**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, for 1 of 8 residents (Resident #9) reviewed for abuse and neglect reporting. The facility failed to report to HHSC within 2 hours when Resident #9 alleged Resident #57 hit her on 06/17/2025. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #9's face sheet dated 07/31/2025 indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included rhabdomyolysis (muscle breaks down rapidly and releases breakdown into the blood), dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), anxiety disorder. Record review of Resident #9's Quarterly MDS assessment dated [DATE] indicated she was usually understood by others, and she understood others. The MDS assessment indicated Resident #9 had a BIMS score of 13, which indicated she was cognitively intact. The MDS assessment indicated Resident #9 required partial/moderate assistance with personal hygiene and toileting hygiene and substantial/maximal assistance with showering/bathing. Record review of Resident #9's care plan with date initiated 07/08/2025 indicated she received physical aggression on 06/17/2025. Record review of Resident #9's Progress Notes dated 06/17/2025 indicated, The resident has informed the RN at this time she was hit on the arms by another resident. The resident states that she was hit by another individual while eating breakfast on her bilateral arms. The resident states she is not in pain and is fine. She also states she could not understand why the other resident hit her and couldn't understand her as she was speaking gibberish. Head to toe assessment conducted, ROM to extremities intact, no bruising noted at the time of assessment. Resident has denied pain. The victim and aggressor have been separated. The DON, ADMIN, RP, MD are aware and have been notified. Signed by MDS Coordinator B. 2. Record review of Resident #57's face sheet indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), recurrent major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and anxiety disorder. Record review of Resident #57's Comprehensive MDS assessment dated [DATE] indicated she was sometimes understood by others, and she sometimes understood others. The MDS assessment indicated Resident #57 was unable to participate in the BIMS because she was rarely/never understood. The Staff Assessment for Mental Status indicated she had a short and long-term memory problem. The MDS assessment indicated Resident #57 had behavioral symptoms which could put others at significant risk of physical injury. Record review of Resident #57's care plan revised 07/07/2025 indicated she had a behavior problem related to increased agitation, episodes of hitting, and episodes of crying and asking for help. Resident #57's care plan indicated she had a potential to be physically aggressive related to dementia and poor impulse control with physical aggression initiated 06/17/2025. Record review of Resident #57's Progress Note dated 06/17/2025 indicated, The RN has been informed by another resident that this resident hit her on her arms. The resident is unable to recall the incident, these resident states, I don't know when asked about her description. The resident was removed away from the victim and placed on Q15 minute monitoring. The DON, ADMIN, RP, MD are aware and have been notified. Signed by MDS Coordinator B. During an interview on 07/30/2025 at 11:40 AM, MDS Coordinator B said Resident #9 reported to her another resident hit her on the arms while she was in the dining room. MDS Coordinator B said the resident who hit Resident #9 was Resident #57. MDS Coordinator B said when Resident #9 reported the incident to her she was still in the dining room, but the aggressor was not in the area so Resident #9 was safe. MDS Coordinator B said she assessed Resident #9, and she did not have any bruising or pain. MDS Coordinator B said she notified the DON, Administrator, RP, and doctor. MDS Coordinator B said she could not remember if it was witnessed or not. MDS Coordinator B said Resident #9 had reported it to her and she reported it to the above authorities. MDS Coordinator B said she reported the incident because it could be considered abuse. During an interview on 07/30/2025 at 11:51 AM, the Administrator said he was notified by MDS Coordinator B of the incident in the dining room between Resident #57 and Resident #9 on 06/17/2025. The Administrator said he did not report the incident because Resident #57 had a history of touching people, and her dementia is really bad. The Administrator said when Resident #57 was close to the other residents she had a tendency to touch the other residents. The Administrator said Resident #57 was not able to articulate things. The Administrator said he talked to Resident #9, and Resident #9 told him Resident #57 hit her and she could not understand why she did it. The Administrator said Resident #9 was confused about Resident #57 hitting her, so he did not report it. During an interview on 07/30/2025 at 12:05 PM, Resident #9 said about 6-8 weeks ago another resident had hit her on her arms in the dining room. Resident #9 said she was not able to understand what the other resident was saying, but the other resident got mad and hit her. Resident #9 said the other resident took her arm back and hit me, it didn't hurt me, but it hurt. Resident #9 said there were 2-3 staff members around, but she did not know their names. Resident #9 said she yelled for help and the staff took her away. Resident #9 said the staff told her she does that to everybody. During an interview on 07/31/2025 at 4:21 PM, the DON said Resident #9 reported Resident #57 hit her in the dining room. The DON said she did not think Resident #57 hit Resident #9 on purpose. The DON said Resident #57 was a touchy feely person, and she thought she reached out and Resident #9 took it as she hit her. The DON said they did an investigation, but they did not report it because Resident #57's BIMS score was too low. Record review of the facility's Abuse Prohibition Policy revised 11/07/2023, indicated, The Abuse Coordinator will report such allegations to the state agency in accordance with state law. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 28 residents (Resident #11) reviewed for MDS assessment accuracy. The facility failed to accurately document Resident #11's tobacco use. This failure could place residents at risk for not receiving care and services to meet their needs.Findings included: Record review of Resident #11's face sheet dated 07/31/2025 indicated he was a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #11 was able to make himself understood and usually understood others. The MDS assessment indicated Resident #11 had a BIMS score of 12, which indicated his cognition was moderately impaired. The MDS assessment did not indicate Resident #11 used tobacco. Record review of Resident #11's care plan revised 06/30/2025 indicated Resident #11 was a smoker. Record review of Resident #11's progress note dated 06/10/2025 indicated Resident #11 was a current smoker. During an interview on 07/30/2025 at 11:40 AM, MDS Coordinator B said she completed Resident #11's Comprehensive MDS assessment with an ARD of 06/14/2025. MDS Coordinator B said Resident #11 should have been coded for the use of tobacco because he smoked. MDS Coordinator B said when she completed the MDS assessments she went through the smoking list and reviewed it. MDS Coordinator B said it was her mistake and she may have overlooked it. MDS Coordinator B said when an MDS was not coded accurately it was an error and could affect the billing, and she did not think it could affect the resident directly. During an interview on 07/31/2025 at 4:43 PM, the Administrator said he expected for the MDS assessments to be coded correctly, according to the policies. The Administrator said the MDS Coordinators were responsible for ensuring this happened. The Administrator said if the MDS was not coded according to the resident's plan the interventions in place would not be beneficial to the patient. Record review of the facility's policy titled, MDS Coding Policy, reviewed 06/02/2025, indicated, .affiliated facilities utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment was completed for 1 of 4 residents (Resident #7) reviewed for PASRR Level I screenings. The facility failed to complete the PASRR level 1 screening for Resident #7 who was admitted on [DATE] and had a diagnosis of Schizophrenia on admission. This failure could place residents who had a mental illness at risk of not receiving a needed assessment PE (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #7's face sheet, dated 07/31/25, indicated he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included schizophrenia (a chronic brain disorder characterized by symptoms like hallucinations, delusions, and disorganized thinking), anxiety (a feeling of unease, worry, or fear, often experienced as a normal reaction to stress), and depression (a common mental health condition characterized by persistent sadness and a loss of interest in activities, significantly impacting daily life). Record review of Resident #7's quarterly MDS assessment, dated 07/19/25, indicated he was severely cognitive impaired on decision making. He was able to make himself understood and he was able to understand others. He received an antipsychotic and an antianxiety medication routinely. Record review of Resident #7's electronic medical records did not indicate a PASRR level 1 screening was done, after he admitted on [DATE]. During an interview and observation on 07/31/25 at 10:33 a.m., the MDS Coordinator F said she had been the MDS Coordinator since November 2024. She said she was responsible to ensure a PL1 was completed on any resident when they admitted to the facility. She said Resident #7 was a previous resident but discharged December of 2024 and re-admitted [DATE]. She said since Resident #7 had been discharged for over 30 days then a new PL1 should have been completed. She said she did Resident #7's PL1 yesterday (07/30/25) after been questioned by the state surveyor, and realizing she had not done Resident #7's PL1. She said since Resident #7's PL1 was not completed then LIDDA was not alerted to do a PE. She said it was important for PL1's to be done to see if a resident would meet the criteria to receive services. During an interview on 07/31/25 at 11:43 a.m., the DON said the MDS Coordinator F was responsible to ensure the PL1 was filled when Resident #7 admitted to the facility. She said if Resident #7 admitted with a diagnosis of Schizophrenia, then a PL1 should have been done so a PE could have been done to determine if he would be able to receive services. During an interview on 07/31/2025 at 12:12 p.m., the Administrator said the MDS Coordinator was responsible to ensure the PL1 was done on admission. He said the risk was that the resident could have had PASRR services since they were admitted with the MI diagnosis. During an interview on 07/31/25 at 12:18 p.m., the Regional Compliance Nurse said they did not have a facility policy for PASRR and used the guidelines from the RAI manual. Record review of the RAI manual section A1500: Preadmission Screening and Resident Review (PASRR): All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions (please contact your local State Medicaid Agency for details regarding PASRR requirements and exemptions). Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. A resident with MI or ID/DD must have a Resident Review (RR) conducted when there a significant change in the resident's physical or mental condition. Therefore, when an significant change in status assessment (SCSA) is completed for a resident with MI or ID/DD, the nursing home is required to notify the State mental health authority, intellectual disability or developmental disability authority (depending on which operates in their State) in order to notify them of the resident's change in status. Section 1919(e)(7)(B)(iii) of the Social Security Act requires the notification or referral for a significant change.1 Each State Medicaid Agency might have specific processes and guidelines for referral, and which types of significant changes should be referred. Therefore, facilities should become acquainted with their own State requirements.Preadmission Screening and Resident Review:Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that Medicaid-certified nursing facilities:Evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID). Offered all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings). Provide all applicants the services they need in those settings.PASRR is an important tool for states to use in rebalancing services. under the Americans with Disabilities Act. PASRR can also advance person-centered care planning by assuring that psychological, psychiatric, and functional needs are considered along with personal goals and preferences in planning long-term care.In brief, the PASRR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have SMI or ID. This is called a Level I screen. Those individuals who test positive at Level I are then evaluated in depth, called Level II PASRR. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident within 48 hours of admission that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 (Resident #123 and Resident #127) of 22 residents reviewed for baseline care plans. The facility failed to address Resident #123's vascular dementia diagnosis on her baseline care plan. The facility failed to ensure Resident #127's baseline care plan was completed within 48 hours of admission. These deficient practices could affect residents who are admitted to the facility with specialized needs and result in missed care.Record review of Resident #123’s face sheet dated 7/31/25 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses diabetes mellitus (disease in which results in too much sugar in the blood stream), high blood pressure, cerebrovascular disease (group of conditions that impact the brain’s blood flow), normal pressure hydrocephalus (where excessive spinal fluid builds up in the ventricles), and history of falling. The face sheet did not indicate Resident #123 had a diagnosis of vascular dementia. Record review of Resident #123’s admission MDS dated [DATE] indicated she could understand others and could make herself understood. The MDS also indicated she had a BIMS score of 11 which meant she had moderately impaired cognition. The MDS also indicated she required substantial/maximal assistance from staff for toileting, bathing, moderate assistance with transfers and setup for eating but did not include the diagnosis for non-Alzheimer’s dementia in section I4800. Record review of Resident #123’s base line care plan dated 07/17/25 and unsigned by a nurse indicated she was a diabetic and alert. The baseline care plan did not indicate Resident #123 had vascular dementia or any cognitive loss. During an interview on 07/28/2025 at 3:27 PM Resident #123’s family member said she feels felt as though the staff does did not know that she has had dementia. During an interview on 07/31/2025 at 4:21 PM, ADON F said Resident #123’s baseline care plan should have been completed within 48 hours of admission date 07/17/25. She said vascular dementia was an important diagnosis to be included in the baseline care plan. ADON F said the failure of not ensuring the baseline care plans were complete and accurate placed a risk for Resident #123’s needs not being met. During an interview on 07/31/2025 at 5:02 PM the DON said she expected the baseline care plan to include the dementia and the cognition as well. She said the charge nurses were responsible and then the ADON should have reviewed and discussed in the morning meetings. During an interview on 07/31/2025 at 5:12 PM the Administrator said the charge nurses were responsible for completing the baseline care plans. He said the dementia diagnosis was important to be included in the baseline care plan. The Administrator said the failure of not completing the baseline care plan and including the dementia diagnosis placed a risk for nurses not being aware of what to treat Resident #123 for and could potentially cause harm to the resident. 2. Record review of Resident #127’s face sheet dated 07/31/25, indicated a [AGE] year-old male who admitted to the facility on [DATE]. Resident #127’s diagnoses included heart failure (heart muscle does not pump blood as well as it should), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and acute respiratory failure with hypoxia (lungs cannot adequately oxygenate the blood, leading to low blood oxygen levels). Record review of Resident #127’s EMR on 07/31/25 indicated the admission MDS assessment had not been completed. Record review of Resident #127’s baseline care plan indicated it was completed on 07/29/25 by LVN R. This indicated the baseline care plan was completed 2 days late. During an interview on 07/31/25 at 12:41 PM, ADON F said the baseline care plan was completed within 48 hours of admission and the admit nurse was responsible for completing it. The ADON said if the admit nurse was not able to complete the baseline care plan, then the oncoming nurse was responsible for completing it. ADON F said the baseline care plan gave the staff a baseline for the care needed to take care of the resident. The ADON said if the baseline care plan was not completed timely then they would not know if the resident’s needs were being met. During an interview on 07/31/25 at 12:44 PM LVN R said she did not complete Resident #127’s baseline care plan when he admitted on [DATE] because he admitted late to the facility and did not have time. She said the oncoming nurse should have completed it. LVN R said they usually relayed what was not completed on the admission checklist to the oncoming nurse during report. LVN R said the nurses were responsible to complete the baseline care plans within 24 hours. She said by not completing the baseline care plan timely, the staff would not know how to care for the resident. During an interview on 07/31/25 at 12:25 PM, the DON said the baseline care plans were completed within 24 hours by the admission nurse. The DON said the ADONs were responsible for checking the resident’s chart the next day to ensure all assessments were completed. The DON said failure to complete the baseline care plans timely placed the resident at risk for the staff not knowing the care the resident required. During an interview on 07/31/25 at 12:51 PM, the Administrator said the baseline care plans were to be completed within 48 hours of admission because they allowed the staff to be aware of the specific needs of the resident. He said the IDT was responsible for ensuring the baseline care plans were completed timely. He said by not completing the baseline care plan the staff would not be able to meet the resident’s needs. Record review of the facility policy “Care Plans-Baseline revised October 2023 indicated: Policy Statement A baseline plan of care to meet the resident’s immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident…”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, 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 2 of 28 residents (Residents #5 and Resident #112) reviewed for care plans. 1. The facility failed to ensure Resident #5's care plan included her fall on 07/19/25 and the use of the non-strip strips and cervical collar (a collar used around the neck to support the neck and spinal cord after an injury) that should always remain in place. 2.The facility failed to update Resident #112's care plans for nectar thick liquids on 06/27/25. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.1.Record review of Resident #5’s face sheet dated 07/31/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses Multiple fractures of Ribs, lack of coordination, high blood pressure, diabetes mellitus (disease in which too much sugar is in the blood stream), and polyneuropathy (general term for peripheral nervous system disorders that impact nerve function in multiple areas of the body). Record review of Resident #5’s admission MDS dated [DATE] indicated she was able to understand others and able to make herself understood. The MDS also indicated she had a BIMS score of 15 which meant she was cognitively intact. The MDS also indicated she had falls in the last month, she had falls in the last six months that resulted in fractures, and she had a fall since admission to the facility. Record review of Resident #5’s care plan revised 05/29/25 indicated she had ADL self-care deficit and required moderate assistance with toileting, transfers, bed mobility, and dressing, and she was independent with eating. The care plan also indicated she had limited mobility, and she was a high risk for falls with interventions to ensure resident was aware of the need to call for assistance, assist with toileting, and assist with transfers. The care plan did not indicate Resident #5 had a fall on 07/19/25 and always required a cervical collar. Record review of Resident #5’s order summary report dated 07/31/25 did not indicate she had an order for the cervical collar. Record review of Resident #5’s hospital encounter dated 07/25/25 indicated she was to always wear the cervical collar when up and out of bed. During an observation on 07/28/2025 at 11:32 AM Resident #5 was sitting in her room in her wheelchair with a cervical collar on her neck. During an interview on 07/31/2025 at 4:55 PM MDS Coordinator Q said she was responsible for completing and updating the care plans for Resident #5. She said she should have care planned the fall on 07/19/2025 in Resident #5’s bathroom and interventions of non-slip strips should have been added but failed to mention the cervical collar. MDS Coordinator Q said they usually had morning meetings daily and they updated the care plans each day, but she did not know how she missed updating Resident #5’s care plan. She said the failure placed a risk of not ensuring the staff were providing the proper care. During an interview on 07/31/2025 at 5:04 PM the DON said she expected the cervical collar and the most recent fall on 07/19/25 with interventions to be included in the care plan. The DON said MDS Coordinator Q was responsible for ensuring Resident #5’s care plan was updated. She said the failure placed the risk of the staff not knowing how to care for Resident #5 and could possibly cause further injuries. During an interview on 07/31/2025 at 5:10 PM the Administrator said the fall on 07/19/25 and the cervical collar use should have been in the care plan along with the intervention for the care. He said MDS Coordinator Q was responsible for updating the care plans for Resident #5. The Administrator said the management staff discussed falls and admissions daily in the meetings. He said the failure placed a risk of harm to the Resident #5 or a repeat of the same incident/fall. 2.Record review of Resident #112’s face sheet, dated 07/31/25 indicated he was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, dysphagia (medical term for difficulty swallowing solids, liquids, or both), dementia (the loss of cognitive functioning — thinking, remembering, and reasoning), hypertension (high blood pressure), and gastroesophageal reflux disease also known as GERD (a digestive disorder where stomach acid frequently flows back into the esophagus, irritating the lining. Record review of Resident 112’s annual MDS assessment, dated 07/10/25, indicated Resident #112 was understood and understood by others. Resident #112 was moderately impaired in decision making. The MDS indicated Resident #112 required assistance with her ADLs such as eating and personal hygiene. The MDS indicated she was altered mechanical diet. Record review of Resident 112’s Physician order dated 06/27/25 revealed Resident #112 had a Regular diet Mechanical Soft texture, Nectar Thickened consistency. Record review of Resident #112’s comprehensive care plan, dated 03/07/25, revealed Resident #112 had a Regular diet, mechanical soft texture, with thin consistency. The intervention was for staff to provide and serve diet as ordered. During an observation and interview on 07/31/25 at 10:39 a.m., RN G looked in Resident #112’s medical records and said she had an order for nectar thick liquid consistence. He said since she required nectar thick liquids it should have been care planed. During an interview on 07/31/25 at 11:07 a.m., the DON said the MDS Coordinator was responsible for the care plans. She said they talked about the resident’s changes during the morning stand-up meeting and the clinical meeting every Wednesday. She said she could not say why the MDS Coordinator F had not updated Resident #112’s care plans. The DON said the nectar thick liquids should have been on Resident #112’s care plan. She said the purpose of the care plans was to keep everyone informed of the resident's wishes and care. During an interview on 07/31/25 at 12:14 p.m., the Administrator said the MDS Coordinator was responsible for the care plans. He said care plans were done for the care the resident needed. He said interventions were put in place so that staff would know what care the resident required. He said department heads were responsible for ensuring the staff was following the care plan. Record review of the facility policy titled, “Comprehensive Person-Centered,” revised 01/23, indicated, “Policy: A comprehensive, person-centered care plan that includes measurable objective and timetable to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident. #13 Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident conditions change.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 28 residents (Resident #110) reviewed for ADLs. The facility failed to provide Resident #10's showers as scheduled for the month of July 2025. These failures could place residents at risk of not receiving needed services and care, decreased self-esteem, and a decreased quality of life. Findings included: Record review of Resident #110's face sheet dated 07/31/2025 indicated he was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), atrial fibrillation (irregular, often rapid heart rate), and type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Record review of Resident #110's Comprehensive MDS assessment dated [DATE] indicated he was understood by others and understood others. The MDS assessment indicated Resident #110 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #110 required partial/moderate assistance with showering/bathing. Record review of Resident #110's care plan revised 07/25/2025 indicated he had an ADL self-care performance deficit related to chronic obstructive pulmonary disease and to provide a sponge bath when a full bath or shower was not tolerated. Record review of Resident #110's shower sheets indicated he received showers on 07/18/2025, 07/23/2025, 07/25/2025, 07/28/2025, and 07/30/2025. There was no shower sheet for 07/21/2025. During an observation and interview on 07/28/2025 at 11:31 AM, Resident #110 said he had only received one bath since his admission, and it was one week ago. Resident #110 said he could not stand the smell of himself. Resident #110 said he did not know when his scheduled bath days were. Resident #110 said the only reason he had gotten the shower was because he reported it to the DON, and she made them give him a shower. Resident #110's hair appeared greasy and disheveled. During an interview on 07/31/2025 at 2:17 PM, CNA C said Resident #110 received his showers on Monday, Wednesday, and Friday on the 2 PM-10 PM shift. CNA C said Resident #110 did not refuse his showers. CNA C said she had not missed giving Resident #110 any showers, and she was not aware that he missed any showers. CNA C said it was important for the residents to receive their showers, so they did not have bad smells. During an interview on 07/31/2025 at 4:04 PM, LVN D said it had not been reported to her that the residents were not receiving showers. LVN D said she was not aware of Resident #110 missing any showers. LVN D said it had not been reported to her that Resident #110 refused any showers. LVN D said it was important for the residents to receive their showers for dignity. During an interview on 07/31/2025 at 4:08 PM, the DON said recently it had not been reported to her that residents were not receiving showers. The DON said she had not been told Resident #110 refused showers. The DON said Resident #110 had not reported to her he missed showers and that he may have told the ADONs. The DON said the ADONs were responsible for reviewing the shower sheets to ensure the residents received their showers. The DON said it was important for the residents to receive their showers because they did not want them to get skin issues or infections, and it was also for their dignity. During an interview on 07/31/2025 at 4:47 PM, the Administrator said showers should be completed according to the shower schedule. The Administrator said the CNAs were responsible for the showers, and the nurses should monitor the showers were completed every shift. The Administrator said if the residents did not receive their showers, it could affect their hygiene and for infection control. Record review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised March 2018, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 6 residents reviewed for quality of care. (Resident #123) The facility failed to begin neurological checks when Resident #123 had an unwitnessed fall on 07/30/25 at 3:10 PM. These failures could place residents at risk of a delay in treatments for the resident's conditions.Findings included: Record review of Resident #123's face sheet dated 7/31/25 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses diabetes mellitus (disease in which results in too much sugar in the blood stream), high blood pressure, cerebrovascular disease(group of conditions that impact the brain's blood flow), normal pressure hydrocephalus (where excessive spinal fluid builds up in the ventricles), and history of falling. Record review of Resident #123's admission MDS dated [DATE] indicated she could understand others and could make herself understood. The MDS also indicated she had a BIMS score of 11 which meant she had moderately impaired cognition. The MDS also indicated she required substantial/maximal assistance from staff for toileting, bathing, moderate assistance with transfers and setup for eating. The MDS also indicated she received antipsychotic medications during the last 7 days or since admission to the facility. Record review of Resident #123's care plan dated 07/29/25 indicated she was at risk for falls r/t disorientation and increased risk of bleeding/bruising due to antiplatelet therapy with interventions to handle resident carefully when turning, positioning, or transferring, and sudden change in mental status, SOB, nose bleeds and report such findings to physician. Record review of Resident #123's fall note dated 07/30/25 at 3:10 PM indicated Resident #123 was found her on the floor beside her bed. During an observation and interview on 07/31/2025 at 09:50 AM Resident #123 was sitting in her wheelchair in the dining room with a family member. Resident #123 said she had a fall and she was ok but had anxiety. During an interview on 07/31/25 at 11:55 AM the DON said Resident #123 had an unwitnessed fall on 07/30/25 and should have had neurological checks check initiated at the time of the fall but the nurse failed to begin the neurological checks. She said she expected neurological checks to be completed on all unwitnessed falls or if a there was a fall with a resident hitting their head. The DON said she spoke with LVN E about the incident and LVN E said she did not feel like Resident #123 hit her head. The DON said the failure to complete neurological checks could place a risk for unknown injuries or change in condition. During an interview on 07/31/25 at 12:28 PM LVN E said she went into Resident #123's room after her fall and she just assumed that she did not hit her head because the way she was laying on the floor. LVN E said she examined Resident #123 and did not feel any bumps but she said the DON further instructed her on 07/31/25 to always begin neurological checks if a resident fall was unwitnessed. LVN E said the failure to start neurological checks after the fall could place Resident #123 at risk for internal bleeding or other issues if she hit her head. During an interview on 07/31/2025 at 4:30 PM The ADON F said the charge nurse at the time of the fall was responsible for starting neurological checks. She said the charge nurse should have assessed the resident, determined any injuries, and looked around and try to figure out how it happened. The ADON said the charge nurse should have notified the Medical Director, the DON, and Resident #123's family. She said neurological checks were expected to be completed for residents that had unwitnessed falls. The ADON F said not completing neurological checks could have caused the nurse to miss a change in condition. During an interview on 07/31/2025 at 5:15 PM the Administrator said he expected the charge nurse to follow the policy for falls and she should have begun neurological checks immediately after the fall when unwitnessed. He said the failure could have caused harm and the nurse could have missed a change in condition. Record review of the facility policy Policy for Resident and Visitor Accident Report revised 06/05/2025 indicated:Policy: The facility will conduct an investigation of all incidents involving residents of the facility.B. Resident Incidents/Accidents:1. If you witness an accident, you must immediately summon help.2. License nurse must: a. Examine the resident and obtain vital signs. B. If the resident hit his/her head or if the incident was unwitnessed initiate neurological checks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 3 residents (Residents #11) reviewed for accident hazards. The facility failed to ensure Resident #11 did not smoke a cigarette in the facility on 12/08/2024 and 07/11/2025. The facility failed to ensure Resident #11 was provided supervision while smoking on 07/29/2025. These failures could place residents at risk of accidents, injuries, or burns. Findings included: Record review of Resident #11's face sheet dated 07/31/2025 indicated he was a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), schizoaffective disorder bipolar type (mental health condition that is marked by a mix of symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania), and heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #11 was able to make himself understood and usually understood others. The MDS assessment indicated Resident #11 had a BIMS score of 12, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #11 required partial/moderate assistance with personal hygiene and bathing and set-up or clean-up assistance for toileting. The MDS assessment did not indicate Resident #11 used tobacco. Record review of Resident #11's care plan revised 07/15/2025 indicated on 07/11/2025 he was placed on a smoking schedule because he was found smoking in his room. Cigarettes and lighter were put in the nurse's cart. Resident # 11's care plan indicated to educate and encourage him to follow the facility designated smoking areas and policy, and he required supervision while smoking. Resident #11's care plan indicated he had an ADL self-care performance deficit related to impaired balance, and he was at risk for falls and injuries. Record review of Resident #11's Order Summary Report dated 07/31/2025 indicated Supervised smoking schedule. 7am 9am 11am 1pm 3pm 5pm 7pm 9pm every shift. Can go out supervised to smoke caught smoking in room with a start date of 07/12/2025. Record review of Resident #11's Smoking Safety Evaluations indicated: 06/11/2024- Resident #11 did not require supervision for smoking. Completed by the Clinical Services Coordinator. 12/08/2024- Resident #11 was confirmed a safe smoker/vaper. A note indicated resident was re-educated to smoke only outside of the building for safety reasons will continue to monitor. Completed by Nurse T. 01/29/2025- Resident #11 was confirmed a safe smoker/vaper. A note indicated resident appears to be a safe smoker at this time. However, resident has failed in the past to comply with smoking policies. Completed by the Social Worker. 04/28/2025- Resident #11 was confirmed to be a safe smoker/vaper. A note indicated no concerns being unsupervised. Completed by the Social Worker. 07/11/2025- Resident #11 was confirmed as not a safe smoker/vaper and must be supervised. Completed by the Social Worker. Record review of Resident #11's progress notes indicated: 12/08/2024 8:01 AM, Subjective : Patient is smoking in his room. Objective : Room smelled of cigarette smoke. Assessment : Patient caught smoking a cigarette in his room. DON notified. Plan : Education on the dangers of smoking indoors and near O2 explained to patient. Contraband (cigarettes and lighters) taken and placed in locked cart. Patient must ask nurse before going out to smoke. Nurse H8:23 AM, Patient caught smoking in his room. 11 cigarettes confiscated along with 9 lighters and locked in the med cart. LVN H 03/12/2025 6:21 AM, Skilled Nurse was informed by aid that Kitchen staff had seen resident on the floor outside the 300 hall exit door, SN made his way to the hall to see resident was in his wheelchair besides his bedroom door. Resident was asked what had happened and he stated that he went outside and began digging through the trash for cigarette butts so he could smoke, resident went further to claim that he had been outside since 1am which was demonstrably false since resident received his medication at 2:30am. Residents vital signs were taking [sic] and as follows: BP 101/57, Pulse 83, O2 97, Temp 96.9. Resident denied being in any pain r/t to fall. SN requested from resident a UA sample to check for UTI and resident refused, resident was also asked if it would be ok to ask the physician to put an order for a lab draw, resident once again refused. Resident has been and continues to be educated on the dangers of continually exiting the building at Night. The Resident was accompanied outside to smoke at the start of his daily smoking schedule. LVN K 04/27/2025 11:40 AM, Four lighters were confiscated from the resident's possession. Resident is still on supervised smoke breaks and is not allowed to keep paraphernalia in his room/possession. Those items must be locked on the nurse's cart. LVN H 07/11/2025 11:51 PM Resident observed by the aide coming out of his room smoking a cigarette wheeling himself down the hall way. When told he couldn't smoke in the building, he needed to put the cigarette out he stated I know am not supposed to smoke in the building am going out. Resident escorted out to smoke, assessed no burn injuries noted, notified the DON and Administrator, took all resident's cigarettes and lighter put the in the nurse's cart, resident was educated and reminded that he was to be put on a smoke schedule and be supervised. He verbalized understanding. LVN L 07/11/2025 10:09 AM LATE ENTRY Reason for smoking/vaping safety evaluation: Fire Safety compromised Facility policy is that all residents who smoke/vape must be supervised, regardless of safety or ability: NoIt [sic] is confirmed resident is NOT a safe smoker/vaper and must be supervised. Social Worker. During an observation and interview on 07/29/2025 starting at 11:22 PM, Resident #11 was observed coming out of his room in his wheelchair propelling himself. Resident #11 wheeled himself down the end of the 300 hall and let himself outside to the smoking area. Resident #11 had the code to go outside. LVN M was in the room with the resident at the end of the hall, the door was open, but Resident #11 passed by without LVN M's knowledge. When outside Resident #11 lit his cigarette and started smoking. Resident #11 was unsupervised by the facility staff. Resident #11 said the nurse up front gave him his cigarettes and a lighter, and he had them in his pocket. Resident #11 said he went outside alone to smoke. Resident #11 said one of the times he had gone out to smoke he fell outside because he got too close to the edge and fell off the concrete. The concrete on the patio of the smoking area was higher than the grass around it, it was not leveled. Resident #11 said he laid on the ground until the lady from the kitchen found him. Resident #11 said he did not remember when it was or how long he laid on the ground until he was found. During an interview on 07/29/2025 at 11:26 PM, CNA N said Resident #11 required supervision when smoking. CNA N said the nurses should have the smoking materials, and she tried to supervise the residents when she saw them going out to smoke because it was nighttime and for safety reasons. CNA N said she was not always able to supervise the residents when they went to smoke outside because sometimes, she did not see them if she was in another resident's room. CNA N said most of the time she was the only CNA on the hall at night. CNA N said it was important to provide supervision to residents while they smoked for safety reasons and because they could catch themselves on fire. CNA N said about 2-3 months ago Resident #11 was found outside on the floor by a kitchen aide when the kitchen aide came in around 5 am. CNA N said that night she tried to supervise him the best she could. CNA N could not remember when the last time she saw Resident #11 was prior to him being found outside. During an interview on 07/29/2025 at 11:36 PM, LVN O said it was her 2nd day working at the facility. LVN O said she did not know who required supervision while smoking. LVN O said the only way she would know was if it was an order. LVN O said she was Resident #11's nurse, and the nurse prior to her told her Resident #11 had been out to smoke at 9 PM. LVN O said it was important for the residents who required supervision to be supervised while smoking so they would not injure themselves or anyone else. During an interview on 07/29/2025 at 11:50 PM, LVN M said he decided based on the resident if they required supervision or not. LVN M said the smoking schedule for both unsupervised and supervised was from 8 AM-9 AM, 12 PM-1 PM, 2 PM-3 PM, and then before dinner was the last smoking time. LVN M said the nurse's keep the cigarettes and lighters for both the supervised and unsupervised smokers. LVN M said Resident #11 did not have any smoking privileges because he had lost them due to smoking in his room. LVN M said all the residents who smoked had the code to get in and out of the door on their own. LVN M said unsafe smoking could result in harm to others and harm to themselves. LVN M said Resident #11 could catch the room on fire or cause burns. During an interview on 07/29/2025 at 11:52 PM, LVN D said she had taken Resident #11 to smoke at 7 PM, and supervised him. LVN D said Resident #11 should not have any cigarettes or lighters. LVN D said if Resident #11 had cigarettes and lighters it was a safety issue for himself and others. During an interview on 07/29/2025 at 11:55 PM, ADON P said she started working at the facility on 06/27/2025. ADON P said residents who were considered safe could keep their own cigarettes and lighters and smoke whenever they wanted, but the residents who were considered unsafe were not able to keep their lighters and cigarettes and had to follow the smoking schedule. ADON P said Resident #11 was the only resident who was considered unsafe because he smoked in the building. ADON P said Resident #11 should not have any smoking materials that the nurse should have them. ADON P said she had asked the staff to take him to smoke at 10 PM. ADON P said all the residents who smoked had the code to go outside to the smoking area, and the residents could go out there when they wanted. ADON P said Resident #11 was allowed to go sit outside and he knew the code to get in and out. ADON P said during the day she checked Resident #11 frequently to ensure he did not have any smoking materials. ADON P said she did not know how Resident #11 was getting the lighters and cigarettes. During an interview on 07/30/2025 at 9:38 AM, the Social Worker said she observed the residents smoking to make sure they did not have any dexterity problems, and she completed the smoking evaluations. The Social Worker said she ensured the residents were aware of the smoking policy, and she enforced it. The Social Worker said if the residents were not following the smoking policy she would take to the Administrator and the nursing staff to determine the next action. The Social Worker said the DON directed her on when to conduct smoking evaluations on the residents. The Social Worker said she has evaluated Resident #11 as a safe smoker because she felt he was safe. Until 7/11/2025, when there was a concern of him smoking so she made him unsafe. The Social Worker said Resident #11's cigarettes and lighters were taken away from him. The Social Worker said if a resident required supervision while smoking, and they were not supervised it placed themselves and others safety at risk. During an interview on 07/30/2025 at 9:53 AM, the DON said Resident #11 was considered an unsafe smoker a couple weekends ago because he was trying to smoke in his room. The DON said the end of last year Resident #11 had done the same thing, and they had placed him on supervised smoking. The DON said Resident #11 would come to them every day and tell them he had learned his lesson, and he was not going to do it anymore, so in April 2025 he was deemed a safe smoker. The DON said on 12/08/2024 Resident #11 was in his room smoking, and he said he had done it because it was too cold to go outside. The DON said from 12/08/2024 to 04/28/2025 Resident #11 should have been a supervised when smoking. The DON said on 04/27/2025 Resident #11 was not supposed to have lighters, and they did not know how he got the lighters because they were checking his room periodically. The DON said on 04/28/2025 Resident #11 was deemed a safe smoker because he kept asking them about smoking and he had not had anymore episodes, so they said they were going to give him a chance and deemed him safe to smoke unsupervised. The DON said they should not have deemed him safe to smoke because he was still breaking the rules. The DON said because Resident #11 was not following the smoking policy it placed himself and others at risk for safety issues. The DON said on 07/11/2025 when Resident #11 was smoking in his room she told the staff to remove all his lighters and cigarettes. The DON said Resident #11 said he did not know why he smoked in his room. The DON said he was placed on a smoking schedule and required supervision when smoking. The DON said Resident #11 should not have been smoking alone outside the night of 07/29/2025. The DON said Resident #11 should never have possession of any cigarettes or lighters that somebody should be assisting him to go out and smoke, and his cut off time was maybe 9 PM. The DON said Resident #11 was placed on 1:1, and they searched his room again and they found 1 box of cigarettes. The DON said on 03/12/2025 she was notified that Resident #11 was found outside on the ground. The DON said she was not notified he had been looking in the trash for cigarette butts. The DON said if she would have been notified, he should have been re-evaluated for his smoking safety and placed on 1:1. The DON said Resident #11 had not had any burns or injuries related to smoking. The DON said only the residents who required supervision had a cut off time for their smoking. The residents who were unsupervised could smoke at any time. While interviewing the DON, the Social Worker entered and said on 12/08/2025 Resident #11 was in his room smoking, therefore, he should have been considered an unsafe smoker. The DON said Nurse T completed the smoking evaluation incorrectly. The DON said Nurse T no longer worked at the facility. The Social Worker said if a resident required supervision for smoking it should be on a list at the nurses' station. The Social Worker said smoking in the building could cause the building to blow up. The Social Worker said not conducting the smoking evaluations correctly was unsafe and placed them at risk of causing a fire or the building blowing up. The Social Worker said Resident #11 not being supervised could result in him hurting himself. During an interview on 0731/2025 at 5:31 PM, the Administrator said on 12/08/2024 when Resident #11 smoked in his room they took his cigarettes and placed him on supervised smoking. The Administrator said from 12/08/2024-04/27/2025 he was supposed to be supervised for smoking. The Administrator said on 07/11/2025 the CNA saw Resident #11 smoking in the facility and stopped him, and he was placed on supervised smoking again. The Administrator said Resident #11 should not have been smoking unsupervised the night of 07/29/2025, and he should not have had any smoking materials. The Administrator said Resident #11 had a BIMS of 14, he was alert and oriented and liked to go outside. The Administrator said Resident #11 had violated the smoking policy and it placed him at risk for danger to others, but he had never burned himself. The Administrator said Resident #11 was required supervision when smoking because he tried to smoke in his room. The Administrator said this could result in the building burning down. Record review of the Facility Smoking Policy-Supervised and Unsupervised revised 11/2024, signed by Resident #11 on 01/30/2025, indicated, It is the responsibility of the facility to provide a safe and hazard free environment for those residents having been assessed as being safe for Facility smoking privileges. The facility is responsible for informing residents, staff, visitors and other affected parties of facility smoking policies through verbal means, distribution and posting. This policy is intended to minimize the risks to: Residents who smoke, including possible adverse effects on treatment Passive smoke to others Fire. The facility is responsible for enforcement of smoking policies. Smoking is prohibited in any room, or area within facility. Smoking is prohibited where flammable liquids, combustible gas or oxygen are stored, and in any other hazardous location. These areas are posted with non-smoking area signs. Residents wishing to smoke while at the facility will have a Smoking Safety Evaluation completed by the interdisciplinary team to determine the resident's ability to follow smoking policies safely If resident is determined to be a Safe Smoker (Facility please check one option) Resident can smoke unsupervised, resident can keep their smoking supplies, and smoke in designated areas at their leisure OR Resident can smoke unsupervised, facility will keep all smoking supplies, and resident can smoke in designed areas at their leisure. If resident is determined to be an Unsafe Smoker then they must be supervised at all times when smoking. Facility staff will keep all smoking supplies and smoking times will be established by the facility and adhered to by the resident. A supervised smoking schedule will be posted and residents will be required to smoke with supervision only, according to the schedule. If a resident is in violation of this facility smoking policy, the Administrator and/or designee will meet with the resident and/or responsible party to discuss the violation. 30 day or immediate discharges may be issued at the discretion of the Administrator/designee pending the severity of the smoking/alcohol violation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 5 residents reviewed for respiratory care. (Resident #42) The facility failed to administer Resident #42's oxygen as ordered on 07/28/25, 7/29/25, and 7/30/25. This failure could place residents who receive respiratory care at risk for developing respiratory complications.Findings included: Record review of Resident #42's face sheet dated 07/31/25, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (lung condition caused by damage to the airways that limit airflow), lung cancer, and acute respiratory failure (lung condition when the lungs cannot exchange oxygen and carbon dioxide properly). Record review of Resident #42's admission MDS assessment dated [DATE], indicated she was sometimes understood and sometimes understood others. Resident #42 had a BIMS score of 12, which indicated her cognition was moderately impaired. Resident #42 received oxygen therapy. Record review of Resident #42's comprehensive care plan dated 07/29/25, indicated Resident #42 had oxygen therapy related to respiratory illness. The care plan interventions indicated oxygen at 2 liters per minute via nasal cannula continuously. May titrate to 3-4 liters per minute to keep oxygen saturations greater than 90 percent. Record review of Resident #42's order summary report dated 07/29/25, indicated Resident #42 had an order for oxygen at 2 liters per minute via nasal cannula continuously. May titrate to 3-4 liters per minute to keep oxygen saturations greater than 90 percent every shift with an order date of 07/18/25. Record review of Resident #42's respiratory administration record dated 07/01/25-07/31/25, indicated she had an order for oxygen at 2 liters per minute via nasal cannula continuously and may titrate to 3-4 liters per minute to keep oxygen saturations greater than 90 percent. The administration record indicated Resident #42 had received oxygen every shift since Resident #42 admitted on [DATE]. During an observation on 07/28/25 at 11:22 AM, Resident #42 was in her bed and received oxygen at 5 liters per minute via nasal cannula. During an observation on 07/28/25 at 3:26 PM, Resident #42 was in her bed and received oxygen at 5 liters per minute via nasal cannula. Record review of Resident #42's progress note dated 07/28/25 at 11:05 PM and signed by RN S, indicated .Resident is up watching television at present.O2 @ 5 LPM via NC. During an observation on 07/29/25 at 09:47 AM, Resident #42 was in her bed and received oxygen at 5 liters per minute via nasal cannula. During an observation and interview on 07/29/25 at 4:48 PM, Resident #42 was in her bed and received oxygen at 5 liters per minute via nasal cannula. Resident #42's family member was at her bedside and said Resident #42's oxygen was supposed to be set at 5 liters because it was what Resident #42 had received when she was at the hospital. During an observation on 07/30/25 at 09:27 AM, Resident #42 was in her bed and received oxygen at 5 liters per minute via nasal cannula. During an observation and interview on 07/30/25 at 9:39 AM, LVN R went into Resident #42's room and observed the oxygen setting. LVN R said Resident #42's oxygen was set at 5 liters. LVN R reduced Resident #42's oxygen rate to 4. LVN R said the oxygen was set at the ordered rate of 4, but Resident #42's family member plays with it. LVN R said the nurse was responsible for checking the oxygen during their morning rounds. LVN R said failure to administer the oxygen at the ordered rate could cause Resident #42 to receive too much oxygen. During an interview on 07/30/25 at 2:35 PM, the Pulmonary Nurse Practitioner said when she saw Resident #42 at the facility her oxygen was constantly set at 5-6 liters and has had to bring it down to 4. She said she had educated the husband on not changing the oxygen setting. The Pulmonary Nurse Practitioner said Resident #42 had a 10-liter oxygen concentrator because she had end stage lung disease and if she had an emergency where she needed more oxygen, then she would have the correct concentrator. During an interview on 07/30/25 at 3:43 PM, Resident #42's family member said he did not touch the oxygen concentrator. He said the doctor at the hospital placed Resident #42's oxygen at 5 liters and he has not moved the settings. During an interview on 07/31/25 at 12:25 PM, the DON said she expected oxygen to be administered as ordered. The DON said the nurses were responsible for ensuring the oxygen was set at the ordered rate. She said failure to administer the oxygen at the ordered rate placed the resident at risk for desaturation or receiving too much oxygen. During an interview on 07/31/25 at 12:51 PM, the Administrator said he expected physician orders to be followed and the oxygen to be set at the ordered rate. He said the nurses were responsible to check during their shift that those orders were in place. Record review of the facility's policy Oxygen Administration and Oxygen Safety reviewed and revised on 07/23/25, indicated . The purpose of this procedure is to provide guidelines for safe oxygen administration and oxygen safety guidelines. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the drug regimen was free from unnecessary drugs for 1 of 5 residents reviewed for medications. (Resident #123) The facility failed to ensure Resident #123 had a diagnosis or adequate indication for quetiapine (Seroquel) (An antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder). The facility failed to ensure the proper consent form 3713 was completed prior to administering the medication quetiapine (Seroquel). This failure could place residents who received antipsychotic medications at risk of receiving unnecessary medication. Record review of Resident #123's face sheet dated 7/31/25 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses diabetes mellitus (disease in which results in too much sugar in the blood stream), high blood pressure, cerebrovascular disease, normal pressure hydrocephalus, and history of falling. The face sheet did not indicate Resident #123 had a diagnosis of vascular dementia. Record review of Resident #123's admission MDS dated [DATE] indicated she could understand others and could make herself understood. The MDS also indicated she had a BIMS score of 11 which meant she had moderately impaired cognition. The MDS also indicated she required substantial/maximal assistance from staff for toileting, bathing, moderate assistance with transfers and setup for eating. The MDS also indicated she received antipsychotic medications during the last 7 days or since admission to the facility. Record review of Resident #123's base line care plan dated 07/17/25 and unsigned by a nurse indicated she was a diabetic and alert. The baseline care plan also indicated Resident #123 was taking psychotropic medications. The baseline care plan did not indicate Resident #123 had vascular dementia, any cognitive loss, nor did she have an approved diagnosis for the medication Seroquel. Record review of Resident #123's pharmacy recommendations dated 07/21/25 and provided to the facility on [DATE] indicated Resident #123 had an order for the antipsychotic medication quetiapine (Seroquel) and consents were required to be on the form 3713 provided by Texas Health and Human Services. The pharmacy recommendations also indicated Resident #123 was not confirmed to have an approved psychiatric diagnosis documented to support the use of the antipsychotic medication quetiapine (Seroquel). Record review of Resident #123's order summary report dated as of 07/29/25 indicated she had an order for:Quetiapine Fumarate oral tablet 25mg Give 1 tablet by mouth at bedtime for depression with a start date of 07/17/25 and no end date. Record review of Resident #123's EMR indicated she had the form 3713 for the antipsychotic medication quetiapine (seroquel) completed on 07/30/25 by the DON after surveyor intervention. During an interview on 07/31/25 at 11:35 AM, the DON said Resident #123 should not be taking quetiapine (Seroquel). She said she normally looked at resident's medications when they admit to the facility after the nursing team (DON and ADONs) reviewed new residents in the morning meeting, but she guessed they missed Resident #123's orders. The DON said Resident #123 should have an approved diagnosis to take quetiapine (Seroquel) and the consent form 3713 should have been completed by the admitting nurse or DON and ADON. The DON said the pharmacy consultant had been to the facility and should have made a recommendation as well but she had not reviewed the reports for Resident #123. She said the failure placed a risk for Resident #123 to have had adverse reactions to the medication. During an interview on 07/31/2025 at 4:34 PM, the facility Psychiatric Nurse Practitioner said she had seen Resident #123 on Tuesday 07/29/25 but she did not get to review her medications until Wednesday 07/30/25 and she discontinued the quetiapine (Seroquel) medication and began another medication Remeron (medication given for depression). She said Depression was not an approved diagnosis for any resident to take quetiapine (Seroquel). The Psychiatric Nurse Practitioner said the failure placed Resident #123 at risk for heart problems, irregular heartbeats, and a stroke. During an interview on 07/31/2025 at 5:13 PM, the Administrator said he was not familiar with the antipsychotic medications and consents but if needed he would have consulted the DON for those things. The Administrator said he expected the nurses to complete the necessary consents to give the medication. He said he expected the staff to follow the policy for antipsychotic medications and he assumed the risk was harm to resident. The Administrator said the risk was not following the policy and giving the patient medication without the proper consent. Record review of the facility policy Medication Management revised 10/01/19 indicated:Policy: In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use.D. The resident's medication regimen is evaluated when one or more of the following occur. When there is a significant negative change from baseline (designated with an asterisk*), medications should be ruled out as a cause in accordance with the policy on adverse consequence detection and prevention (See Preventing Adverse Consequences and Medication Errors Section). a. admission or re-admission.k. Unnecessary drugs - Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used - i. In excessive dose (including duplicate drug therapy) .iv. Without adequate indications for its use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 6 residents (Resident #60) and 1 of 3 medication carts (300-Hall nurse medication cart) reviewed for drugs and biologicals. 1. The facility failed to ensure Resident #60's medication labels for her amlodipine, carbidopa-levodopa, clopidogrel, and hydralazine matched her physician order. 2. The facility failed to ensure LVN D secured the 300-Hall nurse medication cart when it was not in use and unattended on 07/29/2025. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.Findings included: 1. Record review of Resident #60's face sheet dated 07/31/2025 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included essential (primary) hypertension (high blood pressure), dysphagia oropharyngeal phase (disorder or impairment in swallowing), and acute on chronic combined systolic and diastolic congestive heart failure (disorder in which the heart's ability to contract and relax is impaired). Record review of Resident #60's Comprehensive MDS assessment dated [DATE] indicated she was rarely/never understood, and she rarely/never understood others. The MDS assessment indicated Resident #60 was not able to be interviewed for the BIMS because she was rarely/never understood. The Staff Assessment for Mental Status indicated Resident #60 had a long-term and short-term memory problem. Record review of Resident #60's Order Summary Report dated 07/31/2025 indicated: NPO diet with a start date of 06/10/2025. Amlodipine 10 mg give 1 tablet via g-tube one time a day with a start date of 06/11/2025. Carbidopa-Levodopa 25-100 mg give 1 tablet via G-Tube three times a day with a start date of 07/29/2025. Clopidogrel 75 mg give 1 tablet via G-Tube one time a day with a start date of 07/30/2025. Hydralazine 100 mg give 1 tablet via G-tube three times a day with a start date of 07/29/2025. During an observation of medication administration and an interview on 07/29/2025 starting at 9:12 AM, RN G prepared and administered Resident #60's medications via her g-tube. Resident #60's medication labels for the following indicated to administer the medications by mouth: amlodipine 10 mg give 1 tab by mouth once daily carbidopa and levodopa 25/100 give 1 tab by mouth three times daily clopidogrel 75 mg give 1 tab by mouth daily hydralazine 100 mg give 1 tablet by mouth three times a day.RN G said Resident #60 did not take anything by mouth. RN G said the order should match the medication label. RN G said he did not notice the medication label was not correct. RN G said the nurse was responsible for getting the medication label fixed. RN G said the nurses should be making sure the label was correct, and if it was not, they should call the pharmacy to let them know. RN G said the medication label not having the correct route could lead to a mistake. 2. During an observation and interview on 07/29/2025 at 3:04 PM, there was an unlocked, unattended medication cart towards the end of the 300 Hall. LVN D was observed coming down the hallway to the medication cart. LVN D said she was responsible for the 300-hall nurse medication cart, and she had stepped away because she was looking for one of her residents. During an interview on 07/29/2025 at 4:35 PM, LVN D said it was important for the medication cart to be locked when not in use and unattended so the residents could not get into the medication cart and get medications that did not belong to them. During an interview on 07/31/2025 at 4:10 PM, the DON said it was the nurse's responsibility to ensure the medication cart was locked when they walked away. The DON said they needed to ensure it was lock because they did not want any residents to wander over and take medications or somebody could take anything off the medication cart. The DON said the person administering medications should ensure the label was correct and the correct route was on the medication label. The DON said somebody missed it that the ADONs were supposed to be checking the medication carts every other day or at least weekly. The DON said if someone did not know Resident #60 could not receive medications by mouth, they could give it by mouth, and she could aspirate (could go into her lungs). During an interview on 07/31/2025 at 4:48 PM, the Administrator said the medication carts should be locked at all times when the nurse was not close by it. The Administrator said if the medication cart was left unlocked anyone could go by and have access to the medications or confused residents. The Administrator said dangerous things could happen. Record review of the facility's policy titled, Storage of Medications, reviewed 06/24/2025, indicated, 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. 9. Unlocked medication carts are not left unattended. Record review of the facility's policy subject, Labeling of Medications, revised 10/01/2019, indicated, A. When there is a change to a physician order, the nurse receiving the order will affix a Direction Change sticker or equivalent to the label if there is no change in the medication. This sticker will be placed so as not to obliterate any other required information on the medication label. B. When such label appears on the container, the medication nurse checks the resident's medication administration record (MAR) or the physician's order for current information. C. The dispensing pharmacy is informed prior to the next refill of the prescription so the new container will contain an accurate label. 13. Improperly or inaccurately labeled medications are rejected and returned to the dispensing pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 4 residents (Resident #7) reviewed for hospice services. The facility failed to maintain Resident #7's hospice binder containing information related to hospice services provided for the resident such as the most recent plan of care, hospice election form, and physician recertification. These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Findings included:Record review of Resident #7's face sheet, dated 07/31/25, indicated he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included schizophrenia (a chronic brain disorder characterized by symptoms like hallucinations, delusions, and disorganized thinking), anxiety (a feeling of unease, worry, or fear, often experienced as a normal reaction to stress), and depression (a common mental health condition characterized by persistent sadness and a loss of interest in activities, significantly impacting daily life). Record review of Resident #7's quarterly MDS assessment, dated 07/19/25, indicated he was severely cognitive impaired on decision making. He was able to make himself understood and he was able to understand others. The MDS indicated Resident #7 was on hospice services. Record review of Resident #7's comprehensive care plan revised 04/21/25 indicated Resident #7 had a terminal prognosis and was on hospice services. The intervention was to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met, and for the nursing staff to provide maximum comfort for the resident. Record review of Resident #7's physician orders dated 04/09/25 indicated an order for {name} hospice. Record review of Resident #7's hospice binder revealed it did not have the Physician certification of the terminal illness, care plan, IDG (Interdisciplinary Group) meeting or Hospice election form. The last recertification was dated 02/20/25-05/20/25. During an observation and interview on 07/30/2025 at 2:38 p.m., ADON F look at Resident #7's hospice binder. She said the binder did not contain any orders, IDG meetings, plan of care or an updated recertification. She said the hospice company was supposed to bring the information needed in his binder. She said she was not sure how often the binder should be updated but would go ask and come back with an answer. ADON F said she was told by the DON that the binder should be updated every90 days and with any change of condition. She said she was responsible for ensuring the binder was updated. She said it was important for the hospice binder to be updated so staff was aware of his plan of care. During a phone interview on 07/30/2025 at 4:25 p.m., the hospice Office Manager said the binders at the facility should contain any supporting notes or documentation needed for Resident #7. She said they met every two weeks for the IDG meetings and said the documentation should be updated at least every 2 weeks after the IDG meetings. She said they had someone at the office who faxed the information to the facility but had been told the facility was throwing the information away or not updating the books. She said it was important to have the binders at the facility to help the facility know the care and services they were providing. During an interview on 07/31/2025 10:39 a.m., RN G said the hospice book should include the name of the hospice, diagnosis, sign in sheet and face sheet. He said management was responsible for ensuring the hospice binders were updated. He said any information the hospice company had for Resident #7 should be at the facility for effective communication because our care was combined. During an interview on 07/31/2025 at 12:04 p.m., the DON said ADON F was responsible for ensuring the hospice binders were updated. She said the books should be updated yearly and as changes were made. The DON said the failure to ensure those documents were at the facility was due to a lack of communication with the facility and the hospice company. She said all information done by hospice should be at the facility for communication and care coordination. During an interview on 07/31/2025 at 12:11 p.m., the Administrator said it was the ADON's responsibility to ensure all hospice documents were up to date. He said the books should be updated for effective communication between hospice and the facility for the care of the residents. Record review of the facility Hospice Agreement, dated 02/19/25, revealed, Hospice Patient medical records shall be in compliance with Federal State, and local laws and regulations. and with Medicare and Medicaid guidelines. Facility and Hospice shall prepare and maintain complete medical records for Hospice Patients receiving facility services and Hospice services in accordance with the Agreement and shall include all treatments, progress notes. authorizations, physician orders and other pertinent information. Originals of all documents of services provided by Hospice shall be filed and maintained by Hospice at the Hospice office. Copies of all documents of services provided by Hospice shall be filed and maintained in the Facility chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 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 2 of 6 residents (Resident #22 and Resident #53) and 2 of 2 staff (Treatment Nurse and Laundry Supervisor) reviewed for infection control. 1. The facility failed to ensure the Treatment Nurse changed her gloves when she removed Resident #22's dirty dressing on 07/29/25. 2. The facility failed to ensure the Treatment Nurse used proper PPE when providing wound care for Resident #53 on 07/30/25. 3. The facility failed to ensure the Laundry Supervisor was aware of Resident #53 being under contact isolation. These failures could place residents and staff at risk for cross-contamination and the spread of infection.Findings included: 1. Record review of Resident #22’s face sheet dated 07/31/25, indicated an [AGE] year-old female who readmitted to the facility 11/26/24. Resident #22 had diagnoses of dementia (memory loss) and muscle weakness. Record review of Resident #22’s quarterly MDS assessment dated [DATE], indicated she was able to be understood and understood others. Resident #22 had a BIMS score of 13, which indicated her cognition was intact. Resident #22 had one stage 3 pressure ulcer that was present upon admission/entry or reentry. Record review if Resident #22’s comprehensive care plan revised on 05/09/25, indicated she had a stage 3 pressure injury/ulcer to sacrum (triangular bone at the base of the spine). The care plan interventions included to administer treatments as ordered and monitor for effectiveness. Record review of Resident #22’s order summary report dated 07/31/25, indicated Resident #22 had an order to cleanse sacrum with wound cleanser/normal saline, apply collagen, skin prep to surrounding tissue or peri wound, secure with bordered gauze every day with an order date of 05/09/25. Record review of Resident #22’s treatment nurse MAR dated 07/01/25-07/31/25 indicated her wound care was provided daily. During an observation and interview on 07/29/25 at 10:24 AM, the Treatment Nurse entered Resident #22’s room disinfected the bedside table and washed her hands. The Treatment Nurse came back to her cart and obtained the wound care supplies. The Treatment Nurse and ADON F applied PPE and entered Resident #22’s room to perform wound care to Resident #22 sacrum. They both washed their hands and applied gloves. Resident #22 was turned to her right side. The Treatment Nurse removed Resident #22’s soiled dressing from her sacrum and disposed it in trash. The Treatment nurse then proceeded to cleanse Resident #22’s wound with normal saline and gauze. The Treatment Nurse failed to remove her dirty gloves before she cleaned Resident #22’s wound. The Treatment Nurse removed her gloves, washed her hands and proceeded to complete Resident #22’s wound care treatment. The Treatment Nurse and ADON F removed their PPE and washed their hands. The Treatment Nurse said she “could have sworn” she had washed her hands after she removed Resident #22’s dirty dressing. The Treatment Nurse said she was responsible for ensuring infection control was maintained when providing wound care and failure to do so placed the resident at risk for infection. During an interview on 07/31/25 at 12:25 PM, the DON said she expected wound care to be completed as ordered and infection control to be maintained. The DON said the Treatment Nurse should have changed her gloves when she removed Resident #22’s dirty dressing. She said failure to do so placed the resident at risk for infection. The DON said the Treatment Nurse was responsible for ensuring infection control was maintained when she performed wound care treatments. During an interview on 07/31/25 at 12:51 PM, the Administrator said he expected wound care to be performed as ordered and the facility’s infection control policy and procedure be followed. The Administrator said the nurses and the Treatment nurse were responsible to ensure infection control was maintained when wound care was performed. He said failure to do so placed the resident as risk for infection. The Administrator said the Treatment Nurse had told him that was not what had happened, regarding not changing her gloves after removal of the dirty dressing, the day the wound care was observed. 2.Record review of Resident #53’s face sheet dated 07/31/25 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses adult failure to thrive, elevated white blood cell count, malnutrition, and systemic inflammatory response syndrome. Record review of Resident #53’s admission MDS indicated she rarely made herself understood and could rarely understand others. The MDS also indicated she had short-term memory problems and long-term memory problems. Record review of Resident #53’s comprehensive care plan indicated she required enhanced barrier precautions for her feeding tube with interventions in place to provide signage on outside of room, enhanced barrier precautions during high-contact care including wound care. The care plan did not include contact isolation precautions. Record review of Resident #53’s order summary report indicated she had and order for: Isolation Precautions: Contact R/T (MRSA in wound exposure) every shift Initials acknowledge the following: Resident resided in room alone, and received all medications, participated in activities, received all meals, when applicable received all rehab services, and received all ADL care, in room the entire shift. every shift with a start date of 07/15/2025 and no end date. During an observation and interview on 07/30/25 at 2:04 PM the Laundry Supervisor was in the laundry and showed surveyor what the staff used when a resident was under contact isolation (which included an apron and gloves). She said the facility did not have any residents under contact isolation, but when the facility did have residents under contact isolation, their laundry was sent out in clear water-soluble bags and washed separately from other residents to prevent the spread of infection. During an observation and interview on 07/30/25 at 2:50 PM the Treatment Nurse went into Resident #53’s room, turned light on, spoke with Resident #53, moved bedside table, removed Resident #53 belongings on bedside table, and cleaned her bedside table to use for wound care supplies but failed to DON PPE prior to entering the room. The treatment nurse exited the room and used hand sanitizer for her hands and Donned PPE (gown and gloves) to perform the wound care for Resident #53. She performed wound care using proper technique. The Treatment Nurse then removed PPE to exit and only one biohazard box was in room for trash. Resident #53’s room did not have a box for soiled linen. The treatment nurse said she saw the contact isolation on Resident #53’s door and she should have placed the Gown and gloves on prior to entering the room to clean as well as provide care. She said there should also had been another isolation box in the room for soiled linen to be sent to the laundry. The Treatment Nurse said the failures placed increased risk for infection for residents and staff. During an interview on 07/31/2025 at 5:35 PM the DON said she expected the staff to [NAME] PPE prior to going into a resident’s room who is under contact isolation and the proper biohazard boxes to be in the room. She said the risk was increased infection for Resident #53 and spread of infection for the staff. She said the nursing staff were responsible for ensuring everyone is aware. During an interview on 07/31/2025 at 5:40 PM the Administrator said he expected nursing staff to be responsible for all infection control. He said all staff should follow the infection control policy. The Administrator said the failures placed a risk of infection and increased infection for Resident #53. Record review of the facility policy “Infection Control and Prevention revised 10/2022 indicated: Policy statement An infection and prevention program (IPCP)is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection…10) The Attending Physician and the interdisciplinary team will determine the treatment plan for the resident. a. If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infection, the Infection Preventionist will collect data to determine the effectiveness of such measures…11. Prevention of infection…7. Implementing appropriate isolation precautions when necessary…” Record review of the facility’s policy “The [Facility Corporate Name] Skin Integrity Prevention and Treatment Program” revised 07/2018, indicated “Wound Care. a. will follow the Non-Sterile Dressing Change Competency Protocol… c. Adheres to infection control best practices…”.

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 3 meals (lunch meal) reviewed for palatability, attractiveness, and appetizing. The dietary staff failed to provide food that was palatable and appetizing temperature for the lunch meal on 7/29/25.The facility failed to follow puree recipe for carrots served on 7/29/25 (lunch meal). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: 1. Record review of the menu indicated the lunch meal items on 7/29/25 included roasted turkey, carrots, scalloped potatoes, roll and cheesecake. During an interview on 7/28/25 at 11:03 a.m., Resident #67 stated she did not like the food, and the food was nasty tasting. During an interview on 07/28/2025 at 11:26 a.m., Resident #111 stated the food was not okay. During an interview on 7/28/25 at 11:56 a.m., Resident #55 stated the food was an issue around here; Resident #55 stated they do not know how to cook it; Resident #55 stated the food was bad. During observation and sample test tray of lunch meal on 7/29/25 at 12:45 p.m., the Dietary Manager stated the roasted turkey tasted good, carrots was hard and undercooked, scaled potatoes was warm and good, roll was not tasted, and cheesecake was good. The Surveyors stated roasted turkey tasted good, carrots were hard and needed to be hotter, scaled potatoes was good, roll was not tasted, and cheesecake was good. During an interview on 7/30/25 at 10:45 a.m., the Dietary Manager stated the Administrator oversaw him at the facility. The Dietary Manager stated he always tasted the foods every day at every meal. The Dietary Manager stated he did not taste the carrots served for lunch on 7/29/25. The Dietary Manager stated he handled food complaints by talking directly to the resident and seeing what the food complaint was then changing what the resident did not like. The Dietary Managers stated it was important to ensure the food was palatable, attractive and appetizing to the resident so the residents would eat the foods. The Dietary Manager stated people eat with their eyes first and if the food look good the residents would eat the foods. During an interview on 7/30/25 at 11:03 a.m., the Administrator stated he had been the Administrator since October of 2023. The Administrator stated he oversaw the dietary staff. The Administrator stated he ordered test trays from the kitchen once a week or as needed. The Administrator stated he was not aware of any recent food complaints from the residents. The Administrator stated he handled food complaints by talking to the residents and identifying the concerns then covering the concerns accordingly and lastly conducting in-services with the cook. The Administrator stated it was important to ensure the food was palatable, attractive and appetizing to the residents because it was part of what staff did and for the wellbeing and health for the residents. 2. Record review of the facility week 1 menu received on 7/29/25, indicated the lunch meal items included roasted turkey, carrots, scaled potatoes, roll and cheesecake. margarine, salt/pepper packets, choice of beverage, and water. Record review of the recipe for the carrot slice parslied for 10 or less residents on puree indicated to 2/3 cups of milk or appropriate liquid and 1 1/4 quarts of carrot sliced parslied. During observation of puree meal prep on 7/29/25 at 11:16 a.m., [NAME] A blended (1) cup of water and (3-4) Cups of carrot slice parslied. During an interview on 7/29/25 at 11:25 a.m , [NAME] A stated he had been a cook at the facility for 3 weeks. [NAME] A stated he completed in-services on following the recipe upon hire. [NAME] A stated the reason why he used water instead of following the recipe for the puree carrots because it slipped his mind. [NAME] A stated the facility had 8 residents on a puree diet. [NAME] A stated it was important to ensure he was following the recipe for nutritional value for the residents. During an interview on 7/29/25 at 2:51 p.m., the Dietician stated she had been the dietician since the 1st of February 2025. The Dietician stated she was not aware of the dietary staff was using water to puree meals, she said staff was not to use water to puree meals and she expected the dietary staff to follow the puree recipes. The Dietician stated she had limited oversight over the dietary staff, she said she oversaw meal checks and sanitation in the kitchen. The Dietician stated she had a short inspection and a long inspection once a month. The Dietician stated staff had not completed any in-services on following the recipes. The Dietician stated it was important to make sure the dietary staff was following the recipe for consistency of food products, consistency of puree foods, less of weight loss and wound healing. During an interview on 7/30/25 at 10:34 a.m., the Dietary Manager stated he had been the Dietary Manager since March of 2025, and he oversaw the dietary staff. The Dietary Manager stated he hired the cook and trained the cook to not to use water when pureeing foods. The Dietary Manager stated he expected staff to follow the recipe book. The Dietary Manager stated he completed an in-service with the cook on yesterday (7/29/25) for [NAME] A. The Dietary Manager stated it was important to ensure the dietary staff were following the recipe book for correct nourishment for the residents. During an interview on 7/30/25 at 11:00 a.m., the Administrator stated he had been the Administrator since October of 2023. The Administrator stated he was not made aware the dietary staff was not following the recipes and using water to puree foods, he said he expected staff to follow the recipe book The Administrator stated he oversaw the Dietary Manager. The Administrator stated he inspected the kitchen 3 times a week. The Administrator stated he did not have an accurate date of when staff last completed an in-service on following the recipe. The Administrator stated it was important to ensure the dietary staff were following the recipe book because it was in his policy for staff to follow the recipe book. The Administrator stated he would see if the facility had a policy on staff following the recipe. Policy on following the recipe book was requested from the Administrator on 7/30/25 at 11:00 a.m., was not received prior to exit on 7/31/25.Policy on following the recipe book was requested from the Dietary Manager on 7/30/25 at 10:45 am and was not received prior to exit on 7/31/25

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 (1 of 1) kitchen reviewed for dietary services, in that: 1) The Dietary staff failed to label and date all food items. 2) Dietary staff failed to effectively reseal, label and date frozen and refrigerated food items. These failures could place residents at risk for food contamination and foodborne illness. The findings included:During observations with Dietary Manager on 07/28/25 beginning at 10:11 a.m., the following observations were made in the kitchen Refrigerator (1 of 2):-(1) Gallon of premade orange juice was not label, had no expiration date and was prepared on 7/27/25.During observations with Dietary Manager on 07/28/25 beginning at 10:13 a.m., the following observations were made in the kitchen Refrigerator (2 of 2):-(1) sliced cheese bag unsealed, had an open date of 7/26/25 and no expiration date.-(1) cream cheese had a open date of 7/16/25 and no expiration date.-(1) Gallon of honey mustard had an open date of 6/12/25 and no expiration date. -(1) Gallon of honey mustard had a receive date of 11/20/24, open date of 4/16/25 and no expiration date. -(1) Gallon of salad dressing had a receive date of 11/6/24, open date of 7/26/25 and no expiration date.(1) container of spiced apples had an open date of 7/22/25 and no expiration date(1) container of sliced oranges had an open date of 7/24/25 and no expiration date. During observations with Dietary Manager on 07/28/25 beginning at 10:21 a.m., the following observations were made in the kitchen walk-in freezer (1 of 1):(1) hamburger Pattie not placed in a zip lock bag and bag was left unsealed.(1) Garlic biscuits had an open date of 5/27/25 and no expiration date.(1) bag of frozen turkey meat opened 7/11/25 had no expiration date. (1) bag of frozen chicken thighs had an open date of 7/25/25 and no expiration date. (1) box of dinner rolls bad was not sealed closed. (1) precooked hamburger patties bag was not sealed closed.(1) zip lock bag of pepperoni was not labeled or dated.(1) zip lock bag of fish Pattie was opened 2/11/25 and had no expiration date. During an interview on 7/30/25 at 10:50 a.m., the Dietary Manager stated he had been the Dietary Manager since March of 2025. The Dietary Manager stated the Administrator oversaw him at the facility. The Dietary Manager stated all food items found in the refrigerator and freezer were to be labeled, dated with receive date, open date and expiration date. The Dietary Manager stated staff completed in-services on labeling and dating on 7/29/25. The Dietary Manager stated staff last completed in-services on resealing refrigerated and frozen food items back in March of 2025. The Dietary Manager stated he conducted walk throughs in the kitchen every morning. The Dietary Manager stated the Administrator conducted walk throughs in the kitchen 3 times a week. The Dietary Manager stated if was important to ensure staff were labeling and dating refrigerator and frozen food items to ensure staff could tell how long they could use the foods for. During an interview on 7/30/25 at 11:05 a.m., the Administrator stated he had been the Administrator at the facility since October of 2023. The Administrator stated he oversaw the dietary staff at the facility. The Administrator stated all food items found in the refrigerator and freezer were to be labeled, dated with receive date, open date and expiration date. The Administrator stated he was not sure when the dietary staff last completed in-services on labeling and dating in the kitchen. The Administrator stated he was not sure if staff completed in-services on resealing refrigerated and frozen food items in the kitchen. The Administrator stated he conducted walk throughs in the kitchen 3 times a week. The Administrator stated it was important to ensure staff were labeling, dating and resealing refrigerated and frozen food items because he did not want to give the resident something that was expired. Record Review of food receiving a storage policy revised dated on 6/23/25 indicated (8) All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).Record Review of refrigerator and freezer policy reviewed on 6/25/25 indicated Policy statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation, and will observe food expiration guidelines; (7) All food shall 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 dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. (8) Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufactures when expiration dates are in question or to decipher codes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 1 of 10 residents (Resident #1) reviewed for developing and implementing abuse policies. The facility failed to follow its policy to report to the Texas Health and Human Services Commission (HHSC) when Resident #1 alleged that LVN B did not do her treatment on 03/21/25 and she felt neglected. The facility staff did not report to the state agency that Resident #1 felt neglected by her missed wound treatment on 03/21/25. This failure could place residents at risk of neglect, abuse, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet, dated 03/27/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included arthritis (conditions that cause joint pain, swelling, and stiffness), diabetes(is a chronic condition that happens when you have persistently high blood sugar levels), anxiety(characterized by excessive and persistent worry, fear, and nervousness) and dementia(diseases that affect memory, thinking, and the ability to perform daily activities). Record review of Resident #1's quarterly MDS assessment, dated 01/26/25, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 14, which meant she was cognitively intact. The MDS indicated Resident #1 required help with toileting, bed mobility, dressing, transfers, personal hygiene, and independent with eating. The MDS indicated Resident #1 had an open lesion, and it required treatment. Record review of Resident #1's care plan revised on 06/11/24 indicated Resident #1 had an actual impairment to her skin integrity to the left axilla related to an open area where her humerus repair hardware had broken through the skin. The intervention was for staff to follow the facility protocol for treating the injury. Record review of Resident #1's physician's orders dated 03/03/25, indicated, Clean left axilla (the area on the human body directly under the shoulder joint) with normal saline, pay dry, apply silver gel, calcium alginate, and cover with bordered gauze every day shift every Monday, Wednesday, and Friday for metal piece sticking out of left axilla. Record review of Resident #1's medication Administration Record on 03/21/25 for Clean left axilla with normal saline, pay dry, apply silver gel, calcium alginate, and cover with bordered gauze every day shift every Monday, Wednesday, and Friday for metal piece sticking out of left axilla was not signed out as being done. During an interview on 03/24/25 at 12:30 p.m., Resident #1 said she did not have her treatment done on Friday (03/21/25) by LVN B. She said she had asked an unknown staff member to tell the nurse, but the nurse never came. She said she felt neglected and was upset because she had to wait until the next day to have her treatment done. During a phone interview on 03/25/35 at 2:10 p.m., LVN C said on Saturday 03/22/25, Resident #1 said she did not get her treatment done on Friday and had asked for it to be done. LVN C said Resident #1 said she felt neglected because her treatment was not done. LVN C said Resident #1's treatment was supposed to be done on Friday (03/21/25). LVN C said she did Resident #1's treatment on Saturday (03/22/25) but did not tell the abuse coordinator or DON about Resident #1 making the allegation of neglect. She said she had been trained on reporting abuse and should have reported it to the Administrator. She said it was a busy day and forgot to report it. During a phone interview on 03/25/25 at 4:10 p.m., LVN B said Resident #1's treatment was due on Friday (03/21/25), but she was unaware the treatment had not been done. She said they usually had a treatment nurse Monday through Friday and did not realize the treatment nurse was off on Friday (03/21/25). She said the DON had sent a text indicating that the treatment nurse was off and for the nurses to do the treatments, but she said she did not see the text until questioned by the surveyor. LVN B said she did not do Resident #1's scheduled treatment on Friday (03/21/25). During an interview on 03/26/25 at 3:03 p.m., the DON said she expected staff to do treatments as ordered. She said on Friday (03/21/25), the treatment nurse had called off, and she sent a mass text to the nurses letting them know to do the treatments. She said she was unaware Resident #1's treatment was not done until the surveyor reported it to the Administrator on 03/24/25. She said Resident #1's treatment should have been done as ordered. She said she was not aware Resident #1 made the neglect allegation until yesterday (03/25/25) when LVN C called and reported to the Administrator that Resident #1 felt neglected because her treatment was not done. The DON said LVN C should have reported Resident #1, making the allegation of neglect. She said she had LVN C come to the facility and write her statement. She said they have done several in-services on neglect/abuse. The DON said it was important to report and investigate abuse/neglect to prevent further abuse/neglect from occurring. During an interview on 03/26/25 at 4:37 p.m., the Administrator said he was unaware Resident #1 did not get her treatment done on (03/21/25) until the surveyor informed him of her allegation on 03/24/25. The Administrator said he went to talk to Resident #1, and she told him LVN B did not do her treatment on (03/21/25) and she felt neglected. The Administrator said he reported to HHSC, suspended LVN B, started his internal investigation, and staff was in-serviced on abuse/neglect. He said he learned yesterday (03/25/25) that LVN C was aware of Resident #1's neglect allegation but did not report it to him. He said the staff was aware that he was the abuse coordinator and should have reported the allegation of neglect to him. He said any allegation of abuse/neglect should have been reported to him, and his responsibility was to protect the residents, suspend the alleged perpetrator, and report to HHSC within 2 hours. He said the DON/ADON oversaw the process of treatments being done. He said part of their plan of correction was they came up with a back-up plan for when/or if the treatment nurse called off. The Administrator said when allegations were not reported promptly, abuse could continue to occur, and residents could be in danger if the abuse/neglect was continuing. Record review of the facility's Inservice dated 03/24/24 revealed staff were trained on abuse and neglect, exploitation, what abuse and neglect were, and who to report abuse and neglect to. The in-service was conducted by the ADON Record Review of 12 safe surveys conducted by the facility social worker did not reveal any additional concerns. Record review of the facility policy titled Abuse Prohibition Policy, revised 05/17/24, indicated, Intent: This protocol was intended to assist in the prevention of abuse, neglect, and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, voluntary seclusion, and financial abuse. Policy: The facility will prohibit neglect and mental or physical abuse, including involuntary seclusion and misappropriation of property. #2 The facility will investigate alleged or suspected abuse, neglect, or misappropriation of property and will provide notification of information to the proper authorities according to state and federal regulations. Reporting: Any employee who becomes aware of an allegation of abuse, neglect, or misappropriation of resident property shall report the incident to the abuse coordinator immediately. The abuse coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, and injury of unknown source with bodily injury immediately or within two hours of the allegation. The abuse coordinator reports all other allegations of neglect, mistreatment, exploitation, injuries of unknown source, and misappropriation within 24 hours of the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 (Resident #1) residents reviewed for quality of care. The facility failed to ensure that LVN B did Resident #1's left axilla wound treatment as ordered on 03/21/25. This failure could result in residents with wounds not having their treatments performed as ordered, wounds becoming infected, and decreased wound healing. Findings Included: Record review of Resident #1's face sheet, dated 03/27/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included arthritis (conditions that cause joint pain, swelling, and stiffness), diabetes(is a chronic condition that happens when you have persistently high blood sugar levels), anxiety(characterized by excessive and persistent worry, fear, and nervousness) and dementia(diseases that affect memory, thinking, and the ability to perform daily activities). Record review of Resident #1's quarterly MDS assessment, dated 01/26/25, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 14, which meant she was cognitively intact. The MDS indicated Resident #1 required help with toileting, bed mobility, dressing, transfers, and personal hygiene, and was independent with eating. The MDS indicated Resident #1 had an open lesion, and it required treatment. Record review of Resident #1's physician's orders dated 09/23/23 indicated to monitor the left axilla metal rod every shift for signs and symptoms of infection. Record review of Resident #1's physician's orders dated 03/03/25, indicated, Clean left axilla (the area on the human body directly under the shoulder joint) with normal saline, pay dry, apply silver gel, calcium alginate, and cover with bordered gauze every day shift every Monday, Wednesday, and Friday for metal piece sticking out of left axilla. Record review of Resident #1's care plan revised on 06/11/24 indicated Resident #1 had an actual impairment to her skin integrity to the left axilla related to an open area where her humerus repair hardware had broken through the skin. The intervention was for staff to follow the facility protocol for treating the injury and monitor the left axilla metal rod. Record review of Resident #1's medication Administration Record on 03/21/25 for Clean left axilla with normal saline, pay dry, apply silver gel, calcium alginate, and cover with bordered gauze every day shift every Monday, Wednesday, and Friday for metal piece sticking out of left axilla was not signed out as being done. During an interview on 03/24/25 at 12:30 p.m., Resident #1 said she did not have her treatment done on Friday (03/21/25) by LVN B. She said she had asked an unknown staff member to tell the nurse, but the nurse never came. During a phone interview on 03/25/25 at 4:10 p.m., LVN B said Resident #1's treatment was due on Friday (03/21/25), but she was unaware the treatment had not been done. She said they usually had a treatment nurse Monday through Friday and did not realize the treatment nurse was off on Friday (03/21/25). She said the DON had sent a text indicating that the treatment nurse was off and for the nurses to do the treatments, but she said she did not see the text until questioned by the surveyor. LVN B said she could not remember if she looked at Resident # 1's left axilla wound on Friday to see if it had any signs of infection. LVN B said she did not look at Resident #1's treatment MAR on Friday (03/21/25) because she did not know she needed to. She said she was responsible for the medications and thought the treatment nurse had done her treatment. LVN B said she did not do Resident #1's scheduled treatment on Friday (03/21/25). During an interview on 03/26/25 at 3:03 p.m., the DON said she expected staff to do treatments as ordered. She said on Friday (03/21/25), the treatment nurse had called off, and she sent a mass text to the nurses letting them know to do the treatments. She said she was unaware Resident #1's treatment was not done till the surveyor reported it to the Administrator on 03/24/25. She said Resident #1's treatment should have been done as ordered. The DON said the importance of following the wound care physician's orders was for wound healing and prevention of infection. During an interview on 03/26/25 at 4:37 p.m., the Administrator said he was unaware Resident #1 did not get her treatment done on (03/21/25) until the surveyor informed him of her allegation on 03/24/25. The Administrator said he went to talk to Resident #1, and she told him LVN B did not do her treatment on (03/21/25). The Administrator said he expected staff to follow the physician's orders to promote wound healing. Record review of the facility's policy titled Skin Integrity Prevention and Treatment Program, revised 1/2023, indicated, . Wound Care: C Adheres to infection control best practice. Record review of the facility policy titled Abuse Prohibition Policy, revised 05/17/24, indicated, Intent: This protocol was intended to assist in the prevention of abuse, neglect, and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, voluntary seclusion, and financial abuse. Policy: The facility will prohibit neglect and mental or physical abuse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.Record review of Resident #1's face sheet, dated 03/27/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included arthritis (conditions that cause joint pain, swelling, and stiffness), diabetes (is a chronic condition that happens when you have persistently high blood sugar levels), anxiety (characterized by excessive and persistent worry, fear, and nervousness) and dementia (diseases that affect memory, thinking, and the ability to perform daily activities). Record review of Resident #1's quarterly MDS assessment, dated 01/26/25, indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 14, which meant she was cognitively intact. The MDS indicated Resident #1 required help with toileting, bed mobility, dressing, transfers, and personal hygiene, and was independent with eating. The MDS indicated Resident #1 had an open lesion, and it required treatment. Record review of Resident #1's physician's orders dated 03/03/25, indicated, Clean left axilla (the area on the human body directly under the shoulder joint) with normal saline, pay dry, apply silver gel, calcium alginate, and cover with bordered gauze every day shift every Monday, Wednesday, and Friday for metal piece sticking out of left axilla. Record review of Resident #1's care plan revised on 06/11/24 indicated Resident #1 had an actual impairment to her skin integrity to the left axilla related to an open area where her humerus repair hardware had broken through the skin. The intervention was for staff to follow the facility protocol for treating the injury. Record review of Resident #1's care plan dated 01/16/25 indicated Resident #1 required Enhanced Barrier Precautions, also known as EBP (infection control practices designed to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes by focusing on gown and glove use during high-contact resident care activities) related to her wound. The interventions were for staff to use EBP during high-contact resident care activities as applicable, such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, wound care (any skin opening requiring a dressing), and other areas determined to require EBP. During an observation on 03/24/25 at 12:30 p.m., an Enhanced Barrier Precautions sign and a cart were outside Resident #1's room. During an observation on 03/26/25 at 9:15 a.m., LVN A applied gloves, entered Resident #1's room to set up her supplies without a gown on, exited the room, and changed gloves without performing hand hygiene. LVN A re-entered Resident #1's room without a gown, applied gloves, and removed the dressing from Resident #1's left axilla. LVN B did not remove her gloves or perform hand hygiene before cleaning the wound to Resident #1's left axilla with normal saline. LVN A applied silver gel, calcium alginate, and a bordered dressing to Resident #1's left Axilla. LVN A did not change her gloves or perform hand hygiene, then gathered all her trash with the same dirty gloves, pulled up Resident #1's bed covers, and placed her bedside table over the bed. During an interview on 03/26/25 at 9:35 a.m., LVN A said she did not realize she did not change gloves or perform hand hygiene during the wound care for Resident #1. She said she should have changed her gloves and performed hand hygiene when going from dirty to clean to prevent infection in the wound. LVN A said she did not wear the proper PPE when entering Resident #1's room or while performing wound care. She said Resident #1 was on EBP, and she should have worn a gown and glove while in Resident #1's room to prevent the spread of infection. During an interview on 03/26/25 at 3:03 p.m., the DON said she expected staff to perform hand hygiene when they entered or exited a room, when visibly soiled, between dirty and clean, and between glove changes. The DON said the importance of hand hygiene was infection control. The DON said Resident #1 was on EBP, and when staff was in her room to perform care such as wound care, they should have on a gown and gloves to prevent infection. During an interview on 03/26/25 at 4:37 p.m., the Administrator said he expected staff to perform hand hygiene as needed, before and after providing care, in between care, and between glove changes. He said if Resident #1 was on EBP and the nurse was performing wound care, the nurse should have had on a gown and gloves. The Administrator said the importance of hand hygiene and following EBP was infection prevention and cross-contamination. Record review of the facility's police titled Infection Prevention and Control, revised date of 03/18/25, indicated Policy statement: an infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Record review of the facility's police titled Handwashing-Hand Hygiene, revised date of 10/2020, indicated, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: #2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. #7. Use an alcohol-based hand rub containing at least 62% alcohol or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; k. After handling used dressings, contaminated equipment, etc.; #10. Hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Record review of the facility's policy titled Enhanced Barrier Precautions, dated 04/01/24, indicated Enhanced Barrier Precautions for residents with any of the following: wounds and indwelling medical devices even if the resident was not known to be infected Indwelling medical device example include central lines, urinary catheters, feeding tubes, and tracheostomies Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 21 residents (Resident #1 and Resident #2) reviewed for infection control. 1. The facility failed to ensure CNA D and CNA E wore PPE while providing catheter care on Resident #2 on 03/26/25. 2. The facility failed to ensure LVN A wore the proper PPE (gown and gloves), changed her gloves, and performed hand hygiene while performing wound care on Resident #1 on 03/25/25. These failures could place residents and staff at risk for cross-contamination and spread of infection and could potentially affect all others in the building. Findings Include: 1.Record review of a face sheet dated 03/26/25, indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of chronic kidney disease (your kidneys exhibit mild damage, indicated by a slightly reduced estimated glomerular filtration rate), retention of urine (the inability to completely empty the bladder, either acutely (suddenly) or chronically (gradually)), benign prostatic hyperplasia with lower urinary tract symptoms (prostate gland was growing, putting pressure on the urethra and bladder, causing urinary problems like frequent urination, weak stream, and difficulty emptying the bladder). Record review of Resident 2's admission MDS assessment, dated 03/07/25, indicated Resident #2 understood and was understood by others. Resident #2's BIMS score was 15 indicating he was cognitively intact. The MDS indicated Resident #2 required assistance with his transfers, toileting, dressing, hygiene, and set up for eating. The MDS indicated he had an indwelling catheter. Record review of Resident #2's care plan dated 03/03/25, did not indicate enhanced barrier precaution. Record review of Resident #2's order summary dated 03/26/25, indicated foley catheter care every shift and as needed, with a start date of 03/02/2025. During an observation on 03/26/25 at 10:45 a.m., CNA D and CNA E performed catheter care on Resident #2. They both had on gloves but did not have on a gown as part of the appropriate PPE. This surveyor observed no enhance barrier precaution sign on the door or PPE at the door. During an interview on 03/26/25 at 1:30 p.m., RN F stated she did not know what happened to the enhanced barrier precaution sign and PPE, it was at the door the day before. RN F stated it was the nurse's responsibility to make sure the enhanced barrier precaution sign and PPE was at the door. RN F stated if the CNAs were unsure if they needed to wear PPE for a resident with a catheter they should have asked the nurse. RN F stated it was important to use PPE for a resident with a catheter to prevent infection. During an interview on 03/26/25 at 1:38 p.m., CNA D stated she should have asked the nurse if she needed to wear a gown during catheter care. CNA D stated it was important to wear the appropriate PPE during catheter care to prevent the spread of infection. CNA D stated the harm to the resident could be urinary tract infection. During an interview on 03/26/25 at 1:42 p.m., CNA E stated she should have asked the nurse if Resident #2 was in enhanced barrier precautions since he had a catheter. CNA E stated it was important for residents with a catheter to be in enhance barrier precaution, so the resident did not get an infection. CNA E stated the harm of providing catheter care without wearing a gown either the staff or the resident could be exposed to an infection. During an interview on 03/26/25 at 3:00 p.m., the DON stated all of the nursing staff was responsible for ensuring a enhanced barrier precautions sign and PPE was at the residents door and the staff knew to wear PPE while preforming care. The DON stated enhanced barrier precautions were important to keep from passing bacteria. The DON stated the harm to the resident was infection. The DON stated the staff was in-serviced on enhanced barrier precautions as needed, on hire, and annually. During an interview on 03/26/25 at 3:30 p.m., the Administrator stated he expected all staff to follow the guidelines on the sign posted on the door. The Administrator stated the staff was aware of Resident #2 in enhanced barrier precaution. The Administrator stated the sign on the door and the setup outside the door was there the day before. The Administrator stated he made routine rounds to ensure staff was following the guidelines and the DON had given several in-services on enhanced barrier precautions. The Administrator stated the staff should be wearing the proper PPE (gown and gloves) to protect themselves and to keep the spread of infection from other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury for 1 of 3 (Resident #1) residents reviewed for abuse and neglect. The facility staff did not report to the state agency Resident #1's bruising to left brow, temple, and behind right knee on 9/22/24. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings Include: Record review of the face sheet dated 10/3/24 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including anxiety, hypertension (elevated blood pressure), traumatic brain injury (a brain injury caused by an outside force, usually a violent blow to the head), dementia, and heart failure (a chronic condition in which the heart does not pump blood as good as it should). Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 13 and was cognitively intact . The MDS indicated Resident #1 required substantial/maximum assistance with transfers from sitting to lying, lying to sitting on the side of the bed, and chair/bed to chair. The MDS indicated Resident #1 was dependent on staff for rolling left and right and sitting to standing. Record review of the care plan revised on 9/29/24 indicated Resident #1 had impaired cognitive function/dementia or impaired thought processes. Record review of an incident report regarding Resident #1 dated 9/22/24 at 9:34 a.m. written by LVN B indicated, During routine round, CNA notified this nurse about bruises to the right leg behind the knee and left side of brow. The incident report indicated an immediate skin assessment was complete with bruise noted to right leg behind the knew and the left side of the brow. The incident report indicated LVN B notified the Weekend RN Supervisor of the bruising. The incident report indicated the DON, physician and Resident #1's responsible party were notified of the bruising. The incident report indicated Resident #1 was not able to give facility staff a description of how the bruising occurred. The incident report indicated Resident #1's responsible party was spoke to about the bruised areas and the responsible party said Resident #1 bumped it on the assist bar. Record review of a nursing progress note dated 9/22/24 at 1:19 p.m. written by LVN B indicated Resident #1's responsible party was notified of the bruising to her left brow and behind her right knee. The progress note indicated the responsible party was pleased with the phone call and had no other concerns. During an observation and interview attempted on 10/1/24 at 12:32 p.m. Resident #1 was unable to be interviewed. Resident #1 was unable to form words or answer the surveyor's questions. Resident #1 was observed with Black/Purple bruising to left brow and temple area. During an interview on 10/3/24 at 10:53 a.m. LVN B said she worked weekend doubles at the facility. LVN B said she had been working on 9/22/24. LVN B said a CNA reported to her bruising on Resident #1's face. LVN B said she reported the bruising to the RN Supervisor. LVN B said she and the RN Supervisor went and completed an assessment on Resident #1. LVN B said the DON was notified and Resident #1's responsible party was notified. LVN B said Resident #1's responsible party said the bruising was possibly from her neck pillow. LVN B said she had speculated the bruising was from the neck pillow due to the way Resident #1 laid and the neck pillow pushed against her face. LVN B said Resident #1 had poor skin integrity. LVN B said she completed an incident report on Resident #1 related to the bruising. During an interview on 10/3/24 at 1:20 p.m. the DON said she was notified by the RN Supervisor on 9/22/24 regarding Resident #1's bruising to her face and back of legs. The DON said she could not remember when she notified the Administrator of the bruising. The DON said LVN B had contacted the family and was told by the family when they rolled Resident #1, she would sometimes prop her head on the assist bar. The DON said the family had also been placing a positioning device under her legs. The DON said staff did not witness the resident hitting her head and the resident was unable to explain where the bruising originated from. The DON said she sent the weekend RN Supervisor to investigate the bruising. The DON said the bruising to the Resident #1's brow and temple area lined up with the resident's use of a neck pillow and propping head against assist bar when rolled. The DON said the bruising to Resident #1's leg lined up with the positioning device. The DON said the family was not concerned with how the bruising occurred. The DON said she did not consider the bruising an injury of unknown origin due to the most probable cause of the bruising was the assist bars, neck pillow, and positioning device. The DON said she decided the bruising was not reportable. The DON said the importance of reporting injuries of unknown origin was possible abuse. During an interview on 10/3/24 at 1:45 p.m. the Administrator said he did not remember when he was notified of the bruising on Resident #1's head and leg or if it was reported and why or why not. The Administrator said he would find out this information and then tell the surveyor. During an interview on 10/3/24 at 2:17 p.m. the Administrator said he was notified in the morning clinical meeting on 9/23/24 of the bruising to Resident #1's face and leg. The Administrator said when the bruising was discussed in the clinical meeting the DON said she had completed the investigation. The Administrator said he did not report the bruising to the state agency due to the incident report indicating, [Resident #1's] responsible party stated she bumped it on the assist bar and the assist bars were removed due to non-use. The Administrator was unable to say what it was. The Administrator said he assumed it was Resident #1's head. The Administrator said during an investigation the facility generally checked areas in the resident's room for possible causes. The Administrator said he generally does not take the family's word for something happening. The Administrator said every situation was different. The Administrator said the DON performed the clinical investigations and then they discuss the findings. The Administrator said the importance of reporting injuries of unknown origin was to ensure the incident was investigated allowing the facility to make better decisions and implement changes from incidents happening again. Record review of the facility's Abuse Prohibition policy last revised 5/17/24 indicated, The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation. The facility will report the results of the investigation to the enforcement agency in accordance with state law, including the state survey and certification agency .Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions .

**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 (Resident #1) residents reviewed for quality of care. The facility failed to ensure Resident #1's right heel arterial wound treatment orders were updated in the electronic medical records. This failure could result in residents with wounds of not having their treatments performed as ordered, wounds becoming infected wounds, and decreased wound healing. Findings Included: Record review of the face sheet dated 10/3/24 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including anxiety, hypertension (elevated blood pressure), traumatic brain injury (a brain injury caused by an outside force, usually a violent blow to the head), dementia, and heart failure (a chronic condition in which the heart does not pump blood as good as it should). Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 13 and was cognitively intact. The MDS indicated Resident #1 required substantial/maximum assistance with transfers from sitting to lying, lying to sitting on the side of the bed, and chair/bed to chair. The MDS indicated Resident #1 was dependent on staff for rolling left and right and sitting to standing. The MDS indicated Resident #1 had 2 venous and arterial wounds. Record review of the care plan revised on 9/29/24 indicated Resident #1 had an arterial/ischemic ulcer of the right heel with interventions including cleanse wound to right heel with normal apply, pat dry apply Xeroform (a gauze dressing that contains petrolatum and bismuth tribromophenate used to treat a variety of wounds) and cover with bordered gauze (flexible, adhesive, non-woven cloth border secures the dressing in place and is water resistant to help protect the wound from contaminants) every day shift every on Tuesday, Thursday, Saturday, and as needed. Record review of the wound care note dated 9/19/24 indicated Resident #1 had an arterial wound to her right heel measuring 0.5 cm X 0.5 cm X UTD. The wound care note indicated the dressing used to the right heel was xeroform. Record review of the wound care note dated 9/27/24 indicated Resident #1 had an arterial wound to the right heel measuring 1 cm X 0.5 cm X UTD. The wound care note indicated the treatment used to the right heel was betadine. Record review of the skilled wound care communication log dated 9/27/24 indicated the arterial wound to Resident #1's right heel's current treatment was betadine. Record review of the physician orders dated 10/1/24 indicated Resident #1 had an order to cleanse wound to right heel with normal saline, apply Xeroform, and cover with bordered gauze every day shift every Tuesday, Thursday, Saturday, and as needed for wound care starting 9/3/24. Record review of the TAR dated 9/1/24 through 9/30/24 indicated Resident #1's treatment to her right heel was with normal saline, apply Xeroform, and cover with bordered gauze and was provided every scheduled shift without a missing treatment. Record review of the TAR dated 10/1/24 indicated Resident #1's treatment to her right heel was to with normal saline, apply Xeroform, and cover with bordered gauze and was provided every scheduled shift without a missing treatment. During an interview on 10/2/24 at 10:40 a.m. the Treatment Nurse said she received written orders from the Wound Care Physician via email or text. The Treatment Nurse said when she received the orders, she entered them into the electronic medical record. During an interview on 10/2/24 at 10:45 a.m. the Treatment Nurse said the wound care physician came to the facility weekly. The Treatment Nurse said the wound to Resident #1's right heel was healed, and she still need to resolve or heal it out in the electronic medical records. During an observation on 10/2/24 at 10:47 a.m. the Treatment Nurse cleansed the wound to Resident #1's right heel with normal saline then applied betadine. During an interview on 10/2/24 at 3:08 pm the Wound Care Physician said he made rounds at the facility on 9/27/24. The Wound Care Physician said he saw Resident #1. The Wound Care Physician said he made rounds with the Treatment Nurse on 9/27/24. The Wound Care Physician said he had ordered betadine as treatment to Resident #1's arterial wound to her right heel. The Wound Care Physician said he would expect the facility to follow the orders he gave until another physician made rounds and changes to the orders. The Wound Care Physician said he expected orders to be implement within 24 hours. During an interview on 10/3/24 at 9:50 am the Treatment Nurse said she worked Monday through Friday from 8:30 am to 5:00 pm. The Treatment Nurse said on the weekends and when she was off during the week the charge nurses or float nurse performed wound care. The Treatment Nurse said she always made rounds with the Wound care physicians. The Treatment Nurse said she made rounds with the Wound Care Physician on 9/27/24. The Wound Care Physician provided verbal orders for wound care while making rounds. The Treatment Nurse said if the wound care physician saw a wound there would be a treatment in place for the wound. The Treatment Nurse said she did not document the verbal orders. Treatment Nurse the order for Resident #1's treatment to her right heel in the electronic medical records was incorrect and it was her fault. The Treatment Nurse said staff performing wound care in her absence would follow the orders in the electronic medical records and be performing incorrect treatments to Resident #1. The Treatment Nurse said the importance of ensuring wound care orders were followed accurately was for wound healing. During an interview on 10/3/24 at 1:20 p.m. the DON said if a nurse received a verbal order from a physician, it should be input into the electronic medical records and documented in the progress notes. The DON said nurses have 24 hours to document late entries in the progress notes and then they are unable to document a late entry. The DON she expected the wound care physician orders to be followed. The DON said if a verbal order was received by the wound care physician it should be implement immediately and if the order was received on paper or in a report it should be implemented by the end of the day it was received. The DON said if a wound care order was received, and the current treatment was blank she expected the nurse to verify and clarify the treatment order. The DON said if there was a change in the treatment orders, she expected the change to be entered into the electronic medical records. The DON said the importance of following the wound care physician's orders was to promote wound healing. During an interview on 10/3/24 at 1:45 p.m. the Administrator said he expected staff to follow physician's orders. The Administrator said if a nurse received a verbal order, he expected it to be entered into the electronic medical records and documented in the progress notes. The Administrator said if a nurse received a wound care order with the current treatment being blank, he would expect the nurse to obtain clarification for the order. The Administrator said the importance of inputting orders and following physician orders was so a resident did not receive the wrong treatment. Record review of the facility's Skin Integrity Prevention and Treatment Program policy revised 1/2003 indicated, . if non-pressure area-complete new wound evaluation / assessment; c. Notify MD-obtain treatment orders; .e. Update care plan; f. Note on 24 hour report; .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 3 (Resident #1) residents reviewed for pressure injuries. The facility failed to ensure Resident #1's pressure wounds to her sacrum (a triangular bone at the base of the spine) and left calf were treated as ordered by the Wound Care Physician. These failures could place residents at risk for worsening of existing pressure injuries, infection, pain, and decreased quality of life. Findings included: Record review of the face sheet dated 10/3/24 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including anxiety, hypertension (elevated blood pressure), traumatic brain injury (a brain injury caused by an outside force, usually a violent blow to the head), dementia, and heart failure (a chronic condition in which the heart does not pump blood as good as it should). Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 13 and was cognitively intact. The MDS indicated Resident #1 required substantial/maximum assistance with transfers from sitting to lying, lying to sitting on the side of the bed, and chair/bed to chair. The MDS indicated Resident #1 was dependent on staff for rolling left and right and sitting to standing. The MDS indicated Resident #1 was at risk for pressure ulcers. The MDS indicated Resident #1 did not have an unhealed pressure ulcer/injury. Record review of the care plan revised on 9/29/24 indicated Resident #1 had the potential to develop a pressure ulcer/injury related to frequent urinary and/or bowel incontinence, history of pressure injuries, immobility, poor nutritional status/malnutrition: Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed without slough (yellow/white material in the wound bed) or bruising) to sacrum-healed 9/19/24 with interventions including monitor right buttock wound every shift for signs and symptoms of infection, monitor wound to sacrum every shift for signs and symptoms of infection, apply z-guard (zinc oxide) to right buttock ulcer every shift for wound care, and apply z-guard to sacrum every shift for wound care. Record review of the wound care note dated 9/19/24 indicated Resident #1 did not have a pressure wound to her sacrum or left calf. Record review of the wound care note dated 9/27/24 indicated Resident #1 had a pressure ulcer to her sacrum measuring 3.2 cm X 2.2 cm X UTD. The wound care note indicated the dressing used to the sacrum was calcium alginate (highly absorptive, non-occlusive dressings made of soft, non-woven calcium alginate fibers) and bordered gauze (flexible, adhesive, non-woven cloth border secures the dressing in place and is water resistant to help protect the wound from contaminants). The wound care note indicated Resident #1 had a pressure ulcer to her left posterior calf measuring 4 cm X 2.2 cm X UTD. The wound care note indicated the dressing used to the left calf was calcium alginate and bordered dressing. Record review of the skilled wound care communication log dated 9/27/24 for Resident #1 indicated the pressure ulcer to the sacrum's current treatment was blank (without a treatment listed). The skilled wound care communication log indicated the pressure ulcer to the left calf's current treatment was alginate and dry dressing. Record review of the hospice physician's order dated 10/1/24 indicated Resident #1's left calf was to cleanse with normal saline, pat dry, apply xeroform (a gauze dressing that contains petrolatum and bismuth tribromophenate and is used to treat a variety of wounds) with calcium alginate, and cover with bordered gauze 3 times a week and as needed for saturation. Record review of the physician orders dated 10/1/24 indicated Resident #1 had an order to apply z-guard to sacrum every shift for wound care starting 9/2/24. The physician orders did not indicate Resident #1 had a treatment for the pressure wound on her left calf. Record review of the TAR dated 9/1/24 through 9/30/24 indicated Resident #1's treatment to her sacrum was provided every shift without a missing treatment. The TAR indicated Resident #1 did not have a treatment to her left calf. Record review of the TAR dated 10/1/24 indicated Resident #1's treatment to her sacrum was provided every shift without missing a treatment. The TAR indicated Resident #1 did not have a treatment to her left calf. During an interview on 10/2/24 at 10:40 a.m. the Treatment Nurse said she received written orders from the Wound Care Physician via email or text. The Treatment Nurse said when she received the orders, she entered them into the electronic medical record. During an interview on 10/2/24 at 10:45 a.m. the Treatment Nurse said 10/1/24 was the first time she had seen the wound to Resident #1's left calf. The Treatment Nurse said the wound care orders for Resident #1's left calf was not in the electronic medical record. The Treatment Nurse said she performed wound care to Resident #1's left calf on 10/1/24. The Treatment Nurse said the date on the dressing to Resident #1's left calf would be proof of her performing wound care 10/1/24. The Treatment Nurse said the wound care physician came to the facility weekly. During an observation on 10/2/24 at 10:47 a.m. the Treatment Nurse removed the dressing dated 10/1/24 to Resident #1's left calf, cleansed the wound with normal saline, and applied xeroform, calcium alginate, and a bordered dressing. The Treatment Nurse cleansed Resident #1's sacral wound with normal saline and applied zinc oxide. During an interview on 10/2/24 at 3:08 p.m. the Wound Care Physician said he made rounds at the facility on 9/27/24 with the treatment nurse. The Wound Care Physician said he saw Resident #1. The Wound Care Physician said he had ordered calcium alginate and bordered dressing as the treatment for Resident #1's unstageable pressure injury to her left calf and stage III pressure sore to her sacrum. The Wound Care Physician said zinc oxide can heal a pressure sore, but calcium alginate speeds up the healing process. The Wound Care Physician said he would expect the facility to follow the orders he gave until another physician made rounds and changes to the orders. The Wound Care Physician said he expected orders to be implement within 24 hours. During an interview on 10/3/24 at 9:50 a.m. the Treatment Nurse said she worked Monday through Friday from 8:30 a.m. to 5:00 p.m. The Treatment Nurse said on the weekends and when she was off during the week the charge nurses or float nurse performed wound care. The Treatment Nurse said she always made rounds with the wound care physicians. The Treatment Nurse said she made rounds with the Wound Care Physician on 9/27/24. The Treatment Nurse said she did not remember seeing Resident #1's wound to her left calf on 9/27/24. The Treatment Nurse said the Wound Care Physician provided verbal orders for wound care while making rounds. The Treatment Nurse said if the wound care physician saw a wound there would be a treatment in place for the wound. The Treatment Nurse said she could not prove there was a treatment in place for Resident #1's wound to her left calf from 9/27/24 through 10/1/14. The Treatment Nurse said when she saw the wound on Resident #1's left calf on 10/1/24 she did not contact the Wound Care Physician or consult the orders he had sent over. The Treatment Nurse said she had contact Resident #1's hospice company to obtain treatment orders on 10/1/24. The Treatment Nurse said the Wound Care Physician gave her verbal orders to continue treatment of z-guard to Resident #1's sacrum. The Treatment Nurse said she did not document the verbal order and did not clarify the order when the treatment section was blank on the written orders for Resident #1's sacrum. The Treatment Nurse said she would not make up her own orders. The Treatment Nurse said staff performing wound care in her absence would follow the orders in the electronic medical records and be performing incorrect treatments to Resident #1. The Treatment Nurse said the importance of ensuring wound care orders were followed accurately was for wound healing. During an interview on 10/3/24 at 1:20 p.m. the DON said if a nurse receives a verbal order from a physician, it should be input into the electronic medical records and documented in the progress notes. The DON said nurses have 24 hours to document late entries in the progress notes and then they are unable to document a late entry. The DON she expected the wound care physician orders to be followed. The DON said if a verbal order was received by the wound care physician it should be implement immediately and if the order was received on paper or in a report it should be implemented by the end of the day it was received. The DON said if a wound care order was received, and the current treatment was blank she expected the nurse to verify and clarify the treatment order. The DON said if there was a change in the treatment orders, she expected the change to be entered into the electronic medical records. The DON said the importance of following the wound care physician's orders was to promote wound healing. During an interview on 10/3/24 at 1:45 p.m. the Administrator said he expected staff to follow physician's orders. The Administrator said if a nurse received a verbal order, he expected it to be entered into the electronic medical records and documented in the progress notes. The Administrator said if a nurse received a wound care order with the current treatment being blank, he would expect the nurse to obtain clarification for the order. The Administrator said the importance of inputting orders and following physician orders was so a resident did not receive the wrong treatment. Record review of the facility's Skin Integrity Prevention and Treatment Program policy revised 1/2003 indicated, .Weekly Skin Integrity Checks [included]: a. Weekly assessment looking for new wounds-completed by a licensed nurse; b. Documented on/in Treatment Record If new; c. area found- if pressure injury- complete new wound evaluation / assessment [or] if non-pressure area-complete new wound evaluation / assessment; c. Notify MD-obtain treatment orders; d. Notify RP/ or family if they are RP or Resident has directed family to be updated; e. Update care plan; f. Note on 24 hour report; g. Referrals to therapy, dietician or other consultant as deemed necessary; h. Monitor weekly via weekly wound reporting and skin integrity quality assurance processes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided such care, consistent with professional standards of practices for 1 of 4 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1 had orders for oxygen therapy. This failure could place residents at risk of not receiving a therapeutic level of oxygen therapy . Findings include: Record review of the face sheet dated 10/3/24 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including anxiety, hypertension (elevated blood pressure), traumatic brain injury (a brain injury caused by an outside force, usually a violent blow to the head), dementia, COPD and heart failure (a chronic condition in which the heart does not pump blood as good as it should). Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 13 and was cognitively intact. The MDS did not indicate Resident #1 was receiving oxygen therapy. Record review of the care plan revised on 9/29/24 indicated Resident #1 had impaired cognitive function/dementia or impaired thought processes. Record review of the hospice comprehensive assessment dated [DATE] indicated Resident #1 had an order for oxygen 2-4 l/min as needed for shortness of breath. Record review of the physician orders dated 10/1/24 did not indicated Resident #1 had an order for oxygen therapy, oxygen monitoring, or the oxygen tubing to be changed. During an observation on 10/1/24 at 2:32 p.m. Resident #1 was observed with oxygen in place via nasal cannula (a device that delivers extra oxygen through a tube and into the nose) at 2 l/min. The oxygen tube was observed to be undated. During an observation on 10/3/24 at 9:45 a.m. Resident #1 was observed with oxygen in place via nasal cannula (a device that delivers extra oxygen through a tube and into the nose) at 2 l/min. The oxygen tube was observed to be undated. During an interview on 10/3/24 at 11:05 a.m. RN A said residents would require oxygen if they were short of breath or had a decreased oxygen saturation (the percentage of oxygen saturated hemoglobin in the blood compared to the total hemoglobin). RN A said if a resident was short of breath or required oxygen the nurse should contact the doctor to obtain an order for oxygen. RN A said the order for oxygen should be entered into the electronic medical records. RN A said the order should contain whether the oxygen was continuous or as needed, to monitor oxygen saturation every shift, how much oxygen should be administered in l/min, what the delivery method should be, and for the oxygen tubing to be changed and dated weekly. RN A said oxygen tubing should have the nurse's initials and the date it was put in use on it. RN A said if she entered a room, and the oxygen tubing was not dated she would remove the current tubing and replace it with tubing dated for the day she discovered the undated tubing. RN A said without a dated you could not tell how long the oxygen tubing had been in use. RN A said the importance of ensuring the oxygen orders were in the electronic medical record was so the nurses and other staff knew how much oxygen a resident was supposed to be receiving. RN A said the importance of changing the oxygen tubing weekly was to give better oxygen administration and aide in breathing better. During an interview on 10/3/24 at 1:20 p.m. the DON said nurses would know if a resident was receiving oxygen by checking in the electronic medical records. The DON said if a resident was short of breath or had decreased oxygen saturation, she expected the nurses to place oxygen on the resident as not to delay treatment and then notify the physician and obtain an order for oxygen. The DON said the oxygen orders should include the frequency, rate, monitoring oxygen saturation, changing oxygen tubing as needed when visibly soiled or broken. The DON said the importance of oxygen orders was so the nurses knew the needs of the resident and residents with certain respiratory conditions were not over oxygenated. The DON said all hospice orders should be entered into the electronic medical records. Record review of the facility's Oxygen Administration policy revised 5/2024 indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify there is a physician's order for the procedure. Review the physician's orders or the facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident .General Guidelines: 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter .Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs and symptoms of cyanosis (blue tone to the skin and mucous membranes); 2. Signs or symptoms of hypoxia (rapid breathing, rapid pulse rate, restlessness, confusion); 3. Signs and symptoms of oxygen toxicity (tracheal irritation, difficulty breathing, or slow, shallow rate of breathing; 4. Vital signs; 5. Lung sounds .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 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 3 staff (Treatment Nurse), and 2 of 2 residents (Resident #1 and Resident #2) reviewed for infection control. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene while performing wound care on Resident #1 and Resident #2 These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include: 1. Record review of the face sheet dated 10/3/24 indcated Resident #2 was an [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including diabetes, muscle weakness, lack of coordinations, and chronic kidney disease. Record review of the MDS dated [DATE] indicated Resident #2 was understood by others and usually understood others. The MDS indicated Resident #2 had a BIMS of 05 and was severely cognitively impaired. The MDS indicated Resident #2 was at risk for developing pressure ulcers. The MDS indicated Resident #2 did not any unhealed pressure ulcers/injuries. Record review of the care plan last reviewed 8/6/24 indicated Resident #2 resident had actual impairment to his skin integrity related to MASD (moisture associated skin disorder) of the left buttock. During an observation on 10/2/24 at 10:24 a.m. the Treatment Nurse performed wound care on Resident #2. The Treatment Nurse applied gloves and removed the dressing to Resident #2's arm. The Treatment Nurse changed gloves and did not perform hand hygiene. The Treatment Nurse cleansed the wound to Resident #2's arm with normal saline and patted dry. The Treatment Nurse changed gloves and did not perform hand hygiene. The Treatment Nurse applied xeroform (a gauze dressing that contains petrolatum and bismuth tribromophenate and is used to treat a variety of wounds), calcium alginate (highly absorptive, non-occlusive dressings made of soft, non-woven calcium alginate fibers), and bordered dressing (flexible, adhesive, non-woven cloth border secures the dressing in place and is water resistant to help protect the wound from contaminants) to the wound. The Treatment Nurse removed her gloves and performed hand hygiene. Resident #2 rolled to his left side with assistance from a CNA. There was not a dressing on Resident #2's sacrum. The Treatment nurse changed gloves and performed hand hygiene. The Treatment Nurse cleansed wound with normal saline. The Treatment Nurse did not change her gloves. The treatment Nurse applied Medi-honey and calcium alginate to the wound. The Treatment Nurse changed her gloves and did not perform hand hygiene. 2. Record review of the face sheet dated 10/3/24 indicated Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including anxiety, hypertension (elevated blood pressure), traumatic brain injury (a brain injury caused by an outside force, usually a violent blow to the head), dementia, and heart failure (a chronic condition in which the heart does not pump blood as good as it should). Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 13 and was cognitively intact. The MDS indicated Resident #1 required substantial/maximum assistance with transfers from sitting to lying, lying to sitting on the side of the bed, and chair/bed to chair. The MDS indicated Resident #1 was dependent on staff for rolling left and right and sitting to standing. The MDS indicated Resident #1 was at risk for pressure ulcers. The MDS indicated Resident #1 did not have an unhealed pressure ulcer/injury. Record review of the care plan revised on 9/29/24 indicated Resident #1 had the potential to develop a pressure ulcer/injury related to frequent urinary and/or bowel incontinence, history of pressure injuries, immobility, poor nutritional status/malnutrition: Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed without slough (yellow/white material in the wound bed) or bruising) to sacrum-healed 9/19/24 with interventions including monitor right buttock wound every shift for signs and symptoms of infection, monitor wound to sacrum every shift for signs and symptoms of infection, apply z-guard (zinc oxide) to right buttock ulcer every shift for wound care, and apply z-guard to sacrum every shift for wound care. During an observation on 10/2/24 at 10:47 a.m. the Treatment Nurse applied gloves, entered Resident #1's room to set-up her supplies, exited the room, and changed gloves without performing hand hygiene. The Treatment Nurse entered Resident #1's room changed gloves and performed hand hygiene. The Treatment Nurse removed the dressing to Resident #1's left calf. The Treatment Nurse changed gloves and did not perform hand hygiene. The Treatment Nurse cleansed the wound to Resident #1's left calf with normal saline. The Treatment Nurse changed gloves and did not perform hand hygiene. The Treatment Nurse applied xeroform, calcium alginate, and a bordered dressing to the wound on Resident #1's left calf. The Treatment Nurse changed gloves and did not perform hand hygiene. The Treatment Nurse cleansed Resident #1's sacral wound with normal saline. The Treatment Nurse changed gloves and did not perform hand hygiene. The Treatment Nurse applied zinc oxide (a medicated cream, ointment, or paste that treats or prevents skin irritation) to Resident #1's sacral wound. The Treatment Nurse changed gloves and did not perform hand hygiene. The Treatment Nurse exited to the room to obtain betadine and normal saline from her treatment cart. The Treatment Nurse cleansed the wound to Resident #1's right heel with normal saline then applied betadine. The Treatment Nurse removed her gloves and performed hand hygiene. During an interview on 10/3/24 at 9:50 a.m. the Treatment Nurse said she had been nervous when performing wound care observed by the surveyor. The Treatment Nurse said she did not realize she had not performed hand hygiene between glove changes. The Treatment Nurse said hand hygiene should be performed when walking into a resident room, after removing a wound dressing, and when changing gloves. The Treatment Nurse said the importance of proper hand hygiene was for infection control. During an interview on 10/3/24 at 1:20 p.m. the DON said she expected staff to perform hand hygiene when they entered or exited a room, when visibly soiled, and between glove changes. The DON said the importance of hand hygiene was infection control. During an interview on 10/3/24 at 1:45 p.m. the Administrator said he expected staff to perform hand hygiene as needed, before and after providing care, in-between care, and between glove changes. The Administrator said the importance of hand hygiene was infection prevention and to prevent cross contamination. Record review of the facility's Handwashing-Hand Hygiene policy revised 3/2020 indicated, This facility considers hand hygiene the primary means to prevent the spread of infections . All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub containing at least 62:5 alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water in the following situations .g. Before handling clean or soiled dressing, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care .k. After handling used dressings, contaminated equipment, etc.m. After removing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident right that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #11) of 1 resident reviewed for Care Plans. The facility failed to ensure Resident #11 was care planned for Dialysis. This failure could place the resident at risk of needs not being met. Findings included: Record review of Resident #11's face sheet dated 06/13/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnoses included Renal (Kidney) failure and treatment for Dialysis. Record review of Resident #11's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 13 (cognitively intact ). The assessment also indicated the resident had an active diagnosis for Renal Failure and Dialysis treatment. Record review of Resident #11's Physician orders dated 06/13/24 revealed the resident had an active order to receive dialysis three times a week (Tuesday, Thursday, and Saturday), with an active date of 05/07/24. Record review of Resident #11 quarterly Comprehensive care plan dated 05/18/24 revealed no care planning for the Resident's dialysis treatment. In an interview on 06/12/24 at 03:01 PM with MDS Nurse N, she stated she is the MDS Nurse for Long Term Care and Resident #11 was in short- term care. She advised that Resident #11 was receiving dialysis and it should have been on the resident's care plan. She verified that the resident did not have a care plan for dialysis. She stated the risk of not having the resident care of dialysis care planned could result in the resident missing care. In an interview on 06/12/24 at 03:10 PM with MDS nurse S, she stated she was the MDS nurse for Resident #11 and she updated the resident Care plan to ensure residents were receiving all their care needed. She stated Resident #11 was receiving Dialysis and it should have been care planned. She stated she was adding the dialysis care plan to the resident's care plan today. She stated that this was somehow missed. She stated the risk of not having the resident care of dialysis care planned could result in the resident not receiving the proper care. Record review of facility's policy, Comprehensive Person-Centered Care Planning, (undated) Policy & Procedure, Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident . Procedure: . 3. The facility team will provide a written summary . initial goals . any services and treatments to be administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 6 (Resident #7, #26, #40, #76, #86, and#150) of 20 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Resident #7's, #26's, #40's, #76's, #86's, and#150's rooms were cleaned and sanitized . This deficient practice could place residents at risk of living in an unclean and unsanitary environment. Findings included: Record review of Resident #76's face sheet dated 06/13/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnoses included Chronic Obstructive Pulmonary Disease (constricted airway) and Respiratory Failure. Record review of Resident #76's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 14 (cognitively intact). The assessment also indicated the resident had an active diagnosis for Chronic Obstructive Pulmonary Disease and Respiratory Failure. An observation on 06/11/24 at 10:25 AM of Resident #76's and #86's room reflected the air conditioning unit located in the room had dirt particles and black dirt grime on the top and between the vents of the units. Both air filters had a thin layer of dust on them. An observation on 06/11/24 at 10:41 AM of Resident #150's room reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. Both air filters had a thin layer of dust on them. Record review of Resident #26's face sheet dated 06/13/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnoses included Chronic Obstructive Pulmonary Disease (constricted airway) and Respiratory Failure. Record review of Resident #26's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 13 (cognitively intact). The assessment also indicated the resident had an active diagnosis for Chronic Obstructive Pulmonary Disease. An observation on 06/11/24 at 10:50 AM of Resident #26's room reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. Both air filters had a thin layer of dust on them. An observation on 06/11/24 at 11:33 AM of Resident #7's and #40's room reflected the air conditioning located in the room had dirt particles and black dirt grime on the top and between the vents of the units. Both air filters had a thin layer of dust on them. An interview on 06/13/24 at 09:08 AM with Housekeeping H, she stated she had been at the facility for two months and she cleans hall 1. She stated she had cleaning experience so there was not much training required. She stated they had to mop and sweep the floor, clean the bathroom, dust the lights and television units. She stated they are supposed to clean the air conditioning, but she was not cleaning the filters. She was shown photos of the air conditioning in Resident #7, #26, #40, #76, #86, and#150's room, and she stated that she needed to go into all the rooms and reclean them to ensure that they are clean. She stated the risk of the air conditioning not being cleaned could cause trouble with the resident's breathing. An interview on 06/13/24 at 09:16 AM with Housekeeping C, she stated she had been at the facility for about 8 months. She stated they showed her to clean the room. She stated she was trained to clean the bathroom, floors, and windowsills. She stated she did not clean the air conditioning because she is still learning. She was shown photos of the air conditioning in Resident #7, #26, #40, #76, #86, and#150's room and she stated that she needed to go into all the rooms and clean the units. An interview on 06/13/24 at 09:27 AM with the housekeeping supervisor, she stated she had been at the facility for nearly 8 years. She stated they should clean everything in the room. She stated that they are supposed to wipe down the air conditioning and maintenance was supposed to clean the filters. She was shown photos of the air conditioning in Resident #7, #26, #40, #76, #86, and#150's room and she stated that the vents and filters should have been cleaned and that she would get right on it. She stated the risk of the air conditioning not being clean could result in breathing problems for the residents. She stated she would in-service her team on properly cleaning the air conditioning. An interview on 06/13/24 at 09:54 AM with the director of maintenance, he stated he had been at the facility for 8 years. He stated cleaning the air conditioning filters was maintenance responsibility and they are on a monthly schedule to be cleaned. He stated he and his helper clean all the filters in the building and it takes them three days to complete the entire building. He stated they blow off the filter with air and washed them off. He was advised of the filters in the resident #7, #26, #40, #76, #86, and#150's room, and he stated they had issues with keeping the filters in that hall clean. He stated the risk of the filters not being cleaned thoroughly could prevent the resident from getting fresh air. Review of the facility's policy on Safe/Comfortable/Homelike Environment (01/2022) reflected Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 (Residents #26, #76 and #112) of 3 residents reviewed for respiratory care. The facility failed to ensure Resident #26's, #76's and #112's breathing masks were stored in a sanitary manner when they were not being used by the residents. The facility failed to ensure that Resident #76's CPAP mask properly fit the resident and ensured the resident's CPAP machine operated properly. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Resident #76 Record review of Resident #76's face sheet dated 06/13/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnoses included Chronic Obstructive Pulmonary Disease (constricted airway) and Respiratory Failure. Record review of Resident #76's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 14 (cognitively intact). The assessment also indicated the resident had an active diagnosis for Chronic Obstructive Pulmonary Disease and Respiratory Failure. Record review of Resident #76's Physician orders dated 06/13/24 revealed the resident had an active order to apply CPAP at night at bedtime with an active date of 08/24/23. In an observation and interview on 06/11/24 at 10:17 AM with Resident #76, she stated her CPAP machine had not been cleaned since she had it and she could not use it because the mask did not fit her face properly. The mask to the CPAP machine was observed sitting in an open plastic bag. In an interview on 06/13/24 at 11:42 AM with ADON M, she stated she had been at the facility for over 7 years. She stated she is familiar with Resident #76, and she stated she was made aware that the resident's CPAP machine and mask were not functioning properly yesterday. She stated she called the in-house Pulmonologist, and they are ordering her a new CPAP machine and mask and the Pulmonologist will be meeting her tomorrow. She stated the issues the resident was having with her mask was brought to her attention on a 24-hour report, but she did not follow up on it . She stated she also read the resident was refusing to wear her mask, but she did not follow up with the resident to see why. She stated the risk of the resident not having the proper CPAP equipment could result in the resident stopping breathing in her sleep. She stated that the expectation was for any breathing device not in use needed to be bagged to avoid it from getting contaminated and causing an infection. Resident #26 Record review of Resident #26's face sheet dated 06/13/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnoses included Chronic Obstructive Pulmonary Disease (constricted airway) and Respiratory Failure. Record review of Resident #26's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 13 (cognitively intact). The assessment also indicated the resident had an active diagnosis for Chronic Obstructive Pulmonary Disease. Record review of Resident #26's Physician orders dated 06/13/24 revealed the resident had an active order for Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT . (microgram/activated clotting time) 2 puff inhales orally every 12 hours, with an active date of 03/27/24. In an interview and observation on 06/11/24 at 11:00 AM with LVN T, she stated she was the nurse assigned to the hall of Resident #26. She was asked where the resident's mask was for her nebulizer, and she was observed pulling on the tubing and the mask was observed in a nightstand drawer, underneath several items. The mask was in an unsealed plastic bag . She stated that the nebulizer should have been serviced more recently. She stated the risk of not changing the tubing and cleaning the mask could result in infection. Resident #112 Record review of Resident #112's face sheet dated 06/13/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnoses included Sleep Apnea (serious sleep disorder) and morbid obesity. Record review of Resident #112's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 13 (cognitively intact). The assessment also indicated the resident had an active diagnosis for Sleep Apnea. Record review of Resident #112's Physician orders dated 06/13/24 revealed the resident had an active order for CPAP on at bedtime for sleep apnea, with an active date of 06/10/24. In an interview and observation on 06/11/24 at 01:23 PM with LVN T. She was asked where Resident #112's CPAP machine mask was and she observed the mask sitting on top of a mini fridge, unbagged. She stated that the mask should have been placed in a sealed bag once the resident had woken up. She stated the mask should have been placed in a sealed bag to avoid the mask from getting contaminated and causing the resident an infection. In an interview on 06/12/24 at 01:01 PM with the DON, she stated she had been the DON for over 3 years and worked at the facility over 13 years. She was advised of Resident #26's, #76's and #112's, masks being left exposed and not in sealed plastic bags. She stated that the Center for Disease Control (CDC) no longer requires masks to be placed in a sealed container and it was up to the discretion of the facility. She stated she had no policy regarding the mask storage when not in use. Review of the World Health Oganization Website on Care, cleaning and disinfection of respiratory equipment in sterile services department, revealed Ensure cleaned BiPAP/CPAP device is stored in an area where there is low risk of contamination between uses, or that at least 1 minute of contact time has elapsed after the application of the chosen disinfectant (or as specified by the manufacturer) before ventilator device is used on a patient.

Based on observation, 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 only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. The facility failed to ensure food in the facility's freezer, was labeled and dated according to guidelines. The facility failed to ensure the ice machine, located in the facility's kitchen, was cleaned. The facility failed to ensure the tea dispenser was covered after being used. The facility failed to ensure kitchen equipment (food storage bins) were cleaned and sanitary. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 06/13/24 from 09:05 AM to 09:21 AM in the facility's only kitchen reflected: Observation of the ice machine, in the facility kitchen revealed the ice scoop was stored unsanitary in an open clear bag, which was also sitting in a pool of water. One large tea dispenser filled with tea, located in the kitchen area and near the entry into the kitchen, was uncovered and exposed to air-borne contaminants. Three plates of undated salad on a tray located in the walk-in refrigerator. One large container of chicken noodle soup, out of its original container dated 06/03/24 , which was greater than 7 days pass the required expiration. One large bag of unlabeled and undated bag of what appeared to be shredded cheese One gallon container of jalapeno pieces, located in the walk-in refrigerator, was dated 5/24/23. One gallon container of Caesar dressing was undated and revealed no expiration date. One gallon container of mustard was dated 4-3. One large bag of bread sticks in the walk-in freezer was not labeled or dated. One large white bin containing sugar was observed with dirt particles and brown stains along the outer and inner opening of the bin. Two-gallon containers of tartar sauce dated 3-8-23. One large bag of chicken nuggets was unlabeled and undated. One large frozen piece of pork was unlabeled and undated. One large bag of what appeared to be meatballs, was unlabeled and undated. Two packs of hot dog with a use by date of 05/11/24. One bag of what appeared to be frozen biscuits was unlabeled and undated. An interview on 06/14/24 at 09:43 AM with the Dietary Director, she stated she had been at the facility nearly 9 years. She stated she had a line aide date, label and store the food as it was delivered. She stated that both she and the line aide checked food for expiration dates. She was advised of the concerns observed in the kitchen. She stated she had started on making the corrections the next day . She stated they had discarded the expired foods and cleaned the bins through the dishwasher. She stated that she in-serviced her team on the proper storage process on 06/13/24, and she had since cleaned the other items mentioned previously. She stated the risk of the concerns not being addressed could result in the residents getting sick. An interview on 06/13/24 at 01:30 PM with the Administrator, he was made aware of the concerns observed in the kitchen. He stated he expects his kitchen to meet all food storage and kitchen cleanliness requirements. He stated not addressing the concerns mentioned could result in residents getting sick. Record Review of the Facility's policy on Food Storage and Supplies dated 2012, revealed All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened. It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illnesses. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under section3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.