**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 and misappropriation of resident property, were reported immediately to the state survey agency but no later than 2 hours after the allegation was made for 1 of 7 residents (Resident #2) reviewed for abuse and neglect. The facility failed to report an allegation of neglect when Resident #2 was found to have taken barbituates (Fioricet [used to treat headaches]) that belonged to a family member, which resulted in the resident being unresponsive and being sent to the hospital where she received IV fluids. This failure could place the resident at risk of continued abuse. Findings included: Record review of Resident #2's undated admission Record, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on 12/20/24. She had diagnoses which included a chemical imbalance in the brain, and stroke resulting in right sided paralysis and inability to speak. Record review of Resident #2's admission MDS, dated [DATE], reflected a BIMS score was not calculated due to the resident's medical condition. Her Functional Status indicated she required assistance with all of her ADLs. Record review of Resident #2's care plan, dated 12/02/24, indicated she used an antidepressant and an anti-anxiety medication. She had impaired cognition related to dementia and impaired vision. Record review of Resident #2's physician orders reflected no barbiturate medications were prescribed. Review of a nursing note in Resident #2's EHR, dated 12/08/24, reflected: The nurse was notified the staff member that resident cannot wake up, the nurse went to the resident's her [sic] room, the nurse tried to wake up the resident as well but still resident couldn't wake up, assessment done, v/s 180/104 [pulse] 68 [oxygen saturation] 97 [temperature] 97.6, the nurse called 911, pandemics [sic, paramedics] came and took the resident on the a [sic] stretcher to [hospital]. Record review of Resident #2's hospital records reflected the resident arrived unresponsive on 12/08/24 at 7:19 PM and was treated as a possible stroke. The resident's work-up was negative for a stroke, but her urine drug screen was positive for barbiturates. Nursing notes indicated the resident's family member arrived to the ER and identified a purse that had been brought with the resident as her purse. The family member notified the nurse she usually had a plastic bag with some medications in it, and the bag was missing. The family member thought the resident might have gotten into her purse and taken the medications. The medications included a barbiturate. Resident #2 was given IV fluids and had activated charcoal administered via a tube through her nose and into her stomach, because she was not alert enough to drink it, to absorb any medications in her stomach and intestines to minimize their affects. The resident was discharged back to the nursing home on [DATE]. Record review of Resident #2's physician orders reflected no barbiturate medications. Interview on 01/02/25 at 10:30 AM with the Pharmacist revealed after reviewing Resident #2's medication list that none of the medications Resident #2 was prescribed would show up as a barbiturate on a drug screen. Interview on 01/02/25 at 11:00 AM with Resident #2's family member revealed the family member had visited the resident on 12/07/24 and had accidentally left her purse on the resident's bed. She did not realize she had left it until she saw it in the ER with the resident. The family member stated when she looked in the purse she noticed a plastic bag that she kept some medications in was missing. The bag contained 10 ibuprofen, 5 benadryl, and 2 Fioricet (barbiturate headache medication). The family member notified the nurse and thought the resident must have got into her purse and taken the medications. Interview on 01/02/25 at 11:40 AM with RN-B revealed Resident #2 was capable of feeding herself after her food had been cut up, using her left hand, but she was not capable of moving herself, and was unable to stand. RN-B stated she did not think the resident would have been capable of getting into a purse and taking medication out of it since she had use of only her left arm and had poor eyesight. RN-B stated she had not observed any unusual interactions between Resident #2 and her family member. Interview on 01/02/25 at 11:50 AM with the OT revealed he had worked with Resident #2 and his assessment of the resident was she had no torso movement, and she did not have fine motor skills. He stated the purse would had to have been within the immediate reach of Resident #2. The skills of opening a purse, retrieving a plastic bag, opening the bag, and taking the medications were advanced skills, and the resident did not have those skills. Interview on 01/02/25 at 2:46 PM with the Hospital Case Manger revealed she had been made aware by hospital staff of their concerns about the resident's condition. Resident #2 was admitted to the hospital with a diagnosis of intentional overdose. The hospital medical staff thought the resident would not have been able to take the medications from the family member's purse as described without assistance. Interview on 01/02/25 at 3:15 PM with the Social Worker revealed she had not been contacted by the hospital, but the facility staff were aware of the hospital staff's concerns. She stated the facility staff thought it was unlikely that Resident #2 had taken the medications on her own. Interview on 01/02/25 at 4:00 PM with the DON revealed she was aware of the concerns voiced by the hospital staff, but she did not think they could do anything about the family member because there was no proof she had given Resident #2 the medications. The DON stated they could not prevent the family member from visiting, or monitor the visit, but it did not matter because the family member had not visited since the resident had returned from the hospital on [DATE]. The DON stated the facility did not report the incident to HHSC because the hospital staff had reported it to Adult Protective Services. Record review of the facility's electronic visitor log reflected the family member had visited four times between 12/11/24 and 12/30/24, and the family member's prior visits were on 12/12/24, 12/16/24, 12/23/24, and 12/28/24. Interview on 01/02/25 at 4:50 PM with the Administrator revealed he did not notify HHSC of of the incident involving Resident #2 possibly being given by the barbiturate medication by the family member because the hospital had already reported it. Review of the facility's Abuse, Neglect, and Exploitation policy, dated 07/16/24, reflected: .Investigating and Reporting 1. If abuse or neglect is suspected, the Abuse Coordinator or a manager will be immediately notified. 2. Appropriate reporting procedures should always be followed Reporting/Response The facility must immediately report all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property to the Healthcare Administrator, state agency, adult protective services, and all other required agencies

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one (Resident #2) of five residents reviewed for wounds. 1. RN A failed to remove the semi-occulsive dressing (a type of wound dressing that allows air to pass through while protecting the wound from liquids) that secured the negative pressure wound therapy ([NPWT] - wound vac) suction device and tubing over the wound. RN A pulled on the suction device and tubing to remove the old dressing that caused Resident #2 pain and discomfort on 10/26/24. 2. RN A failed to follow the facility's general procedure for wound vac dressing change on 10/26/24. RN A obtained foam dressings from a drawer in Resident #2's room. The foam dressings were non-sterile due to being stored in an opened or undamaged package. RN A did not trim the foam dressing to dimensions that allowed the foam to be placed into the wound bed. RN A applied the foam dressing to the wound and overlapped onto intact skin around the wound. 3. RN A failed to follow facility protocol and don a gown in addition to gloves to reduce the risk of transmission of bloodborne pathogens and apply enhanced barrier precautions (EBP) when he performed wound vac dressing change to Resident #2's right knee on 10/26/24. 4. RN A re-used the wound vac disposable components (suction device and tubing) when he performed wound vac dressing change to Resident #2's right knee on 10/26/24. 5. RN A failed to follow physician orders to apply an ointment as ordered to the surrounding skin around Resident #2's right knee wound on 10/26/24. 6.The facility failed to perform weekly skin assessments for Resident #2 on 10/21/24. These failures placed residents with wounds at an increased risk of infection, wound contamination, unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and failure of the wound to heal. Findings included: A record review of Resident #2's admission Record printed 10/26/24 revealed the resident was a [AGE] year-old female admitted on [DATE]. Resident #2 had diagnoses of unspecified fracture of lower end of right tibia; Unspecified open wound, Right knee, Sequela (a condition that results from a previous illness, injury, or medical intervention); and Infection and Inflammatory reaction due to internal right hip prosthesis, subsequent encounter (routine care during the healing or recovery phase after active treatment was received for a condition). The admission Record reflected 13 days length of stay. A record review of the Comprehensive MDS Admit assessment dated [DATE] reflected Resident #2's BIMS score was 15, which indicated intact cognitive response. The Comprehensive MDS Admit Assessment reflected Resident #2 needed partial assistance from another person to complete ADLs. Section M - Skin conditions revealed Resident #1 was not at risk for developing pressure ulcers/injuries and surgical wound(s) were present on admission. A review of Resident #2's hospital discharge clinical records dated 10/11/24 revealed final discharge instructions that included discharge medications; diet type; Activity: Non-weightbearing to right leg; Wound/Dressing Care: do not submerge incision. Keep wound clean and dry. Perform pin site care daily. Mix ½ Peroxide and ½ Normal Saline and use gauze to clean around pin sites; Follow up with PCP in 1 week after discharge (from hospital); Follow up in 2 - 3 weeks with orthopedic surgeon; Follow up in 1 - 2 weeks with right ankle orthopedic surgeon; and Daily wet to dry dressing change right knee wound. Record review revealed a skin check on admission [DATE]). There were no other skin checks, or a weekly skin assessment performed on Resident #2. Record review of Resident #2 progress notes dated 10/14/24 at 7:34 PM, revealed right lateral knee trauma wound 1.2 cm x 1 cm x 0.1 cm (LxWxD) 90% granulation with moderated serosanguinous drainage. Record review of Resident #2's care plan, initiated 10/16/24, reflected [Resident #2] had an alteration in musculoskeletal status r/t fracture of the right tibia and fibula, external fixator placed 10/09/24; had a chronic infection of the right hip after hip surgery; had actual impairment to skin integrity of the right knee - infection with previous surgery for incision and drainage ([I & D] a minor surgical procedure for skin and soft tissue abscesses) in May 2024, now with wound vac; and on antibiotic therapy doxycycline r/t chronic right hip arthroplasty infection. The care plan interventions included: observation, monitoring, educating, following protocol, assess, evaluation, treatment, and reporting to physician as needed. A review of Resident #2's clinical physician orders reflected: Start date 10/15/24: Daily wet to dry dressing change right knee wound one time a day for wound care [D/C date: 10/25/24] Start date 10/15/24: Do not submerge incision keep wound clean and dry. Perform pin site care daily. Mix ½ peroxide, ½ Normal Saline and use gauze to clean around pin sites. One time a day for Wound care. Start date 10/15/24: Doxycycline Hyclate Oral Tablet 100 mg. Give 100 mg by mouth two times a day for chronic infection. Start date 10/22/24: Mupirocin External Ointment 2%. Apply to right leg wound topically two times a day every Tue, Thu, Sat for right knee wound for 14 administrations. [D/C date: 10/25/24] Start date 10/26/24: Wound care right knee. Cleanse site with wound cleanser. Pat dry, apply black wound vac for dressing. Wound vac at 125 (mm/hg). Change every 3 days and PRN. One time a day every Tue, Thu, Sat. Start date 10/26/24: Mupirocin External Ointment 2%. Apply to right leg wound topically two times a day every Tue, Thu, Sat for right knee wound for 14 administrations. There were no orders noted for weekly head to toe skin assessments. Record review of Resident #2's October 2024 TAR, printed 10/26/24 at 3:59 PM, reflected RN A's user initials for pin site care, wound vac change, and mupirocin applied to right knee wound on Saturday, 10/26/24 that indicated the care was provided in the morning (Qam) as ordered. During an observation and interview on 10/26/24 at 12:02 PM, Resident #2 was sitting upright in chair with legs in a reclined position. The right lower leg had an external fixator (a metal framed medical device mounted on the exterior of the leg with pins inserted through the skin and into the bone of the leg by applying external pressure). There was a clear dressing, dated 10/25/24, on the right outer lateral knee. A suction device and tubing connected the dressing to a tubing attached to a canister a wound vac pump. Resident #2 was awake, alert, and oriented to person, place, time of day, and situation. Resident #2 said wound care was performed yesterday (10/25/24) to clean the pins (external fixator) and the wound vac was placed to the right knee wound. Resident #2 said that she did not know when the dressing would be changed again. Resident #2 said that the pins were supposed to be cleaned daily and the wound vac was supposed to be changed three times a week. During an interview on 10/26/24 at 1:25 PM, RN A said that he worked weekends only from 6AM - 10 PM. RN A was not sure about Resident #2's wound vac dressing change schedule when asked. RN A read the orders out loud, Change every 3 days and as needed. every Tue, Thu, Sat. RN A denied any other wound care needs for Resident #2. When asked what time did [RN A] plan to do the wound vac dressing change, RN A replied, maybe tomorrow. When asked to clarify the order, RN A re-read the order and said, maybe later after dinner. RN A was informed that the investigator wanted to observe (RN A) perform Resident #2's wound care, that included obtaining wound dressing supplies. RN A acknowledged understanding. During an interview and observation of wound care performed by RN A on 10/26/24 at 3:06 PM, there were wound dressing supplies neatly placed on a barrier sheet at the foot of Resident #2's bed, flushed to the right edge. RN A said that he forgot the investigator wanted to observe (RN A) collect wound dressing supplies. RN A performed hand hygiene with soap and water. RN A did not don a clean gown. RN A donned clean gloves and turned off the wound vac. RN A did not clamp the tubing between the canister and the sensor pad. There was no drainage in the tubing noted. RN A pulled at and tugged on the suction device and tubing to remove the dressing from the wound site. Resident #2 grimaced and said that it hurt when RN A pulled on the tubing. Resident #2 informed RN A that she already had pain medicine and to continue with the dressing change. After investigator intervention, RN A lifted the edges of the semi-occlusive dressing and removed the semi-occlusive dressing. The sensor pad (and tubing) and a black foam piece was attached to the. RN A did not discard the old disposable suction device and tubing. RN A placed the disposable suction device and tubing in the windowsill with the semi-occlusive dressing and piece of black foam still attached. RN A said that the DON told him to reuse the sensor pad and tubing because the facility did not have new wound vac supplies. Resident #2's right knee presented a deep red raised wound, approximately one inch (2.54 cm) long and half inch (1.27 cm) wide by visual inspection. RN A did not measure the wound to compare with previous measurements. RN A cleaned the wound with non-sterile gauze soaked with wound cleanser, patted dry with non-sterile gauze, picked up a piece of black foam from the barrier sheet on the bed, and applied to the wound. RN A did not cut the foam to the dimensions of the wound. The black foam covered the wound and overlapped onto the healthy skin around the wound. RN A did not apply barrier cream or skin prep to prevent further breakdown of skin around the wound. RN A placed a piece of adhesive dressing over the foam piece to secure in place. RN A pinched the dressing and cut a small hole. RN A picked up the old suction device and tubing from the windowsill, removed the old adhesive dressing. RN A placed the suction device and tubing over the small hole and secured in place with strips of adhesive dressing. RN A connected the tubing to the tubing attached to the old cannister. RN A turned the wound vac on. RN A told Resident #2 that there was a good seal, and the wound vac was functioning. The dressing did not appear sucked down. During an interview, RN A said that he was checked off a long time ago (greater than two years ago) for wound vac dressing change competency. RN A said a good seal meant there was no air escaping from under the dressing. RN A said reusing the disposable suction pad and tubing increased Resident #2's risk for infection. RN A said that he did not know who was responsible for ordering wound care supplies. RN A said that the DON found some foam pieces in Resident #2's drawer that were not secured in the original sealed package and told him to reuse the suction pad and tubing. During an interview on 10/26/24 at 4:09 PM, the DON said that the nurses performed wound care and were responsible for reordering wound care supplies. The DON said that skin assessments were performed weekly and opportunities for staff to discover changes in skin condition were during showers, bed baths, and when incontinent care was performed. The DON said that she totally agreed with the investigator's observation findings. The DON said that she did tell RN A to reuse the disposable wound vac suction pad and tubing. The DON said that she oversaw a NPWT competency checkoff for RN A and needed to locate the documents. The DON said that Resident #2 admitted with orders to apply wet to dry dressings to the right knee. The DON said that the wound doctor gave orders to apply the wound vac. The DON said that the WMD would determine if there the wound improved or worsened. The DON said that it was not common practice to reuse supplies at the facility. The DON said that reusing disposable supplies can increase risk for infection. The DON said that RN A was supposed to don a gown and gloves when he performed wound care as enhanced barrier precautions to prevent cross-contamination. The DON said that head to toe skin checks were performed by the nurses weekly as a skin care approach to help identify skin conditions early. The DON said that she was unsure why Resident #2 did not have a weekly skin assessment 7 days after admission, 10/21/24, or as soon as it was discovered a skin assessment was not done. The DON said that the facility did not have specific policies related to frequency of skin assessments. Interview on 10/26/24 at 4:45 PM, the DON approached the investigator and said that she spoke with the central supply staff and was informed that the wound vac supplies were ordered and stored in the ADON's office. The DON could not explain why she did not inquire with central supply about the wound vac supplies before telling RN A to reuse disposable supplies. Record review of the facility procedure Guide to Negative Pressure Wound Therapy (NPWT), dated January 2024, read in part: General Procedure o Trim the foam sponge to fit the size of the open wound and place it into the wound; the foam should not extend beyond the wound margin. Dressing Changes o Remove the semi-occulsive dressing (a type of wound dressing that allows air to pass through while protecting the wound from liquids) and carefully remove the foam sponge. Risks and Complications Ensure proper placement of sponge and semi-occulsive adhesive cover; avoid sponge contact with healthy skin. Record review of the facility's procedure for Applying Negative Pressure Wound Therapy, Skill 8-11, dated 2011, reflected: Goal: The therapy is accomplished without contaminating the wound area, without causing trauma to the wound, and without causing the patient to experience pain or discomfort. 3. Perform hand hygiene and put on PPE, if indicated. 10. Using sterile technique, prepare a sterile field and add all the sterile supplies needed for the procedure to the field. 11. Put on a gown, mask, and eye protection. 12. Put on clean gloves. Carefully and gently remove the dressing. If there is resistance, use a silicone-based adhesive remover to help remove the drape. 14. Put on sterile gloves. Using sterile technique, irrigate the wound. 17. Wipe intact skin around the wound with a skin-protectant wipe and allow it to dry well. 19. Put on a new pair of sterile gloves, if necessary. Using sterile scissors, cut the foam to the shape and measurement of the wound. Do not cut foam over the wound. More than one piece of foam may be necessary if the first piece is cut too small. Carefully place the foam in the wound. 23. Assess the dressing to ensure seal integrity. The dressing should be collapsed, shrinking to the foam and skin. Record review of Texas Health and Human (HHS) Infection Prevention and Control Measures for Common Infections in LTC Facilities, Version 1.0, 10/07/22, Enhanced Barrier Precautions (p. 14) reflected: Enhanced barrier precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. Examples of high-contact resident care activities where gown and glove use for enhanced barrier precautions (EBP) are recommended include Wound care: any skin opening requiring a dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering medications for 1 of 3 residents (Resident #3) reviewed for medication administration. RN A failed to administer medications as ordered. RN A informed Resident #3 that he mixed Miralax (brand name of an over-the-counter powder that treats occasional constipation [generic name: Polyethylene glycol (PEG) 3350]) with cranberry juice per Resident #3's request to relieve constipation. Resident #3 did not have an order for Miralax (or generic version). The facility failed to ensure RN A contacted the physician to obtain an order for a medication before administration. This failure placed residents at risk of adverse drug reactions related to drug allergies or not receiving the intended therapeutic benefit of the medication. Findings included: A record review of Resident #3's admission Record, printed 10/27/24, revealed the resident was a [AGE] year-old female admitted on [DATE] from an acute care facility with a left fibula (calf bone) fracture. Record review on 10/27/24 revealed a Comprehensive MDS Admit Assessment was not initiated. A review of Resident #3's hospital discharge clinical records dated 10/26/24 revealed physician discharge instructions; discharge medications; diet instructions; and to schedule a follow up visit with orthopedic surgeon. Record review did not reveal a baseline care plan. A visual/bedside [NAME] report, dated 10/27/24, reflected special instructions for behavior/mood and Lifestyle. There were no interventions or instructions listed. A review of Resident #3's clinical physician orders reflected: Start date 10/27/24 at 6:00 AM: Senokot S Oral Tablet 8.6-50 mg. Give 1 tablet by mouth in the morning for constipation. Hospital discharge medications reflected Senokot S Oral Tablet 8.6-50 mg. Take 1 tablet by mouth two times daily as needed for constipation. Start date 10/26/24 at 9:49 PM: Milk of Magnesia Suspension 7.75%. Give 30cc by mouth every 24 hours as needed for No BM in 3 days. If no results, call MD. Record review of Resident #3's October 2024 MAR, printed 10/27/24, reflected RN A's user initials on 10/27/24 with a comment code that medications, including over-the-counter medications, were not in administered due to not available or received by pharmacy. During an observation and interview on 10/27/24 at 1:07 PM, CNA C performed incontinent care to Resident #3. Resident #3 said that she was constipated and asked the nurse (RN A) for Miralax. Resident #3 said that RN A administered Miralax mixed in cranberry juice. Resident #3 said it had been a couple of days since her last bowel movement. During an interview on 10/27/24 at 6:10 PM, RN A said that he gave Resident #3 Miralax mixed with cranberry juice and a cup of water to help relieve constipation per her request. When inquired about Resident #3 orders, RN A said that he did not really give Resident #3 Miralax, that he just told her that he did to calm her down. RN A said that Resident #3 was upset because she had not received any medications since admission [DATE] around 2:00 PM). RN A could not explain why he did not review Resident #3's orders to see what medications were ordered for constipation as needed. RN A said giving a resident medication that was not ordered could cause harm if allergic to the medication. During an interview on 10/27/24 at 6:30 PM, the DON said that orders must be received from the doctor before any medication was administered. The DON said that it was a collaborative effort between the DON, ADON, and the nurse who entered the orders to ensure the order was correct and that orders were in place for every medication or treatment administered. The DON said that RN A just approached her (10 - 15 minutes prior to interview) and showed her a text to Resident #3's PCP requested an order to administer Resident #3 Miralax. The DON said that the nurse should request and obtain an order before medication was administered to a resident. The DON said a medication not ordered or reviewed by the pharmacy for interactions could be harmful to a resident. The DON said that Resident #3 was upset that she did not receive routine medications that included Alprazolam XR ([Xanax XR] a sedative that can treat anxiety and panic disorder) and oxycodone (a narcotic to treat moderate to severe pain). The DON said that the discharging facility was expected to send a 3-day supply of medications and prescriptions for controlled drugs with a resident admitted to the facility. The DON said that the facility had a locked emergency drug box that contained select medications and controlled drugs as ordered by the physician if medications were not available. The DON said that the nurses should check for availability of medications or call the doctor for alternative medications before telling a resident the medication was not available. The DON said that the facility did not have specific policies related to medication administration.

**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 infectious diseases and infections 1 of 5 residents (Resident #2) reviewed for infection control, in that: 1. RN A failed to follow facility protocol and don a gown in addition to gloves to reduce the risk of transmission of bloodborne pathogens and apply enhanced barrier precautions (EBP) when he performed wound vac dressing change to Resident #2's right knee on 10/26/24. 2. RN A re-used the wound vac disposable components (suction device and tubing) when he performed wound vac dressing change to Resident #2's right knee on 10/26/24. These failures placed residents with wounds at an increased risk of infection, wound contamination, unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and failure of the wound to heal. Findings included: A record review of Resident #2's admission Record printed 10/26/24 revealed the resident was a [AGE] year-old female admitted on [DATE]. Resident #2 had diagnoses of unspecified fracture of lower end of right tibia; unspecified open wound, Right knee, Sequela (a condition that results from a previous illness, injury, or medical intervention); and Infection and Inflammatory reaction due to internal right hip prosthesis, subsequent encounter (routine care during the healing or recovery phase after active treatment was received for a condition). The admission Record reflected 13 days length of stay. A record review of the Comprehensive MDS Admit assessment dated [DATE] reflected Resident #2's BIMS score was 15, which indicated intact cognitive response. The Comprehensive MDS Admit Assessment reflected Resident #2 needed partial assistance from another person to complete ADLs. Section M - Skin conditions revealed Resident #1 was not at risk for developing pressure ulcers/injuries and surgical wound(s) were present on admission. A review of Resident #2's hospital discharge clinical records dated 10/11/24 revealed final discharge instructions that included discharge medications; diet type; Activity: Non-weightbearing to right leg; Wound/Dressing Care: do not submerge incision. Keep wound clean and dry. Perform pin site care daily. Mix ½ Peroxide and ½ Normal Saline and use gauze to clean around pin sites; Follow up with PCP in 1 week after discharge (from hospital); Follow up in 2 - 3 weeks with orthopedic surgeon; Follow up in 1 - 2 weeks with right ankle orthopedic surgeon; and Daily wet to dry dressing change right knee wound. Record review revealed a skin check on admission [DATE]). There were no other skin checks, or a weekly skin assessment performed on Resident #2. Record review of Resident #2 progress notes dated 10/14/24 at 7:34 PM, revealed right lateral knee trauma wound 1.2 cm x 1 cm x 0.1 cm (LxWxD) 90% granulation with moderated serosanguinous drainage. Record review of Resident #2's care plan, initiated 10/16/24, reflected [Resident #2] had an alteration in musculoskeletal status r/t fracture of the right tibia and fibula, external fixator placed 10/09/24; had a chronic infection of the right hip after hip surgery; had actual impairment to skin integrity of the right knee - infection with previous surgery for incision and drainage ([I & D] a minor surgical procedure for skin and soft tissue abscesses) in May 2024, now with wound vac; and on antibiotic therapy doxycycline r/t chronic right hip arthroplasty infection. The care plan interventions included: observation, monitoring, educating, following protocol, assess, evaluation, treatment, and reporting to physician as needed. A review of Resident #2's clinical physician orders reflected: Start date 10/15/24: Daily wet to dry dressing change right knee wound one time a day for wound care [D/C date: 10/25/24] Start date 10/15/24: Do not submerge incision keep wound clean and dry. Perform pin site care daily. Mix ½ peroxide, ½ Normal Saline and use gauze to clean around pin sites. One time a day for Wound care. Start date 10/15/24: Doxycycline Hyclate Oral Tablet 100 mg. Give 100 mg by mouth two times a day for chronic infection. Start date 10/22/24: Mupirocin External Ointment 2%. Apply to right leg wound topically two times a day every Tue, Thu, Sat for right knee wound for 14 administrations. [D/C date: 10/25/24] Start date 10/26/24: Wound care right knee. Cleanse site with wound cleanser. Pat dry, apply black wound vac for dressing. Wound vac at 125 (mm/hg). Change every 3 days and PRN. One time a day every Tue, Thu, Sat. Start date 10/26/24: Mupirocin External Ointment 2%. Apply to right leg wound topically two times a day every Tue, Thu, Sat for right knee wound for 14 administrations. There were no orders noted for weekly head to toe skin assessments. Record review of Resident #2's October 2024 TAR, printed 10/26/24 at 3:59 PM, reflected RN A's user initials for pin site care, wound vac change, and mupirocin applied to right knee wound on Saturday, 10/26/24 that indicated the care was provided in the morning (Qam) as ordered. During an observation and interview on 10/26/24 at 12:02 PM, Resident #2 was sitting upright in chair with legs in a reclined position. The right lower leg had an external fixator (a metal framed medical device mounted on the exterior of the leg with pins inserted through the skin and into the bone of the leg by applying external pressure). There was a clear dressing, dated 10/25/24, on the right outer lateral knee. A suction device and tubing connected the dressing to a tubing attached to a canister a wound vac pump. Resident #2 was awake, alert, and oriented to person, place, time of day, and situation. Resident #2 said wound care was performed yesterday (10/25/24) to clean the pins (external fixator) and the wound vac was placed to the right knee wound. Resident #2 said that she did not know when the dressing would be changed again. Resident #2 said that the pins were supposed to be cleaned daily and the wound vac was supposed to be changed three times a week. During an interview on 10/26/24 at 1:25 PM, RN A said that he worked weekends only from 6AM - 10 PM. RN A was not sure about Resident #2's wound vac dressing change schedule when asked. RN A read the orders out loud, Change every 3 days and as needed. every Tue, Thu, Sat. RN A denied any other wound care needs for Resident #2. When asked what time did [RN A] plan to do the wound vac dressing change, RN A replied, maybe tomorrow. When asked to clarify the order, RN A re-read the order and said, maybe later after dinner. RN A was informed that the investigator wanted to observe (RN A) perform Resident #2's wound care, that included obtaining wound dressing supplies. RN A acknowledged understanding. During an interview and observation of wound care performed by RN A on 10/26/24 at 3:06 PM, there were wound dressing supplies neatly placed on a barrier sheet at the foot of Resident #2's bed, flushed to the right edge. RN A said that he forgot the investigator wanted to observe (RN A) collect wound dressing supplies. RN A performed hand hygiene with soap and water. RN A did not don a clean gown. RN A donned clean gloves and turned off the wound vac. RN A did not clamp the tubing between the canister and the sensor pad. There was no drainage in the tubing noted. RN A pulled at and tugged on the suction device and tubing to remove the dressing from the wound site. Resident #2 grimaced and said that it hurt when RN A pulled on the tubing. Resident #2 informed RN A that she already had pain medicine and to continue with the dressing change. After investigator intervention, RN A lifted the edges of the semi-occlusive dressing and removed the semi-occlusive dressing. The sensor pad (and tubing) and a black foam piece was attached to the. RN A did not discard the old disposable suction device and tubing. RN A placed the disposable suction device and tubing in the windowsill with the semi-occlusive dressing and piece of black foam still attached. RN A said that the DON told him to reuse the sensor pad and tubing because the facility did not have new wound vac supplies. Resident #2's right knee presented a deep red raised wound, approximately one inch (2.54 cm) long and half inch (1.27 cm) wide by visual inspection. RN A did not measure the wound to compare with previous measurements. RN A cleaned the wound with non-sterile gauze soaked with wound cleanser, patted dry with non-sterile gauze, picked up a piece of black foam from the barrier sheet on the bed, and applied to the wound. RN A did not cut the foam to the dimensions of the wound. The black foam covered the wound and overlapped onto the healthy skin around the wound. RN A did not apply barrier cream or skin prep to prevent further breakdown of skin around the wound. RN A placed a piece of adhesive dressing over the foam piece to secure in place. RN A pinched the dressing and cut a small hole. RN A picked up the old suction device and tubing from the windowsill, removed the old adhesive dressing. RN A placed the suction device and tubing over the small hole and secured in place with strips of adhesive dressing. RN A connected the tubing to the tubing attached to the old cannister. RN A turned the wound vac on. RN A told Resident #2 that there was a good seal, and the wound vac was functioning. The dressing did not appear sucked down. During an interview, RN A said that he was checked off a long time ago (greater than two years ago) for wound vac dressing change competency. RN A said a good seal meant there was no air escaping from under the dressing. RN A said reusing the disposable suction pad and tubing increased Resident #2's risk for infection. RN A said that he did not know who was responsible for ordering wound care supplies. RN A said that the DON found some foam pieces in Resident #2's drawer that were not secured in the original sealed package and told him to reuse the suction pad and tubing. During an interview on 10/26/24 at 4:09 PM, the DON said that the nurses performed wound care and were responsible for reordering wound care supplies. The DON said that skin assessments were performed weekly and opportunities for staff to discover changes in skin condition were during showers, bed baths, and when incontinent care was performed. The DON said that she totally agreed with the investigator's observation findings. The DON said that she did tell RN A to reuse the disposable wound vac suction pad and tubing. The DON said that she oversaw a NPWT competency checkoff for RN A and needed to locate the documents. The DON said that Resident #2 admitted with orders to apply wet to dry dressings to the right knee. The DON said that the wound doctor gave orders to apply the wound vac. The DON said that the WMD would determine if there the wound improved or worsened. The DON said that it was not common practice to reuse supplies at the facility. The DON said that reusing disposable supplies can increase risk for infection. The DON said that RN A was supposed to don a gown and gloves when he performed wound care as enhanced barrier precautions to prevent cross-contamination. The DON said that head to toe skin checks were performed by the nurses weekly as a skin care approach to help identify skin conditions early. The DON said that she was unsure why Resident #2 did not have a weekly skin assessment 7 days after admission, 10/21/24, or as soon as it was discovered a skin assessment was not done. The DON said that the facility did not have specific policies related to frequency of skin assessments. Interview on 10/26/24 at 4:45 PM, the DON approached the investigator and said that she spoke with the central supply staff and was informed that the wound vac supplies were ordered and stored in the ADON's office. The DON could not explain why she did not inquire with central supply about the wound vac supplies before telling RN A to reuse disposable supplies. Record review of the facility procedure Guide to Negative Pressure Wound Therapy (NPWT), dated January 2024, read in part: General Procedure o Trim the foam sponge to fit the size of the open wound and place it into the wound; the foam should not extend beyond the wound margin. Dressing Changes o Remove the semi-occulsive dressing (a type of wound dressing that allows air to pass through while protecting the wound from liquids) and carefully remove the foam sponge. Risks and Complications Ensure proper placement of sponge and semi-occulsive adhesive cover; avoid sponge contact with healthy skin. Record review of the facility's procedure for Applying Negative Pressure Wound Therapy, Skill 8-11, dated 2011, reflected: Goal: The therapy is accomplished without contaminating the wound area, without causing trauma to the wound, and without causing the patient to experience pain or discomfort. 3. Perform hand hygiene and put on PPE, if indicated. 10. Using sterile technique, prepare a sterile field and add all the sterile supplies needed for the procedure to the field. 11. Put on a gown, mask, and eye protection. 12. Put on clean gloves. Carefully and gently remove the dressing. If there is resistance, use a silicone-based adhesive remover to help remove the drape. 14. Put on sterile gloves. Using sterile technique, irrigate the wound. 17. Wipe intact skin around the wound with a skin-protectant wipe and allow it to dry well. 19. Put on a new pair of sterile gloves, if necessary. Using sterile scissors, cut the foam to the shape and measurement of the wound. Do not cut foam over the wound. More than one piece of foam may be necessary if the first piece is cut too small. Carefully place the foam in the wound. 23. Assess the dressing to ensure seal integrity. The dressing should be collapsed, shrinking to the foam and skin. Record review of Texas Health and Human (HHS) Infection Prevention and Control Measures for Common Infections in LTC Facilities, Version 1.0, 10/07/22, Enhanced Barrier Precautions (p. 14) reflected: Enhanced barrier precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. Examples of high-contact resident care activities where gown and glove use for enhanced barrier precautions (EBP) are recommended include Wound care: any skin opening requiring a dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident who was incontinent of bladder received appropriate treatment and services for 1 of 2 residents (Resident #1) reviewed for incontinence care. The facility they failed to monitor and document signs and symptoms of bowel movements for Resident#1. This failure could place residents at risk of not having their individual needs met, not receiving necessary care and services, and a decreased quality of life. Findings included: Record review of Resident #1's admission record undated reflected the resident was an [AGE] year-old male, who initially admitted to the facility on [DATE] with a discharge date of [DATE]. Resident#1's diagnoses included hypo-osmolarity and hyponatremia, begin prostatic hyperplasia without lower urinary tract infection, pressure ulcer of sacral region stage, 3, protein calorie malnutrition, Vitamin D deficiency, reduced mobility and need for assistance with personal care. Record review of Resident#1's modified MDS dated [DATE] reflected the Resident #1 refused for toileting hygiene, shower/bathe self and lower body dressing. The MDS reflected Resident #1 was always continent of bladder. Resident#1 had a BIMS score of 07 which indicated serve cognitive impairment. Record review of Resident#1's care plan dated [DATE] reflected: Focus: The resident is incontinent of bladder. Goal: The resident will remain free from skin break down due to incontinence and brief use through the review date and interventions reflected: Brief use: The resident uses disposable briefs. Change per schedule and prn. Clean peri-area with each incontinence episode. Record review of the admission to hospital record dated [DATE] reflected Docusate Sodium 100mg, Colace (stool softener) by mouth every day as needed for constipation. MiraLAX (osmotic laxative - works with water intake in addition to dose) Take 17g by mouth every day. Record review of Resident#1's BM report 15 day look back dated [DATE] to [DATE] reflected no 1st shift (6:00 AM to 2:00 PM) shift documentation of BM movements. On 2nd shift (2:00 PM to 10:00 PM) shift missing documentation on 8/21, 8/22, 8/26,08/27/, 8/28, 8/31,9/01. On 2nd shift no BMs reported on 8/23, 9/2, 9/3,9/4 and 9/5. On 3rd shift (10:00 PM to 6:00 AM) reflected: No BMs on 8/23,8/24,8/29, 8/30,9/4 and 9/5. Record review of Resident #1's July2024, [DATE] and [DATE] MAR reflected: Resident#1 received MiraLAX oral Packet 17 GM (Polyethylene Glycol 3350) Give 1 packet by mouth one time a day for constipation. Review reflected residents received medication every morning. Record review of Resident#1 Juy 2024, [DATE] and [DATE] TAR reflected: Resident#1 did not receive a dose of Docusate Sodium 100mg, Colace (stool softener) by mouth every day as needed for constipation. Record review of Resident#1 hospital records dated [DATE] at 11:24 PM reflected: a large amount of formed stool throughout the colon and rectum. This guidance are concerned for fecal impaction. ADMIT DIAGNOSIS: SEPSIS with SEPTIC SHOCK FINAL DIAGNOSIS: Fecal impaction. ER arrival vital signs: bp: 105/58, HR 92. Record review of the WMD notes dated [DATE] reflected ER physician discussed with the family about hospice, and they indicated that they were unable to get hospice at the current facility. Family requested comfort care and hospice. Resident#1 was admitted on [DATE] to inpatient Hospice. Patient gradually declined as expected. Patient passed away peacefully on [DATE]. Interview with POA on [DATE] at 9:15 AM stated the facility killed Resident#1 by not taking good care of his overall health. POA stated every facility that he had been at he was neglected by staff. The POA stated she had the death certificate stated resident died from septic shook that he had for 8 weeks. POA stated she facility doctor, nursing staff are liars and wrote false reports about providing care for Resident#1. The POA stated she did not know Resident#1 had constipation issues and the facility did not keep her informed. Interview on [DATE] at 5:00 AM LVN D stated he remembered the residents but does remember him having constipation concerns or issues. LVN D stated if a resident goes three days without having a bowel movement, he would contact the MD to put the resident on a different medication if needed. Interview on [DATE] at 5:10 AM RN F stated she did not remember Resident#1. RN F stated CNAs report to the charge nurse any constipation issue and then we call the MD to get orders adjusted. Interviews on [DATE] at 5:25 AM with CNA F and CNA G (overnight shift) stated staff did not remember Resident#1. The CNAs stated they did documentation at the end of the shift about bowel movements. The CNAs described the size, form and shape of the BMs on the Plan of Care task sheet. Interviews on [DATE] at 6:05 AM with CAN C, CNA H, CMA I and CNA J stated staff did not remember Resident#1 CNAs stated they do documentation at the end of the shift about bowel movements. CNA'S describe the size, form and shape of the BMs on the Plan of Care task sheet. CNAs stated if a resident did not have a BM in three days on any shift it would be reported to the charge nurse and MD. Interviews on [DATE] with CNA K and CNA L stated staff did not remember Resident#1 stated they do documentation at the end of the shift about bowel movements. CNA'S describe the size, form and shape of the BMs on the Plan of Care task sheet. CNAs stated if a resident did not have a BM and three days it would be reported to the MD by the charge Nurse. Interview on [DATE] at 2:25 PM the ADON stated Resident#1 would refuse medication. ADON stated she does not remember Resident#1 reporting constipation concerns. ADON stated staff worked four days on and two days off. ADON stated CNAs reported in the POC about Bowel movements for all residents. ADON stated if a resident did not have a Bowel Movement in three days it was reported to the charge nurse who notified the MD. ADON stated any change of condition or concerns with residents are reported to the on coming staff and documented in the nurse's notes. ADON stated information about Bowel movements needed to be documented to determine if the Resident needed to be on a different medication. Interview over the phone on [DATE] at 4:30 PM the MD stated he did a head-to-toe assessment on Resident#1 on and he did not see any concerns with constipation at that time. MD stated he checked the resident stomach and there was no tightness and no discomfort reported by the resident at that time. Interview on [DATE] at 6:25 PM the DON and Administrator stated residents' bowel movements were measured by small, medium, and large. The DON revealed softness and firmness was documented on the task list for CNAs to complete. The CNAs were responsible for documenting this information in the POC. DON stated all resident's bowel movements are monitored in the POC and the CNAs know to report to the charge nurse if the resident did not have a BM for three days or more. The Charge nurse would report it to the MD. The MD would put in a different order for the resident. The Administrator stated he expected the nursing staff to document the information correctly so that staff would be alerted about concerns. The Administrator and DON stated the facility did not have a policy for monitoring bowel movement.

Based on observations and interviews, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents, for 1 of 3 medication carts (medication cart #1) observed for medication storage. On 10/27/24 at 6:08 PM, RN A failed to ensure medications were secured or attended to by authorized staff when RN A did not lock medication cart #1. On 10/27/24 at 6:08 PM, RN A failed to ensure medications were secured or attended to by authorized staff when RN A left a medication cup with two pills and a resident's medication blister pack with pills on top of the medication cart unattended. These failures place residents at risk of a potential for more than minimal harm if a resident accessed and ingested medications or drug diversion. Findings included: In an observation on 10/27/24 at 6:08 PM revealed medication cart #1 in Tower A unattended and not under direct observation of authorized staff. The lock was in the out position and the drawers were able to be opened and left the medications accessible. Residents' routine and PRN medication blister packs and OTC medications were organized in drawers of the medication cart. At 6:10 PM, RN A returned to the medication cart. During an observation and interview on 10/27/24 at 6:10 PM, RN A approached the medication cart where the investigator was standing and said that he was down the hall getting medications from LVN B's cart that were not available on his cart. RN A reached down and pushed the cart lock into the locked position. The click was heard when the cart locked. RN A said that he did not have a specific nurse cart. RN A said that he placed residents at risk of taking medications that may be allergic to or someone could steal medications because the cart was not locked. During an interview on 10/27/24 at 6:30 PM, the DON said that it was unacceptable to leave medication carts unlocked and unattended or not within direct line of site and arms reach for resident safety and to prevent drug diversion. The DON said that it nurses were responsible for securing medications whenever they were away from the medication cart. The DON said if residents could access the medications, swallow a medication that they are allergic to, or have an adverse reaction. The DON said she would hold a one-to-one verbal session with RN A about medication storage and drug diversion to prevent reoccurrence. The DON stated surveillance of locked medication carts are conducted regularly for quality assurance. The DON said that that facility did not have a specific policy related to Medication Storage - Storage of Medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident was treated with respect and dignity and cared for in an environment that enhanced his or her quality of life for 2 (Resident #19 and #24) of 3 residents reviewed for dignity. The facility failed to treat Resident #19 and #24 with dignity and enhance their quality of life when the residents were not provided a privacy bag for their catheter bag (drainage bag outside of the body that collects urine). This failure placed residents at risk of not having their right to dignity maintained. Findings included: Review of Resident #19's face sheet, dated 08/16/24, reflected that Resident #19 was an [AGE] year-old male admitted to the facility on [DATE]. Resident #19 was diagnosed with flaccid neurogenic bladder (the bladder did not function properly because of muscle and nerve damage). Review of Resident #19's Comprehensive Care Plan, dated 08/19/24, reflected Resident #19 had an indwelling catheter related to neurogenic bladder (bladder does not function properly because of nerve damage) and one of the interventions was catheter care each shift. Review of Resident #19's MDS Quarterly Assessment, dated 08/23/24, reflected Resident #19 had moderate cognitive impairment with a BIMS score of 08. The MDS Assessment indicated Resident #19 had an indwelling catheter. Review of Resident #19's Physician's Orders, dated 05/07/22, reflected a 22 French (French: unit used to indicate the size of the catheter) suprapubic catheter (device inserted into bladder to drain urine) for neurogenic bladder. Change monthly on the 7th and ending on the 8th of every month for neurogenic bladder. Observation on 09/04/24 at 09:55 AM revealed Resident #19 lying in bed. Resident #19's catheter bag was hanging on the side of the bed that faced the door. This was visible when standing in the resident's doorway. It was not touching the floor. The catheter bag was not in a privacy bag and the contents were visible. Observation on 09/05/24 at 11:07 AM revealed Resident #19 lying in bed. Resident #19's catheter bag was hanging on the side of his bed that faced the door. The catheter bag still did not have a privacy bag and contents were seen from the doorway of the resident's room. Resident #24 Review of Resident #24's face sheet, dated 08/15/24, reflected Resident #24 was a [AGE] year-old male admitted on [DATE]. Resident #24 was diagnosed with obstructive uropathy (blockage of urine flow). Review of Resident #24's Comprehensive Care Plan, dated 08/16/24, reflected Resident #24 had an indwelling catheter related to obstructive uropathy (blockage of urine flow) and one of the interventions was position catheter bag and tubing below the level of the bladder and away from entrance room door. Put bag in privacy cover. Review of Resident #24's MDS Comprehensive Assessment, dated 08/23/24, reflected Resident #24 had intact cognition with a BIMS score of 14. The MDS Comprehensive Assessment indicated Resident #24 had an indwelling catheter. Review of Resident #24's Physician's Orders, dated 08/15/24, reflected a 16 French (French: unit used to indicate the size of the catheter) suprapubic catheter (device inserted into bladder to drain urine). Change catheter drainage bag and tubing every 14 days and as needed. Observation on 09/04/24 at 10:22 AM revealed Resident #24 was sitting in the recliner in his room. Resident #24's catheter bag was hanging on the side of the bed that did not face the doorway. It was not touching the floor. The catheter bag was not seen from the doorway but was visible when standing in front of the resident. The catheter bag was not in a privacy bag and the contents were seen. Observation on 09/05/24 at 11:00 AM revealed Resident #24's catheter bag was still not in a privacy bag. Resident #24 was sitting in his recliner. The catheter bag was not visible from the doorway, but the contents of the bag were seen when standing in front of the resident. During an interview with CNA D on 09/05/24 at 11:22 AM, she stated that every resident with a catheter bag was supposed to have it covered with a privacy bag, even when the resident was in his or her room. During an interview with the Nurse Manager on 09/05/24 at 11:30 AM, she stated the resident's catheter bag should have been covered when in public view and using a privacy bag was a discreet way to do that. The Nurse Manager stated she did not know the facility policy for covering a catheter bag when the resident was in his or her room. During an interview with the ADON on 09/05/24 at 11:36 AM, she stated she did not know the facility policy, but that the catheter bag was normally in a privacy bag. The ADON stated she previously worked in hospitals and we didn't use privacy bags there. During an interview with LVN A on 09/05/24 at 01:15 PM, he stated all residents' catheter bag should be covered whether the resident was outside or inside the room. LVN A stated that was for the resident's dignity and so other people did not see what was in the catheter bag. LVN A said that the best practice was for the catheter bag to be in a privacy bag. During an interview with RN D 09/06/24 at 09:14 AM, she stated it was standard to have the resident's catheter bag in a privacy bag whether the resident was in or out of their room. Review of the facility policy Resident Rights, revised 04/16/2024, reflected Residents have the right to be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that assessments accurately reflected the resident's status for one (Resident #142) of seven residents reviewed for Accuracy of Assessments. The facility failed to ensure Resident #142's Comprehensive MDS Assessment accurately reflected that Resident #142 was using a CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open). This failure could place residents at risk for not receiving care and services to meet their needs, for diminished function of health, and for regressions in their overall health. Findings included: Review of Resident #142's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #142 was diagnosed with sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Review of Resident #142's Comprehensive MDS Assessment, dated 08/30/2024, reflected Resident #142 had moderate impairment in cognition with a BIMS score of 08. Resident #142's Quarterly MDS Assessment did not indicate that the resident was using a CPAP. Review of Resident #142's Comprehensive Care Plan on 09/04/2024 reflected no care plan for CPAP. Review of Resident #142's Physician Order on 09/04/2024 reflected no order for CPAP. Observation on 09/04/2024 at 9:09 AM revealed Resident #142 was in her wheelchair, sleeping. It was observed that a CPAP machine was on top of the resident's right side table. A nasal pillow mask (a small, soft, cushioned inserts that rests at the entrance of the nose) was attached to the CPAP machine. Observation and interview with Resident #142 on 09/04/2024 at 10:56 AM revealed resident was in her wheelchair, awake. It was observed that the nasal pillow mask for was still on top of the resident's side table. Resident #142 said she used the CPAP even before she was admitted to the facility. She said she could put it on and take it off but sometimes a staff would put it on and take it off. She said the staff were reminding her the benefits of using the CPAP. In an interview with LVN A on 09/04/2024 at 1:46 PM, LVN A stated the residents should be properly assessed everyday so that the staff could provide the best care possible. He said assessment was done during, admission, when there was a fall, or there was a change in condition. In an interview with the DON on 09/06/2024 at 8:26 AM, the DON stated an accurate assessment was important so that the staff would know how to take care of the residents. She said the care plan of the residents would be based on the assessment of the resident. She said if a resident was using a CPAP, it should be reflected on the medical diagnosis, physician orders, the MDS, and the care plan. She said if the residents were not properly assessed, the proper care and needs would not be met. The DON checked the resident's profile and confirmed that Resident #142 was triggered for care plan. The DON said the expectation was that the residents were properly assessed not only during admission but every day to see if there were changes in condition, any refusal of care, or a resident acting different than usual. She said she would collaborate with the MDS Nurse to audit the MDS Assessments and make the appropriate changes. She said she would do an in-service about accurate assessment and to document the assessment. In an interview with the ADON on 09/06/2024 at 8:39 AM, the ADON stated if a resident was using a CPAP, it should be reflected on the system to make sure the effectiveness of the resident's use of the CPAP. She added there should be an accurate assessment to know how to care for the residents. The ADON said if there was no accurate assessment, there could be a misunderstanding about the care needed by the resident and the resident might not be able to get the treatment needed. In an interview with the Administrator on 09/06/2024 at 8:51 AM, the Administrator stated the current condition of the resident should be reflected in the system to address the current needs of the resident. He said she would coordinate with the DON to evaluate the situation. Observation and interview with MDS Nurse on 09/06/2024 at 9:02 AM, the MDS Nurse stated she was responsible for doing the MDS Assessment. She said the CPAP would be triggered once it was on the physician order. The MDS Nurse logged on to her computer, checked the resident's profile, and confirmed that Resident #142 was not triggered for CPAP in the MDS assessment. She then checked the physician order and saw the physician order for CPAP that was just transcribed by LVN A on 09/06/2024 at 8:46 AM. She said since the CPAP already had a physician order, she would trigger it on the MDS. She said the medical diagnosis, physician order, the MDS, and the care plan should be all in synched to provide a clear overview of the resident's current condition. She said she would make an audit to make sure the MDS would reflect the current condition of the residents. Record review of facility policy, New admission Assessment Operations and Service Standards Manual revised April 16, 2024 revealed Service Standard: Each new resident should be assessed in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #142) of seven residents reviewed for Care Plans. The facility failed to ensure Resident #142 was care planned for CPAP. This failure could place the residents at risk of not receiving the necessary care and services. Findings included: Review of Resident #142's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #142 was diagnosed with sleep apnea. Review of Resident #142's Quarterly MDS Assessment, dated 08/30/2024, reflected Resident #142 had moderate impairment in cognition with a BIMS score of 08. Resident #142's Quarterly MDS Assessment did not indicate that the resident was using a CPAP. Review of Resident #142's Comprehensive Care Plan on 09/04/2024 reflected no care plan for CPAP. Review of Resident #142's Physician Order on 09/04/2024 reflected no order for CPAP. Observation on 09/04/2024 at 9:09 AM revealed Resident #142 was in her wheelchair, sleeping. It was observed that Resident #142 had a CPAP machine with a nasal pillow mask (a small, soft, cushioned inserts that rests at the entrance of the nose) was on top of the resident's right-side table. Observation and interview with Resident #142 on 09/04/2024 at 10:56 AM revealed the resident was in her wheelchair, awake. It was observed that the nasal pillow mask for CPAP was still on top of the table. Resident #142 said she used the CPAP at night, and it helped her sleep better. In an interview with the DON on 09/06/2024 at 8:26 AM, the DON stated every resident needed a comprehensive care plan to make sure the residents received the applicable and appropriate care needed. The DON said the care plan should be in place so that the staff providing care would be on the same page. The DON stated the care plan was important because it reflected the resident's problem lists, goals, and intervention. She said the care plan should be resident-centered and should show what specific care the resident needed. She said the expectation was for all residents to have a complete and detailed care plan. She said she would coordinate with the MDS Nurse to audit the care plans of the resident. In an interview with the ADON on 09/06/2024 at 8:39 AM, the ADON stated it was important that residents have a care plan to fully provide the care and services the residents needed. She said without the care plan, the staff would not be synched on the care of the residents and their needs would not be addressed. She said the expectation was all the issue of the residents were care planned. In an interview with the Administrator on 09/06/2024 at 8:51 AM, the Administrator stated all the residents should have a care plan appropriate to their needs. He said without the care plan, the staff would not know the goals and the interventions needed by the residents. The Administrator concluded that the expectation was for the staff to ensure that the residents were care planned accordingly. He said he would coordinate with the DON to make sure all the residents were care planned. Observation and interview with MDS Nurse on 09/06/2024 at 9:02 AM, the MDS Nurse stated she was responsible in making the care plan. She said since the CPAP was not triggered in the MDS, Resident #142 did not have a care plan. She said after triggering it in the MDS, she would do the care plan to reflect the goals and the interventions. The MDS Nurse stated care plans were important to ensure the residents were getting the care needed. She said care plans served as guides on how the staff would take care of the residents. The MDS Nurse added that without the care plans, the staff might overlook the interventions needed by the residents. Record review of facility's policy, Resident Plan Of Care Operations and Service Standards Manual revised April 16, 2024 revealed Service Standard . develop a plan of care for each resident . Utilizing the assessment . team will develop a plan of care for each resident . 4. The care plan will identify problem areas and interventions needed to meet the needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to review and revise the 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 #23) of 6 residents reviewed for Care Plan reassessment and revisions. The facility failed to ensure Resident #23's care plan included the resident receiving a dietary supplement (Ensure), twice daily based on a comprehensive nutritional assessment completed by the dietician on 08/16/24. This failure could place the resident at risk for excessive weight loss. Findings included: Record review of Resident #23's Face Sheet, dated 09/06/2024, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included Alzheimer's Disease with late onset and malnutrition. Record review of Resident #23's MDS dated [DATE] revealed, she had a Brief Interview for BIMS score of 05 (severely cognitively impaired) and for ADL care it stated, for transfers, toileting, and bathing, the resident required total assistance. Section K of the MDS indicated the resident had no weight loss of 5% or more in the last month or 10% loss or more in the last 6 months. Record review of Resident #23's Comprehensive care plan dated 08/12/24 revealed the resident's intervention for her care regarding potential nutritional problem was Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, > 5% in 1 month, > 7.5% in 3 months, > 10% in 6 months. There was no intervention indicating the nutritional supplement of Ensure to be included in the resident's assessment. Record review of Resident #23's Comprehensive Nutritional assessment dated [DATE] revealed the resident was not meeting nutritional needs with average intake of 25%-51% and provide Ensure BID to aid in meeting nutritional needs. Record review of Resident #23's orders dated 09/04/24 revealed no physician orders for the Ensure shakes. Record review of Resident #23's weight in the facility's system of record revealed the resident weighed 133.9 pounds on 08/12/24 and was weighed again on 08/22/24 at 127 pounds, which was a 5.15% weigh loss. . In an interview on 09/05/24 at 10:40 AM, the Dietitian stated that she had documented in Resident #23's Dietary Nutritional Assessment on 08/16/24, which stated the following, provide resident with Ensure BId to aid in meeting nutritional needs until PO intake improves to >50%. She stated that the resident was forecasted to have weight loss but to attempt to slow down the weight loss by providing the resident an Ensure two times a day. She stated the nursing staff should have requested the orders for the Ensure from the physician. she stated she was not scheduled to review the resident's weight plan until 09/16/24. She stated she did not know why the resident did not have orders for the Ensure and that she would follow up with nursing to see why. She stated the risk of the resident not receiving the Ensure could result in her having possible preventable weight loss. She stated that she had submitted physician orders for the resident to receive Ensure twice daily but it somehow got rejected. She stated that she also should have added it to the resident's care plan, which would ensure that the resident received the dietary aide. She stated she was overall responsible for following up to ensure the resident had the physician orders for the Ensure shake. She stated she also added it to the resident's care plan. In an interview on 09/05/24 at 10:40 AM, the DON was made aware of Resident #23 not having a weight loss of 5.15% in less than two weeks and she stated the resident had refused the Ensure shakes, but she was advised that there were no progress notes indicating the resident refusing the Ensure shake and she also did not have any orders for the Ensure Shake. The DON stated the resident was receiving some other type of nutritional assistance, but she was advised that there were no orders observed for any else. She stated the resident should have had orders for the Ensure shake and she should have had it care, planned by the dietician, which she will ensure that the Dietician had completed. She stated the risk of not providing the resident the Ensure shake could result in unintended weigh loss. Record Review of the Facility's policy on Resident Care Plan dated 04/16/2024, revealed The plan of care will identify problems areas and interventions needed to meet the needs of the resident. The interdisciplinary team is responsible for updating the care plan when there is significant change in the resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that residents received additional nutrition resources, based on comprehensive assessments reviewed for 1 (Resident #23) of 4 residents reviewed for assisted nutrition. The facility failed to ensure Resident #23 received her Ensure shake twice daily, based on a dietary comprehensive assessment completed by the Dietitian on 08/16/24. This failure placed the resident at risk of unnecessary weight loss or slowing a diagnosis that causes weight loss. Findings included: Record review of Resident #23's Face Sheet, dated 09/06/2024, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included Alzheimer's Disease with late onset and malnutrition. Record review of Resident #23's Quarterly MDS dated [DATE] revealed, she had a BIMS score of 05 (severely cognitively impaired) and for ADL care it stated, for transfers, toileting, and bathing, the resident required total assistance. Section K of the MDS indicated the resident had no weight loss of 5% or more in the last month or 10% loss or more in the last 6 months. Record review of Resident #23's Comprehensive care plan dated 08/12/24 revealed the resident's intervention for her care regarding potential nutritional problem was Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, > 5% in 1 month, > 7.5% in 3 months, > 10% in 6 months. Record review of Resident #23's Comprehensive Nutritional assessment dated [DATE] revealed the resident was not meeting nutritional needs with average intake of 25%-51% and provide Ensure BID to aid in meeting nutritional needs. Record review of Resident #23's orders dated 09/04/24 revealed no physician orders for the Ensure shakes. Record review of Resident #23's weight in the facility's system of record revealed the resident weighed 133.9 pounds on 08/12/24, which was her first weigh-in since being admitted on [DATE]. and was weighed again on 08/22/24 at 127 pounds, which was a 5.15% weigh loss. . In an interview on 09/05/24 at 10:40 AM, the Dietitian stated that she had documented in Resident #23's Dietary Nutritional Assessment on 08/16/24, which stated the following, provide resident with Ensure BId to aid in meeting nutritional needs until PO intake improves to >50%. She stated that the resident was forecasted to have weight loss but to attempt to slow down the weight loss by providing the resident an Ensure two times a day. She stated the nursing staff should have requested the orders for the Ensure from the physician. She stated she was not scheduled to review the resident's weight plan until 09/16/24. She stated she did not know why the resident did not have orders for the Ensure and that she would follow up with nursing to see why. She stated the risk of the resident not receiving the Ensure could result in her having possible preventable weight loss. She stated that she had submitted physician orders for the resident to receive Ensure twice daily but it somehow got rejected, she stated she was not sure if she had completed the submission process. She stated that she also should have added it to the resident's care plan, which would ensure that the resident received the dietary aide. She stated she was overall responsible for following up to ensure the resident had the physician orders for the Ensure shake. She stated she also added it to the resident's care plan. In an interview on 09/05/24 at 10:40 AM, the DON was made aware of Resident #23 having a weight loss of 5.15% in less than two weeks and she stated the resident had refused the Ensure shakes. She was advised that there were no progress notes indicating the resident refusing the Ensure shake and she was advised that the resident did not have any orders for the Ensure Shake. The DON stated she meets with her Dietician to discuss residents with weight loss concerns monthly. The DON stated the resident was receiving some other type of nutritional assistance, but she was advised that there were no orders observed for any other nutritional supplement else. She stated the resident should have had orders for the Ensure shake and she should have had it care planned. She stated the risk of not providing the resident the Ensure shake could result in unintended weigh loss. Record Review of the Facility's policy on Monitoring Weight Loss dated 04/16/2024, revealed The dietician will work with the nursing staff and other members of the interdisciplinary team to determine an appropriate plan of action which will be presented to the primary physician for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 and to help prevent the development and transmission of communicable diseases and infections for two (Resident #7 and Resident #145) of eight residents observed for Infection Control. 1. The facility failed to ensure that CNA C changed her gloves and performed hand hygiene while providing incontinent care to Resident #7. 2. The facility failed to ensure that CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #145. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #7's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #7 was diagnosed with reduced mobility and need for assistance with personal care. Review of Resident #7's Quarterly MDS Assessment, dated 06/11/2024, reflected that Resident #7 was cognitively intact with a BIMS score of 14. Resident #7's Quarterly MDS Assessment indicated that the resident was incontinent for bowel and bladder. Review of Resident #7's Comprehensive Care Plan, dated 07/17/2024, reflected that Resident #7 was incontinent for bladder and one of the interventions was clean peri-area with each incontinent care. Observation on 09/04/24 at 11:18 AM revealed CNA C was about to transfer Resident #7 to her recliner using a sit-to-stand lift (a mechanical device designed to assist individuals in moving from a sitting position to a standing position and vice versa). CNA C entered the room with the sit-to-stand. CNA C put on a pair of gloves, she did not do hand hygiene before putting on the pair of gloves. CNA C assisted the resident into a sitting position at the side of the bed. CNA C then placed the protective strap around the resident's chest and hooked it on the sit-to-stand lift. CNA C raised Resident #7 into a standing position. Before transferring the resident to the recliner, CNA C pushed the sit-to-stand lift to the bathroom because the resident said she wanted to relieve herself. Before lowering the resident down to the toilet seat, CNA C pulled the resident's brief down and then lowered the resident onto the toilet seat. While the resident was relieving herself, the brief fell on the floor. CNA C took off the brief, threw it on the trash can, and then tied the plastic bag where she threw the brief. CNA C took off her gloves and put on a new pair of gloves, she did not sanitize her hands before putting on the new pair of gloves. CNA C then took a new brief from the sink that was just behind her, opened it, and placed it on the side of the sink. When the resident said that she was done, CNA C raised the resident up, pulled some wipes, and cleaned the resident's bottom. After cleaning the resident's bottom, CNA C took the opened brief that she placed at the side of the sink that was behind her and put it on the resident. CNA C did not change her gloves after cleaning the resident's bottom. After putting on the brief, CNA C rolled the sit-to-stand lift and lowered the resident to her recliner. CNA C took off her gloves, threw it, and left the room. She did not wash her hands after incontinent care and the transfer. In an interview with CNA C on 09/05/2024 at 1:13 PM, CNA C stated hands should be washed or sanitized before and after doing incontinent care. She said the hands should also be sanitized before putting on clean gloves. CNA C said hand hygiene was important to prevent the spread of germs. She said she should have done hand hygiene and changed her gloves after touching the soiled brief, after cleaning the resident's bottom, and before touching the new brief. She said she was in a hurry and forgot to change her gloves before getting the new brief. 2. Review of Resident #145's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #145 was diagnosed with weakness and malaise (a general feeling of discomfort, illness, or uneasiness). Review of Resident #145's Comprehensive MDS Assessment, dated 08/20/2024, reflected Resident #145 had a severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated that the resident was incontinent for bladder and bowel. Review of Resident #145's Comprehensive Care Plan, dated 08/21/2024, reflected Resident #145 was incontinent for bladder and one of the interventions was clean peri-area with each incontinent care. Observation on 09/05/2024 at 12:43 PM revealed CNA B was called by Resident #145's family member because the resident wanted to go to the bathroom. Resident #145 was already inside the bathroom and was waiting for CNA B. CNA B put on pair of gloves and assisted the resident to stand up from the wheelchair. CNA B did not do hand hygiene before putting on the gloves. CNA B instructed the resident to pivot, lowered the resident's pull-up, and then assisted the resident to sit down on the toilet seat. The pull-up was observed to be soiled. When the resident was done relieving herself, she told CNA B that she was done. CNA B assisted the resident to stand up, pulled some wipes, and cleaned the resident's bottom from middle to back. CNA B instructed the resident to sit down again so she could change the soiled pull-up. CNA B took off the resident's shoes followed by the resident's pants. CNA B then pulled the soiled pull-up and threw it on the trash can. CNA B then reached out to the sink and took a new pull-up from the side of the sink. She did not change her gloves after cleaning the resident's bottom, taking off the resident's shoes and soiled pull-up. CNA B then put on the new pull-up, followed by the resident's pants, and then the resident's shoes. In an interview with CNA B on 09/05/2024 at 12:56 PM, CNA B stated she should do hand hygiene before doing any care for a resident. She confirmed that she did not wash her hands nor sanitized her hands before putting on her gloves. She said, during incontinent care, the gloves should have been changed after touching the shoes and the soiled pull-up. She added that after touching anything that was dirty or soiled and before touching the clean items, hand hygiene should be done. She said hand hygiene should also be done in between changing of gloves. She said if hand hygiene and changing of gloves were not done, cross contamination and infection could happen. In an interview with LVN A 09/05/2024 at 1:47 PM, LVN A stated hand hygiene was the basic component in the prevention of cross contamination and development of infection. LVN said hand hygiene should be a part of the staff's routine, especially those that were providing direct care. He said staff should do hand hygiene before and after any care. He continued that the gloves should be changed after touching anything that was dirty or soiled and before touching the clean items. He said hands should also be sanitized in between changing of gloves. In an interview with the DON on 09/06/2024 at 8:26 AM, the DON stated that hand hygiene was the most effective way to prevent cross contamination and infection. She said, first, it should be done before and after every care. She continued that secondly, the gloves should be changed after touching any soiled items. She said for this case, the gloves should have been changed after touching the shoes and the soiled brief and pull-up. She said lastly, every time staff change their gloves, they should do hand hygiene before putting on a new pair of gloves. She said the expectation was for the staff to do hand hygiene before and after any care, to change their gloves from dirty to clean, and to do hand hygiene when changing the gloves. She said he will do an in-service and check-off about infection control and would monitor the issue personally. In an interview with the ADON on 09/06/2024 at 8:39 AM, the ADON stated she was the Infection preventionist of the facility. She said hand hygiene was included in all the procedures of any care. She said the staff should do hand hygiene before and after any care. She said gloves should be changed when transitioning from dirty to clean. She said not doing hand hygiene could cause of cross contamination and probable infections. She said the expectation was for the staff to do hand hygiene before and after every care, after changing their gloves, and when transitioning from a dirty area to a clean area. The ADON said they would do in-service about infection control. In an interview with the Administrator on 09/06/2024 at 8:39 AM the Administrator stated not doing hand hygiene before and after any care, not changing the gloves after touching soiled items, and not sanitizing the hands in between changing of gloves could contribute to cross contamination and probable infection. He said the expectation was for the staff to follow the policy and procedures pertaining to infection control. He said he would collaborate with the DON to in-service the staff about infection control. Review of facility policy, Hand Hygiene Operations and Service Standards Manual revised April 16, 2024 revealed Service Standard: Handwashing is the most important procedure to follow to prevent the spread of infection . can use alcohol-based hand sanitizer . hand hygiene should be performed . before and after client contact . after removing gloves . after touching contaminated items. Policy for Incontinent Care requested on 09/05/2024 at 12:04 PM and on 09/06/2024 at 10:22 PM but was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #8, Resident #21, and Resident #143) of thirteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #8, Resident #21, and Resident #143's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #8 Review of Resident #8's Face Sheet, dated 09//06/2024, reflected that the resident was an [AGE] year-old male admitted on [DATE]. Resident #8 was diagnosed with generalized muscle weakness, unsteadiness on feet, and difficulty in walking. Review of Resident #8's Comprehensive MDS Assessment, dated 08/16/2024, reflected that Resident #8 had a moderate impairment in cognition with a BIMS score of 08. Resident #8 required substantial assistance in toileting, shower, and dressing. Review of Resident #8's Comprehensive Care Plan, dated 08/29/2024, reflected that Resident #8 was high risk for falls related to deconditioning and one of the interventions was to be sure the resident's call light was within reach. Observation and interview on 09/04/2024 at 10:20 AM revealed Resident #8 was in his wheelchair beside his bed. Resident #8 was putting on his t-shirt and said he just had a shower. He said CNA C showered him and then made his bed. Resident #8 then said CNA C went out of the room to get a pair of new socks for him. He said CNA C haven't come back since after the shower and he was planning to call her to know where his socks were. He said he cannot call CNA C because his call light was on the floor, and it was hard for him to pick it up. It was observed that the resident's call light was on the floor behind his wheelchair. He said the CNA who made his bed did not make sure his call light was secured. Observation and interview with CNA C on 09/04/2024 at 10:43 AM revealed CNA C went inside Resident #8's room and put on the resident's socks. Resident #8 said CNA C was the aide that made his bed. After putting on the socks, CNA C then went out of the room and still did not notice that the resident's call light was on the floor. When prompted to check the resident's call light, CNA C looked up and said the call light was not on. When prompted to check on the call light's placement, CNA C went back inside the room, saw the call light on the floor, picked it up, and put it on top of the resident's bed. CNA C stated she gave the resident his shower and made his bed. She said she did not notice the call light was on the floor when she left the room. She said she should have made sure the call light was accessible to Resident #8 in case he needed something. She said the call lights were important because the resident use them to let the staff know that they needed something. Without the call light, the needs of the resident will not be known. Resident #21 Review of Resident #21's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #21 was diagnosed with generalized muscle weakness, unsteadiness on feet, and difficulty in walking. Review of Resident #21's Comprehensive MDS Assessment, dated 08/09/2024, reflected that Resident #21 had a moderate cognitive impairment with a BIMS score of 11. Resident #21 required substantial assistance in toileting, shower, and dressing. Review of Resident #21's Comprehensive Care Plan, dated 07/29/2024, reflected that Resident #21 was at risk for falls related to gait balance problems and one of the interventions was to ensure/provide a safe environment. Observation and interview on 09/04/2024 at 8:54 AM revealed Resident #21 was in her wheelchair, awake. The resident's call light was observed on the floor beside the bed. She said she just came back from breakfast. She said she saw the call light on the floor when she was ushered inside the room after breakfast but the one who pushed her wheelchair did not notice the call light was on the floor. Observation and interview on 09/04/2024 at 10:28 AM revealed Resident #21 was still sitting in her wheelchair, awake. She said her call light was still on the floor. She said she frequently used it, but it should be where she could reach it in case she needed something. Observation on 09/04/2024 at 10:48 AM revealed after leaving Resident #8's room, CNA C proceeded to Resident #21's room, saw the call light on the floor, picked it up, and placed it on the bed. CNA C told Resident #21 that her call light was on the bed. Resident #143 Review of Resident #143's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old male admitted on [DATE]. Resident #143 was diagnosed with weakness, reduced mobility, and unsteadiness on feet. Review of Resident #143's Comprehensive MDS Assessment, dated 08/27/2024, reflected Resident #143 required substantial assistance in toileting, shower, and dressing. Review of Resident #143's Comprehensive Care Plan, dated 08/28/2024, reflected that Resident #143 had an ADL self-care performance deficit related to fatigue and impaired balance and one of the interventions was to encourage the resident to use bell for assistance. Observation and interview with Resident #143 on 09/04/2024 at 8:46 AM revealed resident was in his bed, awake. It was observed that Resident #143's call light was on the floor under the bed. Resident #143 stated he was trying to look for his call light because he wanted to get up but cannot find it. He said he cannot even find the cord of his call light. He said several staff already went inside the room and did not notice his call light was on the floor. Observation and interview with RN D on 09/04/2024 at 8:55 AM, RN D stated call lights should be with the residents all the times, because they use the call lights to call for help or assistance if needed. She said the residents used the call lights to communicate to the staff that they needed something. She added that if the call lights were not with the residents, the residents might fall trying to do things by themselves or get frustrated because they could not call the staff. She said all the staff were responsible in making sure the call lights were within reach of the residents. RN D went inside Resident #143's room, picked up the call light, and handed it to Resident #143. In an interview with the DON on 09/06/2024 at 8:26 AM, the DON stated call lights were important for the residents and they should be placed where the residents could access them without difficulty. The DON said the call lights were the residents' mode of communication so they could tell the staff they needed something. She said even if the residents seldom use them, the call lights should still be placed somewhere accessible. She said all the staff, from nurses, CNAs, therapy, housekeeping, and management, were responsible in ensuring that the call lights were within reach. The DON said the expectation was for the staff would be mindful that every time they leave the residents' room, the call lights were within reach. The DON said she would conduct an in-service and check-off about the call lights. She said she would personally monitor that all the residents' call lights were within reach. In an interview with the ADON on 09/06/2024 at 8:39 AM, the ADON stated the call lights should not be on the floor or in a place not accessible to the residents because the residents needed them to call the staff. The ADON said if the call lights were not within reach, the residents would not be able to call the staff and their needs would not be met. The ADON said the expectation was for all the staff to make sure the call lights were within the reach of the residents. The ADON said they would do an in-service about call lights being accessible to the residents. In an interview with the Administrator on 09/06/2024 at 8:51 AM, the Administrator stated the call lights should not be on the floor because the residents needed them to call the staff. The Administrator said the residents might be having an emergency and staff would not know. The Administrator said the staff should be make sure the call lights were within reach. The Administrator said he would coordinate with the DON regarding call lights and would constantly remind them that before leaving the room, make sure the call lights were with the resident. Record review of facility's policy Accommodations For Residents Who Cannot Use the Call light Operations and Service Standards Manual revised July 16, 2024 revealed . goal is to have a call light available and within reach of all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #29, Resident #142, and Resident #144) of eight residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #29's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored. 2. The facility failed to ensure that Resident #142 had an order for CPAP and her nasal pillow mask (a small, soft, cushioned inserts that rests at the entrance of the nose) for CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was stored properly. 3. The facility failed to ensure Resident #144's nasal cannula was properly stored. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Review of Resident #29's Face Sheet, dated 09/06/2024, reflected that the resident was an [AGE] year-old female admitted on [DATE]. Resident #29 was diagnosed with chronic respiratory failure with hypoxia (insufficient amount of oxygen in the body), emphysema (a lung disease that damages the air sacs in the lung causing shortness of breath), and chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident #29's Quarterly MDS Assessment, dated 08/26/2024, reflected that Resident #29 had moderate impairment in cognition with a BIMS score of 12. Resident #29's Quarterly MDS Assessment indicated that the resident was on oxygen therapy. Review of Resident #29's Comprehensive Care Plan, dated 08/20/2024, reflected that the resident had emphysema/COPD with chronic respiratory failure related to smoking and one of the interventions was O2 via nasal prongs at 2 L/min. Review of Resident #29's Physician Order, dated 08/19/2024, reflected O2 at 2L/Min Via (through) NC. Observation and interview with Resident #29 on 09/04/2024 at 8:41 AM revealed that Resident #29 was in her wheelchair, awake. It was observed that she had a portable oxygen tank behind her wheelchair. A nasal cannula was attached to the portable oxygen tank. It was observed that the nasal cannula was coiled on the right hand grip of the wheelchair. The nasal cannula was not bagged and there was no bag hanging at the back of the wheelchair. Resident #29 stated she was on oxygen because of her respiratory problems. Said she would use the nasal cannula on her wheelchair when she needed to go out of her room. She said she never saw a plastic bag for her nasal cannula at the back of her wheelchair and for the nasal cannula connected on the oxygen concentrator. 2. Review of Resident #142's Face Sheet, dated 09/06/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #142 was diagnosed with sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Review of Resident #142's Comprehensive MDS Assessment, dated 08/30/2024, reflected Resident #142 had moderate impairment in cognition with a BIMS score of 08. Resident #142's Comprehensive MDS Assessment did not indicate that the resident was using a CPAP. Review of Resident #142's Comprehensive Care Plan on 09/04/2024 reflected no care plan for CPAP. Review of Resident #142's Physician Order on 09/04/2024 reflected no order for CPAP. Observation on 09/04/2024 at 9:09 AM revealed Resident #142 was in her wheelchair, sleeping. It was observed that a CPAP machine was on top of the resident's right-side table. A nasal pillow mask was attached to the CPAP machine. The nasal pillow mask for CPAP was not bagged. Observation and interview with Resident #142 on 09/04/2024 at 10:56 AM revealed resident was in her wheelchair, awake. It was observed that the nasal pillow mask for CPAP was not bagged. Resident #142 said she used the CPAP even before she was admitted to the facility. She said she could put it on and take it off but sometimes a staff would put it on and take it off. She said did not know if the staff would put it on a plastic bag and said nobody told her to not just put the CPAP mask on the table. 3. Review of Resident #144's Face Sheet, dated 09/06/2024, reflected that the resident was an [AGE] year-old female admitted on [DATE]. Resident #144 was diagnosed with chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of Resident #144's Comprehensive MDS Assessment, dated 08/26/2024, reflected that Resident #144 was cognitively intact with a BIMS score of 13. Resident #144's Quarterly MDS Assessment indicated that the resident was on oxygen therapy. Review of Resident #144's Comprehensive Care Plan, dated 08/23/2024, reflected that the resident had chronic respiratory failure and COPD r/t smoking and one of the interventions was O2 via nasal prongs at 4 L/min. Review of Resident #144's Physician Order, dated 08/22/2024, reflected O2 at 4 L/Min Via NC. Observation on 09/04/2024 at 10:51 AM revealed Resident #144 was in her bed, sleeping. Resident #144 was on oxygen administration at 4 liters per minute via nasal cannula. The nasal cannula was connected to an oxygen concentrator. Resident #144 also had a nasal cannula at the back of her wheelchair connected to a portable oxygen tank. The nasal cannula was coiled on the left-hand grip of the wheelchair with the prongs of the nasal cannula hanging and was touching the left rear wheel of the wheelchair. The nasal cannula was not bagged and there was no bag at the back of the wheelchair. Observation and interview with LVN A on 09/04/2024 at 11:08 AM, LVN A stated the CPAP nasal pillow, and the nasal cannula should not be exposed nor touching anything because it could cause cross contamination and infection. He said the things mentioned should be bagged when not in use. LVN A went inside Resident #144's room and confirmed the resident's nasal cannula was not bagged and was touching the rear wheel of the wheelchair. LVN A disconnected the nasal cannula attached to the oxygen tank and threw it on the trash can. He said he was going to change it and put it on a bag. LVN A then went to Resident #29's room and confirmed the nasal cannula at the back of the wheelchair was not bagged. LVN A disconnected the nasal cannula, threw it, and said he was going to change it. LVN A went to Resident #142's room and saw the nasal pillow mask for CPAP on the table. LVN A placed the nasal pillow mask for CPAP inside the plastic bag. He said he noticed the nasal pillow mask for CPAP on the table when he checked on Resident #142 but forgot to put it in the plastic bag. Observation and interview with LVN A on 09/04/2024 at 1:46 PM, LVN A stated there should be an order for CPAP because it was a treatment being done to the resident. LVN A checked Resident #142's physician order and said the resident did not have an order for CPAP. He said he saw the CPAP and the suction machine but did not check if there was an order for it. He said the physician orders were important so the staff would know the medications or treatments needed by the resident. He said without the orders, the care needed by the residents would not be addressed. He said he will put the order on the system. In an interview with the DON on 09/06/2024 at 8:26 AM, the DON stated the nasal cannula and the CPAP mask should be bagged when not in use to keep it clean. She said if those breathing apparatus were not bagged, were exposed, or touching surfaces that were not clean, there could be cross contamination, respiratory infection, and oxygen administration could be compromised. The DON said the staff, including her, were responsible in monitoring if the nasal cannula and CPAP mask were bagged when not in use. She said there should be an order for the use of the CPAP. She said that through the physician orders, the staff would know what medications or treatments were needed by the residents on the daily basis. She said without the orders, the staff would not know what to do. She opened Resident #142's profile and confirmed there was no order done for the CPAP. She continued that even though the staff knew what to do and what to give, there should still be an order before executing any treatment or administering any medication. She said the expectation was for the staff to be mindful in making sure that the nasal cannula and the CPAP mask of the residents would be bagged when not in use. She said another expectation was for all the treatment and medications of the residents had orders. The DON said she would conduct an in-service and check-off about the respiratory care. She said she would personally monitor if the staff were bagging the nasal cannula and CPAP mask. She said she would also include the breathing mask used for nebulization. In an interview with the ADON on 09/06/2024 at 8:39 AM, the ADON stated she was the Infection Preventionist of the facility. She said the nasal cannula and the CPAP mask should be bagged when not in use. She said if the nasal cannula and the CPAP mask were exposed and touching surfaces that were dirty, cross contamination and possible respiratory infections could occur. She said the expectation was for the staff to bag the nasal cannula and the CPAP mask when not in use. She said she would coordinate with the DON pertaining respiratory care. In an interview with the Administrator on 09/06/2024 at 8:51 AM, the Administrator stated everything that the residents were using should be kept clean to prevent infection and all the orders would be in the system. He said since he was not a clinician, he would coordinate with the DON on how to go forward about the issue of respiratory care. Policy for Respiratory Care and Oxygen Administration requested on 09/05/2024 at 12:04 PM but was not provided. The Administrator stated on an email dated 09/05/2024 at 1:32 PM that they do not have specific policies for Respiratory Care, Oxygen Therapy, and Physician Order . The email stated, In the Implementation of services and procedures each facility will utilize the appropriate resources such as [NAME] manual, CDC control and prevention . The resources mentioned were also not provided prior to exit.

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. 1. The facility failed to ensure expired foods in the facility's refrigerator and freezer were discarded according to guidelines. 2. The facility failed to ensure foods in the refrigerator and freezer were properly sealed from air-borne contaminations. 3. The Executive Chef, Cook, and Culinary Aide failed to properly wear a hair and beard covering while breakfast was being prepared and served, in the kitchen area. 4. The facility failed to clean the food storage bins in the dry food storage area. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 09/04/24 from 08:50 AM to 09:05 AM in the facility's main kitchen reflected: The Executive Chef was observed in the kitchen area during breakfast service, not wearing a beard covering. His beard was approximately ¼ inch in length. Cook V was observed in the kitchen area during breakfast service, wearing a baseball cap style hat and she had a large rolled up ponytail sticking out of the back of the cap with no hairnet, and she also had about at least two inches of hair sticking out of the bottom of the cap. Culinary Aide S was observed in the kitchen area during breakfast service, wearing a chef skull cap, and he also had at least an inch of hair sticking out of the bottom of the cap. The findings in the kitchen refrigerator included the following: One large tin tray containing a tin container of shredded cheese, a tincontainer of shredded carrots, a tin container of sliced cucumbers, and a tin container containing cherry tomatoes did not have stored date. One tin tray containing 6 tin containers of butter, sour cream, shredded cheese, and bacon bits did not have stored date. One large tin tray of asparagus did not have stored date. One large tin tray of broccoli did not have stored date. One large tin tray of sliced carrots did not have stored date. One large tin tray of stringed beans did not have stored date. One opened bag of spinach was unlabeled and did not have stored date. One large bowl of soup had a hole in the clear cover, exposing it to air contaminants, and it was unlabeled and did not have stored date. One large tin tray of greens did not have stored date. One large tin tray of sauce did not have stored date. One small tin container marked salsa, did not have stored date. One small tin container of gravy was unlabeled and did not have stored date. One large tray of raw lobster tails was unlabeled and did not have stored date. One tin tray of raw shrimp was unlabeled and did not have stored date. One large bag of peperoni did not have stored date. One large bag of meat was unlabeled did not have stored date. One bag of franks was sitting in a tin tray unlabeled and did not have stored date. One large tin tray of cooked pasta was unlabeled and did not have stored date. The findings in the kitchen freezer included the following: One large bag of frozen beef patties, in a zip locked bag, unsealed and open to air contaminants. One large bag of frozen yellow fruit, in a zip locked bag, unsealed and opem to air contaminants. Two large trays of frozen croissants were uncovered and open to air contaminants. Two large trays of muffins were uncovered and open to air contaminants. The findings in the dry food storage area included the following: Two large white bins containing sugar and flour had brownish and blackish dirt stains all over the outer portion of the bins and the inside openings of the bins. One large container of beans (unknown type) was uncovered and open to air contaminants. One large bag of sliced almonds was unsealed and open to air contaminants. In an interview on 09/06/24 at 11:28 AM, the Executive Chef and the Director of Culinary Services was advised of the concerns observed in the kitchen area. The EC stated everyone was responsible for labeling and dating the foods in the kitchen. He stated he had a utility person that was responsible for labeling and dating the food when it arrived from the trucks, and the cooks were responsible for dating the food cooked at the end of the day, before storing it. They were shown pictures of the concerns and the EC stated he had made the corrections observed. The EC stated that everyone was responsible for checking the foods in the storage areas to ensure that it was sealed properly. The EC stated they had deep cleaned the kitchen every Sunday after brunch. The EC stated they cleaned the dry storage area, including the storage bins daily. The EC was advised of himself and the two staff members being observed not wearing the proper head and face coverings, and he stated he had corrected the issue by ensuing everyone was wearing a hairnet. The EC the concerns observed in the kitchen could contaminate foods and make the residents sick. In an interview on 09/06/24 at 11:28 AM, the Administrator was advised that there were concerns observed in the kitchen. He mentioned that he had spoken with the EC. He advised that the issues could cause food contamination and would be resolved. Record Review of the Facility's policy on Food Storage dated 04/16/2024, revealed Buckner strives to prepare, distribute, and served food under sanitary conditions. Food and supplied will be stored according to the current standards of practice. 1. Dry food storage should be maintained in a clean and dry area free of contaminants. 2. Refrigerator storage Safe practices include: d. Labeling, dating, and monitoring food. All food handling and safety must comply with the Texas Food Establishment Rules (TFER) and the CMS and Texas Health and Human Services Commission (HHSC) 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 § 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES SUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD (6) Wearing, where appropriate, in an effective manner, hair nets, headbands, caps, beard covers, or other effective hair restraints. TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES SUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD Subpart B - Buildings and Facilities Sec. 110.35 Sanitary operations. 5) Sanitizing agents shall be adequate and safe under conditions of use. Any facility, procedure, or machine is acceptable for cleaning and sanitizing equipment and utensils if it is established that the facility, procedure, or machine will routinely render equipment and utensils clean and provide adequate cleaning and sanitizing treatment. (e) Storage and handling of cleaned portable equipment and utensils. Cleaned and sanitized portable equipment with food-contact surfaces and utensils should be stored in a location and manner that protects food-contact surfaces from contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program with a system for preventing, identifying, and controlling infections and communicable diseases for all residents, staff, visitors, and other individuals providing services based upon national standards for 1 (A-Tower) of 2 halls reviewed for infection control. The facility failed to have an effective protocol in place to prevent the spread of COVID-19 that followed nationally accepted standards for contact tracing testing or broad-based testing after CNA A tested positive for COVID-19 on 12/29/23. The facility had not implemented testing on days 1, 3, or 5 to identify others who may have been exposed. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: Interview on 01/10/24 at 8:50 AM with the Administrator and DON revealed the facility did not have any COVID positive cases. The DON stated CNA A tested positive for COVID on 12/29/23. The Administrator and the DON stated CNA A was on vacation for 4-5 days prior to testing positive, her last day of work was on 12/24/23. The DON stated CNA A was assigned to A-Tower prior to testing positive. The DON stated they were only testing symptomatic staff and residents, and they tested anyone who had close contact with CNA A. Observation on 01/10/24 between 9:40 AM - 10:30 AM of A-Tower revealed no observations of residents showing any symptoms of COVID-19. There were 24 residents residing on A-Tower. Interview on 01/10/24 at 12:20 PM with LVN B revealed she was the assigned nurse for A-Tower. She stated CNA A was one of the CNAs assigned to her hall. She stated residents had been tested for COVID-19; however, she could not recall when the last time they were tested. She stated they have COVID tests available to use for resident who show symptoms of COVID. Interview on 01/10/24 at 12:26 PM with LVN C revealed he was the nurse assigned to B-Tower. He stated the facility was only testing residents who were showing signs and symptoms of COVID. He stated they have tests available at the facility. He stated if a resident is exposed for COVID they would monitor for signs and symptoms of COVID and if they do have symptoms they would test. He stated staff and residents had not been tested and could not recall when the last time a resident was tested for COVID. Interview on 01/10/24 at 12:37 PM with CNA A revealed she had tested positive for COVID on 12/29/23. CNA A stated the last time she worked was Tuesday (12/26/23), she stated she was assigned to A-Tower. She stated she had close contact with residents on A-Tower. CNA A stated on 12/25/23 she felt congested, she stated she thought it was allergies. She stated she wore a surgical mask on 12/25/23 and 12/26/23. CNA A stated she was not on vacation. CNA A stated on 12/29/23 she notified the facility of her positive results. CNA A stated she returned to work on 01/03/24. She stated she did not and was not tested on [DATE] when she returned to work. CNA A stated she was not sure if the facility tested the residents who reside on A-tower who she had close contact with on 12/25/23 and 12/26/23. Interview on 01/10/24 at 1:18 PM with the ADON revealed she was the infection preventionist and was responsible for infection control for the facility. The ADON said the residents and staff were only tested for COVID if they showed signs and symptoms of COVID. She stated CNA A tested positive for COVID on 12/29/23, and only 1 additional staff was tested for COVID because she was roommates with CNA A. She stated they had not tested any residents since 12/19/23. The ADON stated they were only testing residents who were symptomatic per facility policy and CDC guidelines. She stated the facility corporate office reviews the CDC guidelines and would update the facility policies and would notify them of any updates. She stated she had not received any updates to their polices. The ADON stated she was not sure what the CDC recommended at the time, but the facility would follow the recommendations of the CDC. The ADON and Surveyor reviewed the CDC guidelines and the ADON stated she was not aware that the recommendations were to test on the 1st, 3rd, 5th day. The ADON stated the potential risk would all be there due to residents always having visitors; however, she stated the potential risk would be an outbreak if residents were exposed to COVID. Interview on 01/10/24 at 2:15 PM with the DON revealed corporate office and ADON were responsible for reviewing the CDC guidelines and any updates regarding COVID-19. She stated after reviewing the nursing schedules for 12/25/23 and 12/26/23, CNA A's last day of work was on 12/26/23. She stated CNA A was not on vacation. She stated until this day (1/10/24) she had not seen can A's positive test. The DON said she did not test CNA A prior to returning to work and she did not test residents who had close contact with CNA A on 12/25/23 and 12/26/23. She stated she was unaware of the CDC guidelines regarding testing staff and residents who were exposed to COVID-19. The DON stated they were only following the facility policy to only test residents who were showing signs and symptoms of COVID. The DON stated there would always be a potential risk of an outbreak of any illness; however, if they had someone that became symptomatic, the facility would have tested. Interview on 01/10/24 at 2:20PM with the Administrator revealed it was the responsibility of corporate office and the facility staff to review the CDC guidelines and any updates. The Administrator stated they follow facility policy regarding symptomatic residents. He stated the facility monitors all residents for signs and symptoms of COVID. He stated the CDC guidelines are just recommendations and they follow facility policy. Review of facility's The Sign-In Sheet dated 12/25/23 and 12/26/23 revealed CNA A worked on 12/25/23, 12/26/23 and was assigned to A- Tower middle section. Review of facility line list COVID positive Residents/Staff List revealed CNA A was positive for COVID-19 on 12/29/23. Review of facility's Pandemic Policy (COVID-19), revised date 02/27/23 reflected the following: It is the policy of this community to minimize exposures to respiratory pathogens and promptly identify residents, visitors and team members with clinical features and an epidemiologic risk for the COVID-19. We will adhere to federal and state/local recommendations that protect our residents and team members from the spread of infectious disease, including COVID-19 and COVID-19 variants . Skilled follow CDC guidance for Health care Settings: Quarantine will apply to residents who are not up to date with all recommended COVID-19 vaccine dose and who have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine after their exposure even if viral testing is negative. Team members caring for confirmed or suspected COVID-19 residents should use full PPE. Residents can be removed from Transmission-Based Precautions after day ten following the exposure (day 0) if they do not develop symptoms. Although the residual risk of infection is low, healthcare providers could consider testing for SARS-CoV-2 within 48 hours before the time of planned discontinuation of Transmission-Based Precautions. Team Members are required to immediately report symptoms of infectious/contagious illness or possibility of exposure to COVID-19 to his or her direct supervisor and the community director of human resources. The Infection Preventionist or Director of Nursing will collaborate with the team member to identify individuals, equipment, and locations the team member encountered. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated on 05/08/23, accessed on 01/10/24 on the CDC website reflected: .Nursing Homes .Stay connected with the healthcare-associated infection program in your state health department, as well as your local health department, and their notification requirements. Report SARS-CoV-2 infection data to National Healthcare Safety Network (NHSN) Long-term Care Facility (LTCF) COVID-19 Module. See Centers for Medicare & Medicaid Services (CMS) COVID-19 reporting requirements. Section 2. Placement of residents with suspected or confirmed SARS-CoV-2 infection Ideally, residents should be placed in a single-person room as described in Section If limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location. Responding to a newly identified SARS-CoV-2-infected HCP or resident When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP are not generally necessary unless residents meet the criteria described in Section 2 or HCP meet criteria in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. However, source control should be worn by all individuals being tested. In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of Empiric use of Transmission-Based Precautions for residents and work restriction of HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction's public authority recommends these and additional precautions. If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that 1 (Resident #188) of 1 resident who is fed by enteral means, received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #188) of 3 residents reviewed for enteral feeding. The Facility failed to ensure Resident #188's feeding bag was dated as per facility' policy. This failure could place the residents at risk for nutritional problems. Findings included: Review of Resident #188's Face Sheet, dated 08/10/23, revealed resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included disorders of electrolyte imbalance and fluid balance, other specified anemias, essential hypertension, and personal history of other malignant neoplasm of large intestine. Review of Resident #188's Physician's Order dated 08/01/2023 reflected, feeding by pump Osmolite 1.5 cal @ 60 ml/hr via peg-tube continuous for 22/hrs/day. (May use Jevity 1.5 cal if Osmolite is unavailable). Review of Resident #188's admission MDS, dated [DATE] reflected that resident had severe cognitive impairment with a BIMS score of 07. Resident required extensive assistance of two staff for bed mobility, transfer, locomotion off unit, dressing, toilet use, and personal hygiene. Record review of Resident #188's Comprehensive Care Plan, dated 08/02/2023 revealed that resident requires tube feeding and interventions were the resident needs assistance with tube feeding and water flushes . See MD orders for current feeding orders. Observation on 08/08/2023 at 12:01 PM revealed Resident #188 was in bed resting with Jevity 1.5 cal plus hydration continuous feeding via peg-tube with feeding rate of 60 ml per hour. Feeding initiated at 02:00 AM, 515 ml of feeding formula left at 12:01 PM. Bed was raised to 45 degrees angle. The feeding formula was timed but was not dated. Interview with the DON on 08/10/2023 at 09:16 AM, DON stated that it was important to know when the feeding formula was hung. This was to know how long it had been there and to ensure that the formula was in its best quality. If not dated and timed, the resident might not be receiving the adequate amount of nutrition needed or the feeding formula is stale already and no one knew because there was no date and time. The DON stated that going forward these would be added to the daily rounds and would keep on reminding the staff to adhere to the policies. Interview with the Administrator on 08/10/2023 at 11:10 AM administrator stated that all staff must observe and follow the best practice for the residents to have a high quality of care. Record review of the facility policy, Enteral Feedings - Safety Precautions, rev. May 2014 revealed Preparation 1. All personnel responsible for preparing, storing, and administering enteral nutrition formula will be trained, qualified and competent in his or her responsibilities . Preventing errors in administration 1. Check enteral nutrition label . Check the following information: . c. Date and time formula was prepared . 2. On the formula label document initials, date, and time the formula was hung/administered, and initial that the label was checked against the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 (Resident #4) of 3 residents observed for infection control. The facility failed to ensure that the two prongs of Resident #4's nasal cannula (a device used to deliver supplemental oxygen to an individual. It consists of a lightweight tube on which one is connected to the oxygen source and the other end splits into two prongs and are placed in the nostrils) was off the floor and not touching any surface when not in use. This failure could place the residents at risk of cross-contamination and infections. Findings included: Review of Resident #4's Face Sheet, dated 08/10/23, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified moderate Dementia, acute chronic systolic (Congestive) heart failure, unspecified anemia, and shortness of breath. Review of Resident #4's Physician's Order dated 7/24/2023 reflected, O2 at _3_L/Min via nasal cannula as needed for SOB. Review of Resident #4's admission MDS, dated [DATE] reflected resident had a severe cognitive impairment with a BIMS score of 04. She required supervision for eating and extensive assistance of two staff for bed mobility, transfer, locomotion on unit, dressing, toilet use, and personal hygiene. Record review of Resident #4's Comprehensive Care Plan, dated 07/21/2023 revealed that she had a Congestive Heart Failure and interventions were . monitor/document for labored breathing . monitor/document/report PRN any s/sx of Congestive Heart Failure . SOB upon exertion . Observation on 08/08/2023 at 11:09 AM revealed Resident #4 was on her bed resting with O2 at 3 liters per minute via nasal cannula attached to an oxygen concentrator. It was also observed that she had an oxygen tank at the back of her wheelchair with a nasal cannula attached. The prongs of the nasal cannula on the wheelchair was hanging on the backrest of the wheelchair with the prongs touching the surface of the backrest. Observation on 08/09/2023 at 08:34 AM revealed Resident #4 was eating breakfast. Oxygen tank was still at the back of the wheelchair with a nasal cannula attached. The prongs of the nasal cannula were touching the floor. Interview with LVN O on 08/09/2023 at 9:21 AM, LVN O stated that the cannula should not be touching the floor. LVN O further stated that the cannula should be changed immediately before the resident uses it. This could result to infection to residents that did not have any infection or more medical issues for residents that were already sick. LVN O has been with the facility for almost five years and also stated that he works on the weekend. LVN O said that all staff should ensure that the nasal cannula is free from contaminations. Interview with CNA D on 08/09/2023 at 10:03 AM, CNA D stated the CNAs put on the nasal cannula when a resident was transferred to the wheelchair. If the nasal cannula was not clean or seen touching the floor, it should be reported to the nurse so it could be changed. CNA D added that nasal cannula on the floor could cause infection and particles from the floor could enter the opening and could cause blockage. Interview with the ADON on 08/09/2023 at 11:08 AM, ADON stated that the nasal cannula should not be touching any surface or be on the floor when not in use. ADON stated that it could cause infection and pulmonary issues, and other medical issues. Interview with CNA R on 08/10/2023 at 9:04 AM, she stated that before transferring a resident that uses O2, the staff should ensure that an Oxygen tank and nasal cannula were on the wheelchair. CNA R stated that the nasal cannula should be clean and kept clean because it would cause a lot of medical issues. If the nasal cannula was seen on the floor, it should be changed. Interview with the DON on 08/10/2023 at 9:16 AM, DON stated that using contaminated cannula could develop infection. It should not be touching any surface and should be bagged when not in use. Her expectation was that all the staff would follow Infection Prevention Protocol. Record review of facility policy, Equipment, Cleaning, rev. 05/2007, Policy It is the policy of this facility to implement the follow procedures to ensure equipment is cleaned and cared for appropriately. Procedures: 1. Reusable resident items are cleaned and disinfected for residents . 4 . disinfectants will be utilized for non-critical items.

**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 2 of 2 residents (Resident #4 and Resident #23) reviewed for respiratory care. The facility failed to ensure Resident #4's (two tubings) and Resident #23's (one tubing) nasal cannula tubing were dated. This failure could place residents at risk of not having their respiratory needs met. Findings included: Review of Resident #4's Face Sheet, dated 08/10/23, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included Unspecified Moderate Dementia, Acute Chronic Systolic (Congestive) Heart Failure, Unspecified Anemia, and Shortness of Breath. Review of Resident #4's Physician's Order dated 7/24/2023 reflected, O2 at _3_L/Min via nasal cannula as needed for SOB. Review of Resident #4's admission MDS, dated [DATE] reflected she was cognitively impaired with a BIMS score of 04. She required supervision for eating and extensive assistance of two staff for bed mobility, transfer, locomotion on unit, dressing, toilet use, and personal hygiene. Record review of Resident #4's Comprehensive Care Plan, dated 07/21/2023 revealed that she had a Congestive Heart Failure and interventions were . monitor/document for labored breathing . monitor/document/report PRN any s/sx of Congestive Heart Failure . SOB upon exertion . Review of Resident #23's Face Sheet, dated 08/10/23, revealed a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified systolic (Congestive) heart failure, chronic respiratory failure, unspecified chronic obstructive pulmonary disease (COPD), and unspecified anemia. Review of Resident #23's Physician's Order dated 07/28/2023 reflected, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML, 3 milliliter inhale orally every 4 hours as needed for SOB or Wheezing via nebulizer. Review of Resident #23's Physician's Order dated 7/26/2023 reflected, O2 at _3_L/Min via nasal cannula every shift. Review of Resident #23's Physician's Order dated 7/30/2023 reflected, Change Oxygen Tubing & Bubblers every night shift every Sunday. Review of Resident #23's admission MDS, dated [DATE] reflected resident was moderately impaired cognitively with a BIMS score of 09. She required supervision for eating, limited assistance for locomotion on unit and extensive assistance of two staff for bed mobility, transfer, locomotion off unit, dressing, toilet use, and personal hygiene. Record review of Resident #23's Comprehensive Care Plan, dated 07/21/2023 revealed that resident has COPD and chronic respiratory failure with hypoxia (low level of oxygen in body tissues) and interventions were Give aerosol or bronchodilators as ordered . Monitor for difficulty breathing (Dyspnea) on exertion .Monitor for s/sx of acute respiratory insufficiency .Monitor/document/report PRN any s/sx of respiratory infection .OXYGEN SETTINGS: O2 via NC@3L /m Observation on 08/08/2023 at 11:09 AM revealed Resident #4 was on her bed resting with O2 at 3 liters per minute via nasal cannula. The tubing the resident was using was attached to the oxygen concentrator. It was also observed that she had an oxygen tank at the back of her wheelchair with a nasal cannula attached. Both tubings of the nasal cannula connected to the oxygen concentrator and the tubing attached to the oxygen tank at the back of the wheelchair had no dates of when the tubings were last changed. Observation on 08/08/2023 at 10:49 AM revealed Resident #23 was on wheelchair talking to her family member, on O2 at 3 liters per minute via nasal cannula. The nasal cannula was connected to an oxygen concentrator. The tubing had no date of when it was last changed. Interview with Resident #23 on 08/08/2023 at 10:49 AM, resident #23 stated that the nasal cannula was not changed on a weekly basis. Resident #23 added that she seldom saw the nasal cannula being changed. Interview with LVN O on 08/09/2023 at 9:21 AM, LVN O stated that the tubing should be changed routinely because it was made of plastic and was prone to cracking and leaking thus reducing the amount of oxygen being delivered. LVN O also added that old tubings could be a breeding ground for bacterial growth. LVN O stated that any nurse could change the nasal cannula as scheduled or as needed and put the date on it. LVN O stated that he did not notice that the tubing has no date. Interview with the ADON on 08/09/2023 at 11:08 AM, ADON stated that her expectation would be that the nasal cannula should be changed weekly. The ADON stated that not changing the tubing could lead to infection. Bacteria could remain on the tube and could cause the resident to be sicker. Interview with the DON on 08/10/2023 at 9:16 AM, DON stated that she was made aware by the ADON about the tubings not dated. The DON verbalized that it was important to change the tubings so there won't be a buildup of bacteria that could lead to infection. It should be dated to show that the tubing was changed and to know when it should be changed again. The DON said that the staff should follow the policy and the best standard. Record review of facility policy, Oxygen Administration, rev. October 2010 revealed The purpose of this procedure is to provide guidelines for safe oxygen administration . After completing the oxygen set-up . The date and time that procedure was performed.

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 kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerator, and freezer were stored and dated according to guidelines. The facility failed to ensure that staff was wearing the proper head and face coverings when serving food. The facility failed to ensure proper discarding of expired food stored in the refrigerator and freezer storage area. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observation on 08/08/23 at 09:20 AM included: One Pitcher of juice (Unknown) unlabeled and undated in the refrigerator. One package of six English Muffins with expiration date of 05/06/23 in the refrigerator. One large fruit platter of grapes, pineapples, strawberries, cantaloupes, and berries was unlabeled and undated in the refrigerator. One quart pitcher of Caesar dressing was undated in the refrigerator. One quart pitcher of Balsamic Vinaigrette dressing was undated in the refrigerator. One quart pitcher of Ranch dressing was undated in the refrigerator One quart pitcher of Blue Cheese dressing was undated in the refrigerator One quart pitcher of Italian dressing was undated in the refrigerator One quart pitcher of Raspberry Vinaigrette dressing was undated in the refrigerator One quart pitcher of Honey Mustard dressing was undated in the refrigerator One 5lb. bag of fries was unlabeled and undated in the refrigerator One 5lb. bag of fries was unsealed, unlabeled and undated in the refrigerator Two large trays of cookies or biscuits was exposed, unlabeled, and undated Five large boxes of potatoes were stored under a cooking preparation table located in the main kitchen of the facility. One large box of bananas was stored under a cooking preparation table and near a cleaning bucket located in the main kitchen of the facility. One tray of bread located in the dry storage room was unsealed. One large container of sugar appeared to have two small dark in color bugs observed laying on the top surface located in the dry storage room. One large container of gluten free flour located in the dry storage room, observed with a lid that had a lot of dirt particles all over it. One large container of Buffalo Sauce was observed to have a Good Thru Date of 08/02/23 Interview and observation with Executive Chef B on 08/08/23 at 09:15 AM revealed he was observed working in the Main kitchen of the facility on the 11th floor with no head cover on. Executive Chef B had hair on his head that measured approximately an inch in length that was uncovered. He advised that he was aware he should have had a head cover on, but stated he was not wearing one because he was not preparing food. He was advised that he was observed preparing for lunch and he did not reply. He stated the risk of not wearing a head covering could result in food contamination and residents getting sick. Interview with Sous Chef P on 08/08/23 at 09:20 AM in the main kitchen of the facility revealed he was shown the concerns observed in the kitchen. He stated that he would have them corrected immediately. He advised the risk of these concerns being present could result in food borne illnesses. He advised that Executive Chef B was responsible for managing the kitchen. Interview and observation with Culinary Server L on 08/08/23 at 11:30 AM revealed he was observed working in the Sub kitchen of the third floor, plating food for residents, with no beard cover on. Culinary Server L had a beard of about an inch in length that was uncovered. He advised that he was aware he should have had a beard cover on, but forgot to put one on. He stated the risk of not wearing a beard covering could result in hair falling in the food and residents getting sick. Interview and Observation with Culinary Lead V on 08/10/23 at 10:30 AM revealed, she was observed entering and exiting the facility's main kitchen, while food was being prepared with no head cover on. Culinary Lead V had long braids going down her back that was exposed. She stated she should have had her hair covered but was only in the kitchen briefly. She stated the risk of not covering her hair could be hair transferring to food and residents getting sick. Interview with Executive Chef B on 08/10/23 at 10:45 AM. he was shown pictures of the concerns discovered during the initial walk through of the facility's main kitchen on the 11th floor. He stated that he was made aware of the findings by Sous Chef P, and had corrected all of them. He stated that he was overall responsible for ensuring proper dating and labeling of foods and he was also overall responsible for ensuring food was covered appropriately and expired food was discarded. He stated he thought the head covering were being worn appropriately and thought staff complied. He stated he would ensure staff covered their entire hair and facial hair. He stated that all of these concerns were a threat to the residents because they could get sick. He stated that they were contracted and often follow Assisted Living Guideline but understand that they also had to follow guidelines for Skilled Nursing. Interview with the Administrator on 08/10/23 at 10:55 AM, he was shown the pictures of the concerns discovered in the main kitchen of the facility, on the 11th floor, and he was advised of the concerns of some kitchen staff members not wearing the appropriate hair and beard coverings. He advised that the Kitchen staff were contracted, and he would communicate the concerns to the contracted company's department leadership. He advised the risk of the concerns identified could result in food contamination and residents getting ill. Review of the Facility policy and Procedure on Safety and Sanitation dated 02/2018, referencing Hair Restraints/Beard Guards revealed, Hair nets must be worn by all who are in the kitchen production areas. As an alternative, team members may wear an approved Unidine hat. Beards are not recommended for any team members who handles food; however, if a team member had a beard/Facial Hair ¼ growth or more, then a beard guard must be worn at all times while in the kitchen and/or handling food. The product should not be consumed after the date on the package due to the product's perishable nature and the product should be disposed of. Foods that have been opened or prepared must be covered. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. Processed reduced oxygen foods that exceed the use-by date or manufacturer's pull date cannot be sold in any form and must be disposed of in a proper manner. All equipment and utensils must be cleaned and sanitized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all drugs and biological medications were labeled to include the expiration date and failed to ensure medications had acceptable labeling for one (Hall A Medication Cart) of two medication carts reviewed for labeling and storage. The facility failed to ensure insulin vials were dated after they were opened. This failure could place residents at risk of not receiving the therapeutic dose of medication. Findings included: Observation of the medication cart for Hall A on [DATE] at 11:29 AM revealed, one insulin vial, lispro 100 unit/ml which was opened, partially used, and not labeled with the open date . Interview on [DATE] at 11:38 AM with RN A, who was the charge nurse for Hall A, revealed she knew insulin pens/vials were supposed to be dated once they were opened or after they were removed from the refrigerator and placed on the cart. She stated she knew she was supposed to check her cart every time she reported to work to ensure insulins were labeled and dated. She stated the side effects of giving expired medication was they will not work and will not be effective. She stated she has not been trained on labeling and dating the insulins since she has been working for the three months, but she knew it was the best standard of practice to label and put an opening date on insulin vials once opened. Interview on [DATE] at 12:41 PM with the DON revealed it was her expectation that staff date the insulin pens once they pulled them from the refrigerator, but it was all nurses responsibility to check the carts and ensure insulins were dated and labeled. She stated it was her responsibility to monitor and she stated pharmacist also checked the carts during his monthly visits. She stated if the staff were not putting the opening dates on the insulin pens and vials that required an opening date it placed residents at risk of having reactions like the medication being ineffective since they cannot tell of the potency. Review of the facility's policy storage of medications, revised [DATE], reflected: the facility should ensure that medications and biologicals that 10 have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines:or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier .Once any medication or biological package is opened, facility should follow manufactures /supplier guidelines with respect to expiration dates for opened medications . Facility staff should record the date opened on the primary medication container (vial bottle, inhaler) when the medication has a shortened expiration date once opened or opened. If a multi dose vial of an injectable medication has been opened or accessed (e.g., needle punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer ) date for that opened bottle.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for one (medication cart for Halls B) of two medication carts and for two (medication room for Halls A and B) of two medication rooms reviewed for pharmacy services. The facility failed to ensure expired medications in nurses medication carts for hall B and medication rooms for halls A and B were removed and destroyed. This failure could place residents at risk of not receiving the therapeutic dose of medication. Findings included: Observation of the medication cart for Hall B on 06/27/22 at 11:47 AM revealed, one bottle of nitroglycerin 0.4 mg with expiration date of February 2022. Observation of the medication room for Hall B on 06/27/22 at 11:59 AM revealed, one bottle of Coenzyme Q10 with an expiration date of April 2022 and one box of Arginaid 4.5 grams with an expiration date of 05/15/22. Observation of the medication room for Hall A on 06/27/22 at 12:28 PM revealed, one bottle of Daily multivitamin with expiration date of August 2021, one bottle of Vitamin E with expiration date of January 2022 and one bottle magnesium chloride with an expiration date of August 2021. Interview on 06/27/22 at 11:56 AM with LVN B, regarding the medication cart and medication room for hall B, revealed she knew it was the nurses' responsibility to check the medication cart and medication storage for the expired medication, but she stated it was the responsibility of the night shift nurses to check the carts and remove all expired medications for destruction. She stated they had posting in the medication rooms that acts as reminders for the nurses. She denied receiving any training regarding labeling and storage, but she stated she knew it was a standard practice to check carts for expired medications. Interview on 06/27/22 at 12:34 PM with RN A, regarding the medication room for hall A, revealed she knew it was the nurses' responsibility to check the medication room for the expired medication, but she stated it was the responsibility of the night shift nurses to ensure medication rooms are free from expired medication. She stated failure to remove them, and the resident get them they will not get the expected therapy and, they can have side effects on residents. Interview on 06/27/22 at 12:41 PM with the DON revealed it was the responsibility of the night shift nurses to check and ensure that the medications in the medication stores and carts were not expired. She stated it was her responsibility to monitor and nurses are expected to check the carts and medication rooms every night .she had posted a note to show the night shift was responsible, and it was her responsibility to follow-up and ensure the nurses were doing what was expected of them, but she had not done that in a while. She stated failure to check on expiration dates could lead to a resident not getting the expected therapy on those medications. She stated she had not done any in-service on expired medications that is documented but she reminds staffs verbally on expiration dates and labeling. She stated she had not done any training because she did not think there was a need since she had not noted any problem. Interview on 06/28/22 at 11:23 AM with LVN C, who worked on night shift, revealed she knew it was the night nurses' responsibility to check the medication cart and medication storage for the expired medication, but she did not check because she had a busy night and she forgot. She stated they had posting in the medication rooms that acts as reminders for the nurses. She stated the worst that can happen if the expired medications were not removed on the carts and medication rooms and were administered to resident, the residents could develop an adverse reaction and the medications could be less potent. Review of the facility's policy storage of medications, revised January 2022, reflected: the facility should ensure that medications and biologicals that 10 have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines: or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. Medications with a manufactures expiration date expressed in month and year (e.g., May 2022) will expire the last day of the month. Facility should ensure the medications and the biologicals for expired, or discharged or hospitalized residents are stored separately, way from use ,until destroyed or returned to the provider. Facility personnel should inspect nursing stations storage areas for proper storage compliance on a regular scheduled basis.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 (Kitchens #1 and #2) of two kitchens in that: 1. There were unlabeled and/or unsealed, and expired food items in the main kitchen on the 11th floor (Kitchen #1). 2. There were unlabeled and/or unsealed, and expired food items on the 3rd floor kitchen (Kitchen #2). 3. Culinary Aides were not wearing hairnets or following proper infection control in the kitchen. Findings included: Observation on 06/26/22 at 9:45 AM of Kitchen #1 refrigerator revealed expired spoiled cantaloupe that had brown and black spots. The black spots were softer than other spots of the cantaloupe. A container labeled pitted olives with dates 05/01/22 to 05/07/22. Four bags that appeared to be meat in freezer not labeled and unsealed. Out of the four bags, two bags were clear and twisted at the top, one bag was a paper brown bag folded over and one gray plastic grocery store bag tied at top. Interview on 06/26/22 at 10:00 AM with Chef A revealed he started working at the facility on 06/20/22. The refrigerator and freezer were checked daily for expired food by all culinary staff. Chef A stated residents could become ill from eating expired food. Observation on 06/26/22 at 10:45 AM of Kitchen #2 refrigerator and freezer revealed: Mixed melon container with no date, expired cherry tomatoes dated 06/21/22 to 06/24/22, shredded cheese not sealed and undated, yogurt and soda beverages not labeled with resident's names and dates. Interview on 06/26/22 at 10:55 AM with Culinary Aide A in Kitchen #2 revealed she has worked in the facility for seven years. All culinary staff in Kitchen B are responsible and expected to check for expired foods at the end of their shift. All culinary staff in Kitchen B are responsible for labeling food before putting in the refrigerator. Hairnets are always worn in the kitchen. Observation on 06/26/22 at 1:00 PM revealed Culinary Aide A worked in Kitchen #2. Culinary Aide B was in kitchen preparing plate for resident with no hairnet or gloves and went back into the dining room. Culinary Aide C had on facemask not covering nose, and no hairnet and was preparing food. Culinary Aide D had no face mask and no hairnet. Culinary Aide E, came from dining room to kitchen to prepare food to go with a resident, did not wash hands before preparing food, was not wearing hairnet or gloves. Interview on 06/26/22 at 1:30 PM revealed Culinary Aide A had worked at the facility three years temporary and two years with company. Culinary Aide A revealed, hairnets are supposed to be worn in the kitchen when fixing residents foods. Culinary staff check fridge and freezer temperatures daily and for expired food. Interview on 06/26/22 at 1:38 PM revealed Culinary Aide B started orientation on Wednesday 06/22/22 and had not had in-service on hairnets. Culinary Aide B stated if a hairnet was not worn hair could get in the resident's food. Interview on 06/26/22 at 1:45 PM with Culinary Aide C revealed she has worked in the facility for five days. Culinary Aide C stated, she has been In-service on wearing a hairnet and infection control . Culinary Aide C revealed, anytime they were in the kitchen they were supposed to wear a hair net. Culinary Aide C stated food could fall into food and can be gross. Culinary Aide C stated she knew hairnets should be worn. Interview on 06/26/22 at 1:56 PM with Culinary Aide D revealed hairnets were located on the wall as you walk into the kitchen. Culinary Aide D stated hairnets are to always be worn in the kitchen. He has not had infection control training. Interview on 06/26/22 at 2:05 PM with Culinary Aide E revealed he had been working for the facility for two years and has not been in-service on wearing a hairnet or infection control. Interview on 06/26/22 at 2:20 PM Dining Room Manager revealed an in-service was done last month on hairnets and infection control. Dining room manager reported that staff working behind the lines in the kitchen should be wearing gloves when serving, face mask and hairnet. The Dining Room Manager reported this was mandated recently. Interview on 06/28/22 at 4:00 PM with Culinary Coach revealed she did not have any answers to questions about Kitchen A and Kitchen B policy and procedures and called the Culinary Director. The Culinary Director did not interview. Chef B was called on the phone by the Culinary Coach, and he came into the dining room to interview. Interview on 6/28/22 at 4:15 PM with Chef B revealed Chef B has been working in the facility for two months. Chef B reported culinary servers were not supposed to go past the steam tables without wearing hair nets. Chef B stated production staff should be fixing extra plates. Review of the facility's policy on food safety labeling procedures dated 12/15/20 reflected: In addition to writing the date to use by on the label, also apply the current day's date. The number of days to use the product includes the current day the product is prepare Cover, label and date unused portions and open packages. Complete all sections on a .date label or use an approved labeling system. Products are good through the close of business on the date noted on the label. Review of the facility's policy on refrigerated food dated 12/15/20 reflected: unused portions of canned fruits and vegetables transferred to clean approved storage containers label and date container .sort produce daily to remove spoiled pieces . Review of the facility's Safety and Sanitation policy and procedure revised Febuary 2018, reflected: hairnets must be worn by all who are in the kitchen production area. As alternative, team members may wear an approved Undine hat. Review of the facility's policy on resident food from the outside community policy dated 01/01/21, reflected: any food or beverage that is not labeled with resident name and dated will be discarded immediately Review of the US FDA Food Code, dated 2017, reflected the following: FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.