm, FM #23 stated according to [The Facility] the Former BOM A misappropriated $11,700. They stated the Former BOM A was the only one they spoke to about Resident #1's financial matters. They stated when Resident #1 moved to the Nursing home in 2023 the Former BOM A told them to make the checks payable an LLC Company because that company controlled the facility. They stated the checks cleared with the bank, but they never received monthly statements or receipts. They stated they never considered talking to anyone else from the corporate office or Associate ED because of not thinking there was an issue. They stated there were times they would get a statement saying they owed more money, but the Former BOM A said to ignore the delinquency notices, because they were sent out in error. They stated a couple of weeks ago BOM B told them they were not responsible for what was misappropriated. They stated they used to do automated bank draft but when Resident #1 moved to the Nursing home floor he was told he had to write paper checks. They stated about two checks was written out to the LLC Company. They stated after hearing about what Former BOM A did they were first shocked j[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #9) reviewed for reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents The facility failed to ensure Resident #9's laundry was being done on a frequent basis. This failure could result in the resident being exposed to toxic fumes, skin irritation, and respiratory concerns. Findings Included: Review of Resident #9's Face Sheet, dated 05/04/23, revealed she was an 80 -year-old female admitted on [DATE]. Relevant diagnosis included dementia (memory loss), bipolar (manic depression), and psychotic features (hallucinations) Review of Resident #9's MDS (Minimum Data Set) assessment, dated 04/15/2023 stated she was not cognitively intact with a BIMS score of 5. The resident's MDS indicated the resident Usually Understands - misses some part/intent of message but comprehends most conversations. Record review of Resident 9's Progress notes reviewed from 10/10/22 thru 05/04/23 revealed no documentations of the resident refusing to have her laundry done and record review of the Resident's care plan did not indicate an assessment nor intervention for the resident refusing to have her laundry cleaned. An observation on 05/02/23 at 10:00 AM with Resident #9 revealed her living area had a strong urine smell and the smell was determined to be from a large laundry basket which contained dirty clothes overflowing from it. Interview on 05/03/23 at 1:45 PM with the Administrator and the DON revealed they were made aware of Resident #9's room smelling of urine due to her laundry not being done. They advised the Resident was a hoarder and refusing to have her laundry cleaned. They were advised that progress notes were reviewed and there was no documentation regarding the resident ever refusing any type of services, especially her laundry. They advised that staff failed to document the resident's refusal of laundry and needed to do a better job documenting when resident refused services. They advised that more attempts should have been made to clean the resident's laundry more frequently and not allowed it to have accumulated the way that it did. Interview with LVN A on 05/04/23 at 11:07 AM revealed she had been at the facility for 9 months. She stated she monitored the hall of Resident #9. She stated she was familiar with the resident, and she stated she thinks the resident often refused to have her laundry done. She stated the resident often refuses the laundry aide from cleaning her laundry so she thought family members would sometimes take it with them to clean. She stated the resident did leave her room throughout the day and she often left the facility with family. So there were opportunities for staff to get the resident's laundry to clean it. Interview with Housekeeping Manager on 05/04/23 at 11:16 AM revealed she was aware of Resident #9's concerns with her laundry not being done. She stated the resident often refused to allow someone to touch her laundry. She stated she was not at work that past Tuesday (5/2/23), but she stated the laundry aide that was at the facility advised her that the resident was refusing to have her laundry done. She stated she did go into Resident #9's room on 05/03/23 at 2:30 PM, and they removed 2 large trash bags of urine-soaked clothing. She stated the resident often wets herself throughout the day and just changed her clothing. She stated she always told the nursing staff when the resident refuses to have anyone touch her laundry. She stated she is sure there is a risk to the resident having that large amount of dirty clothes stored in the room. She stated she would get with the nursing staff to create a plan. Review of the facility's policy on Quality of Care, undated, revealed Residents and their Families or representatives have the right to expect and receive the high-quality care that meets their individual needs and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that comprehensive person-centered care plans were developed and implemented for each resident, consistent with the resident rights , that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #183) reviewed for Care Plans. The facility failed to ensure Resident #183 had oxygen therapy included in her comprehensive care plan. This failure placed resident at risk of not receiving immediate care if assistance was needed. Findings Included: Review of Resident #183's Face Sheet, dated 05/04/23, revealed she was a 79 -year-old female admitted on [DATE]. Relevant diagnoses included Chronic obstructive pulmonary disease (lung disease), Rheumatoid lung disease (scarring of lungs), and Unspecified atrial fibrillation (irregular heartbeat). Review of Resident #183's MDS (Minimum Data Set) assessment, dated 04/06/2023 stated she was cognitively intact with a BIMS score of 14. The resident's MDS indicated the resident required Oxygen therapy. Record review of Resident #183's orders revealed CONTINUOUS O2 AT 2L/MIN TO MAINTAIN O2 SATS >92% - TITRATE 1L/MIN PROGRESSIVELY AND CHECK O2 SATS UNTIL MAINTAINED AT > 92% - CONTACT PHYSICIAN IF UNABLE TO MAINTAIN O2 SATS >92%, dated 04/10/23. Record review of Resident #183's care plan, on 05/03/23 which was last reviewed on 04/03/23, revealed the resident's care plan did not have Respiratory Care identified as a focus of care for the resident. Observation and interview with LVN B on 05/02/23 at 11:23 AM revealed he was asked about the resident's Humidifier Oxygen concentrator and he advised that the container needs to be changed out every 5 days or when the water is below the line. LVN B advised the nurses are responsible for ensuring this is checked and serviced. LVN B stated the risk of the humidifier not having any water in it was the resident could experience dry nose, discomfort, and experience nose bleeds. LVN B observed the humidifier and air hose and stated that it should have been changed out and he proceeded to change it out. He was asked if this medical diagnosis should have been care planned and he stated yes. He was asked the risk to Resident #183 not having the Oxygen use care planned and he stated the resident could miss out on proper care. Interview with Contracted MDS Nurse on 05/04/23 at 11:00 AM, revealed she was responsible for ensuring Resident 183's care plan was being implemented. She stated the MDS would guide her on what should be care planned and she agreed the resident's need for oxygen therapy should have been care planned. The MDS nurse stated the risk of Resident #183 not having the oxygen therapy was not care planned and could result in missed care. Interview on 05/03/23 at 1:45 PM with the Administrator and the DON revealed they were aware of Resident #183's humidifier on the oxygen concentrator being empty by LVN A. The Administrator and DON were advised of Resident #183's Care Plan not including the resident's continuous oxygen therapy. They advised that this concern should have been included on her Care plan so an intervention could have been implemented. They advise that they had a contracted MDS Nurse that Implemented and updated resident care plans. The Administrator and DON advised the nurses were responsible for ensuring the resident's humidifier was changed out appropriately. Record review of facility policy, Comprehensive Person-Centered Care Planning, rev. Jan. 2022, revealed Policy It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 6 residents (Resident #183) reviewed for Respiratory Care. The facility failed to provide respiratory care when Resident #183's humidifier bottle was not replaced when empty. This failure placed resident who required oxygen at risk of not receiving the prescribed oxygen or nasal irritation. Findings Included: Review of Resident #183's Face Sheet, dated 05/04/23, revealed she was a 79 -year-old female admitted on [DATE]. Relevant diagnoses included Chronic obstructive pulmonary disease (lung disease), Rheumatoid lung disease (scarring of lungs), and Unspecified atrial fibrillation (irregular heartbeat). Review of Resident #183's MDS (Minimum Data Set) assessment, dated 04/06/2023 stated she was cognitively intact with a BIMS score of 14. The resident's MDS indicated the resident required Oxygen therapy. Record review of Resident #183's orders revealed CONTINUOUS O2 AT 2L/MIN TO MAINTAIN O2 SATS >92% - TITRATE 1L/MIN PROGRESSIVELY AND CHECK O2 SATS UNTIL MAINTAINED AT > 92% - CONTACT PHYSICIAN IF UNABLE TO MAINTAIN O2 SATS >92%, dated 04/10/23. Record review of Resident #183's care plan, on 05/03/23 which was last reviewed on 04/03/23, revealed the resident's care plan did not have Respiratory Care identified as a focus of care for the resident. Observation and interview on 05/02/23 at 11:22 AM with Resident #183 revealed the resident sitting in a chair and she was wearing an oxygen mask in her nose. The resident indicated that her nose was dry and she was having slight nose bleeds. She stated she did not think her humidifier had any water in it. The humidifier tank on the Oxygen concentrator was observed and there was little to no water in the container and the container was dated 04/21/23. Observation and interview with LVN B on 05/02/23 at 11:23 AM revealed he was asked about the resident's Humidifier Oxygen concentrator and he advised that the container needs to be changed out every 5 days or when the water is below the line. LVN B advised the nurses are responsible for ensuring this is checked and serviced. LVN B stated the risk of the humidifier not having any water in it was the resident could experience dry nose, discomfort, and experience nose bleeds. LVN B observed the humidifier and air hose and stated that it should have been changed out and he proceeded to change it out. Interview on 05/03/23 at 1:45 PM with the Administrator and the DON revealed they were aware of Resident #183's humidifier on the oxygen concentrator being empty by LVN A. The Administrator and DON advised the nurses were responsible for ensuring the resident's humidifier was changed out appropriately. They advised the risk to the resident not having her humidifier accurately full, could resullt in the humidifier not working correctly and causing nose dryness and possible irritation. In review of facility policy, Respiratory Policies and Procedures, rev. 02/01/2020, stated Procedures: 1 . Inlet filters on oxygen concentrators shall be visually inspected and cleaned/replaced as necessary. 2 personnel staff shall visually inspect . treatment compressors for inlet filter status, operational verification, and general cleanliness. Inlet filters, suction canisters, and suction tubing will be cleaned/replaced in soiled. External surfaces will be wiped down with a facility and manufacturer approved solution.

Based on observation, interview, and record review, the facility failed ensure residents had a safe, functional, sanitary, and comfortable environment for 1 of 5 residents (Resident #5) reviewed for environment. The facility failed to ensure Resident #5's air vents were free of dirt, dust, debris, and sediment accumulation. This failure could place residents at risk of not residing in a homelike environment. Findings Included: In observation on 05/04/2023 at 9:50 AM revealed Resident #5 resting in bed in her room Resident's air vent located above her head to her right side appeared to have a large amount of dirt, dust, debris, and sediment accumulation on approximately 70% of the vent, with additional dirt, dust, debris, and sediment accumulation up inside the ventilation area. Resident #5 was not verbal and could not be interviewed at the time of observation. In interview with LVN A on 05/04/2023 at 9:51 AM she stated that the air vent was dirty and she thought it needed to be cleaned immediately because Resident #5 was vulnerable. She stated it was an infection control risk for the resident to have a dirty air vent. She stated that MNTSPVSR cleaned the carpet in Resident #5's room this morning and he should have addressed the vent at that time. In interview with the DON on 05/04/2023 at 9:52 AM she stated that the air vent was dirty and stated it could affect the resident as an infection control risk. She stated her expectations were for MNTSPVSR to maintain the air vents to ensure they are clean. In interview with MNTSPVSR on 05/04/2023 at 12:16 PM he stated that he was responsible for housekeeping as well as maintenance. He stated there was not any process in place to ensure the air vents were clean and properly maintained. He stated his expectations were for the staff to report any concerns to him for the air vents to be addressed. He confirmed there was a maintenance log for concerns but denied any recent reports of air vent concerns. He stated that he was in Resident #5's room that morning to clean her carpet but did not notice the dirty vent at that time. He stated it was his responsibility to ensure the air vents were clean. He stated it was important for a resident's dignity to reside in a clean room. In interview with the Administrator on 05/04/2023 at 1:30 PM she stated her expectations were for the air vents to be clean. She stated it was MNTSPVSR's responsibility to ensure a clean environment. She stated it was important for the residents to reside in a clean environment for infection control and dignity concerns. Review of facility maintenance log on 05/04/2023 15 1:25 PM revealed no evidence of environmental cleanliness concerns. Review of facility grievances on 05/04/2023 at 12:26 PM revealed no evidence of environmental cleanliness concerns. Review of facility policy, Homelike Environment, 02/2021, revealed Policy Statement . Residents are provided with a safe, clean, comfortable and homelike environment . Policy Interpretation and Implementation . 2. The facility staff and management maximizes . characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment.

Based on observations, interviews, and record reviews, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's one and only main kitchen in the facility and one and one and only substation kitchen for the skilled nursing floor,3 reviewed for kitchen sanitation. 1. The facility failed to ensure the facility's main kitchen dry storage area was free of dirt and debris 2. The facility failed to ensure cooking and serving equipment in the substation kitchen for the skilled nursing floor were cleaned to sanitary conditions. 3. The facility failed to ensure the Iced tea dispenser in the facility's main kitchen was covered and free of risk of cross contamination These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observation on 05/02/23 at 9:49 AM in the Facility's main kitchen, revealed the dry storage room floor that initially looked clean but when food storage racks were moved, the floors revealed several dirt stains under the storage racks and along the edge of the walls were thick dirt buildup. Interview with Dietary Manager on 05/02/2023 at 9:49 AM in the facility's main kitchen dry storage room, revealed he observed the dirt stains under the storage racks and the thick dirt buildup alongside the wall. He stated he was responsible for ensuring all areas of the kitchen are thoroughly cleaned. He stated he was unsure of when the last time the dry storage area floor was thoroughly cleaned. The Dietary Manager stated the risk of not thoroughly cleaning the kitchen area thoroughly could result in bacteria build up and possible contamination of food, which could make residents ill. Observation on 05/02/23 at 11:30 AM in Facility's main kitchen revealed an Iced Tea dispenser that was full of tea. The dispenser was located along the main traffic area of kitchen staff and there was no top observed on the dispenser to protect it from contamination. The kitchen staff was observed preparing to serve Iced tea to residents for lunch. Interview with Dietary Manager on 05/02/23 at 11:30 AM revealed the Iced tea was prepared by a kitchen staff at approximately 05:30 AM. He stated the Iced Tea should have been covered once it was prepared and the risk of not covering the Iced Tea dispenser could result in contamination and air-borne illnesses. Observations on 05/03/2023 at 11:30 AM in the substation kitchen for the skilled nursing floor revealed the following: One Ice scoop holder hanging on the wall revealed dirty water housed in the bottom of the holder, where the Ice scoop was resting. One Four-Panned Steam table revealed three of the four pans with extensive calcium and lime build-up along the bottom of the pans. One white refrigerator revealed dirt on the kitchen equipment, especially on the top of the refrigerator, which displayed build up dust, dirt, and grime. Interview with Dietary Manager on 05/04/2023 at 10:50 AM revealed, he was shown the pictures of the findings in the substation kitchen for the skilled nursing floor. He stated that he was responsible for ensuring the cleanliness of the area and he stated he had not assigned it to any kitchen staff. He stated he was creating a cleaning schedule to ensure the area was cleaned more frequently. He stated the risk to the residents of the facility thoroughly cleaning and sanitizing the areas mentioned could result in residents getting sick from foodborne illness. Interview with Administrator on 05/04/2023 at 11:50 AM revealed she was made aware of the findings in the kitchen by the Dietary Manager. She stated her expectation was for the kitchen staff to ensure that they are following proper procedures for storing and cooking foods while practicing sanitary conditions and the risk to the residents could be that they contract an air-borne illness. Record Review of facility's policy and procedures for Cleaning and Sanitation of Dining and Food Service Areas (undated), revealed The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Review of the US Food and Drug Administration 2017 Food Code Guide revealed Chapter 4-6001.1 Equipment, Food contact Surfaces, Nonfood-contact Surfces and Utensils (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. Chapter 6-501.12 (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean

Based interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 16 days of the 4-month review period. The facility failed to ensure the facility maintained the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. This failure placed residents at risk of receiving higher levels of patient care. Findings Included: Based on the facility provided time sheets for Registered Nurses for the review period from January 2023 to May 2023, the facility failed to have the required RN coverage of at least 8 consecutive hours a day,on the following dates: 02/10/23- (0 hours recorded) 02/26/23- (0 hours recorded) 02/27/23- (0 hours recorded) 02/28/23- (0 hours recorded) 03/07/23- (0 hours recorded) 03/08/23- (0 hours recorded) 03/09/23- (0 hours recorded) 03/10/23- (0 hours recorded) 03/16/23- (0 hours recorded) 03/17/23- (0 hours recorded) 03/23/23- (0 hours recorded) 04/18/23- (0 hours recorded) 04/26/23- (0 hours recorded) 04/27/23- (0 hours recorded) 04/28/23- (0 hours recorded) 04/29/23- (0 hours recorded) Interview with the Administrator and the DON on 05/04/23 at 1:00 PM, revealed they were aware that they did not have sufficient RN coverage on a consistent basis. They said they were trying to recruit more RNs but it had been very challenging hiring them. They stated they hired a new RN that was starting June 2023 to cover weekend hours. They said not having an RN at the facility 7 days a week, for 8 consecutive hours a day, could place residents at risk of not receiving specific care only an RN could provide. Review of the facility's policy on Quality of Care, undated, revealed Residents and their Families or representatives have the right to expect and receive the high-quality care that meets their individual needs and preferences.