**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 18 residents (Residents #30 and #59) reviewed for care plans. 1. The facility failed to revise Resident #30's comprehensive care plan to reflect the resident's change in cognitive status. 2. The facility failed to revise Resident #59's comprehensive care plan to reflect the resident's discontinued use of anti-depressant medication. These deficient practices could cause confusion for staff members responsible for providing direct care for residents and medication administration and place residents at risk of receiving improper care. The findings were: 1. Record review of Resident #30's face sheet, accessed on 12/11/2024, revealed the resident was an [AGE] year old female admitted to the facility on [DATE] and again on 08/11/2024 with diagnoses including hypokalemia (a condition where the potassium levels in the blood are lower than normal), cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die), and type II diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin, leading to high blood sugar levels). Record review of Resident #30's quarterly MDS assessment dated [DATE] revealed a BIMS of 15, indicating the resident had full cognition. Record review of Resident #30's comprehensive care plan, last review completed 12/06/2024, revealed a focus area indicating: I have impaired cognitive function or impaired thought process r/t CVA. LOW BIMS SCORE 8. Date Initiated: 06/11/2024. Created on: 06/11/2024. Created by: ADON. Revision on: 06/27/2024. The goal was to maintain the current level of cognitive function, and interventions/tasks included keeping the resident's routine consistent and to provide consistent caregivers as much as possible to reduce confusion, administer medications as ordered, ask yes/no questions and break tasks into one step at a time. During an interview on 12/12/2024 at 12:45 PM, the ADON stated Resident #30's comprehensive care plan did not reflect her current cognitive status and should have been updated to indicate her improved cognition. The facility hired a new social worker within the past two months who completed the most recent assessment for this resident and did not make her aware there had been a change in the resident's cognition level. During an interview on 12/12/2024 at 1:30 PM, the DON stated Resident #30's cognition had been moderately impaired due to a stroke but it had improved since her last assessment and the resident's comprehensive care plan should have been updated by the ADON, who was responsible for updating care plans, to reflect the change. 2. Record review of Resident #59's face sheet, accessed on 12/12/2024, revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses including dementia (a brain disorder that causes a progressive decline in cognitive function, memory, thinking, and behavior), bipolar disorder (a mental health condition characterized by significant and persistent mood swings between periods of extreme elation and deep depression) and major depressive disorder (a serious mental illness that affects how people feel, think, and act). Record review of Resident #59's quarterly MDS assessment dated [DATE] revealed a BIMS of 15, indicating the resident had full cognition. Section I, Active Diagnoses, indicated I5800 Depression was checked, and Section N, Medications, N0415 High-Risk Drug Classes: Use and Indication, C - Antidepressant was not checked. Record review of Resident #59's comprehensive care plan, last review completed 11/27/2024, revealed a focus area indicating: I require anti-depressant medication r/t Dx: Depression. Date Initiated: 8/21/2023. Created on: 08/21/2023. Created by: ADON. The goal was the resident will have no complications related to anti-depressant medication, and interventions/tasks included administering medication per MD orders, educating the resident and/or family regarding all potential side effects and risk associated with psychotropic medications, and monitoring for target/behavior symptoms. Further review of this comprehensive care plan did not indicate a focus area indicating a diagnosis of depression. Record review of Resident #59's consolidated physician's orders for the month of December 2024 revealed there were no orders for any psychotropic medications. During an interview on 12/12/2024 at 12:45 PM, the ADON stated Resident #59's comprehensive care plan was incorrect. The resident was no longer taking any anti-depressant medications and this focus area should have been removed, and the diagnosis of depression should have its own focus area in the care plan to ensure interventions were in place for this diagnosis. During an interview on 12/12/2024 at 1:40 PM, the DON stated Resident #59's care plan should not have included the focus area of anti-depressant medication, which the resident was no longer taking, and instead should have included the diagnosis of depression as a focus area, with goals and interventions for this diagnosis. It was important to update comprehensive care plans to ensure proper care was provided for residents. Record review of facility policy Care Plans revised January 2023 revealed, The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs, medical condition, preventive measures .the care plan should be initiated upon admission, continued to be developed during the initial 48-72 hours, throughout the completion of the admission comprehensive assessment. The care plan should be updated and reviewed at least quarterly thereafter, then annually and with significant changes in conditions as defined in the RAI manual. Additional updates to the care plan may be done as indicated. Record review of the CMS RAI Version 3.0 Manual dated October 2019 revealed .to evaluate the information gained through both the comprehensive assessment processes in order to identify problems, causes, contributing factors, and risk factors related to the problems .the IDT must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's goals, preferences, strengths and problems.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 5 residents (Resident #62) reviewed for incontinent care, in that: The facility failed to ensure CNA C thoroughly cleaned Resident #62 while providing incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #62's face sheet, dated 12/12/2024, revealed an admission date of 06/19/2018, and a readmission date of 04/01/2024 with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood), Severe obesity, Need for assistance with personal care, Hypothyroidism (under active thyroid), Hypertension (high blood pressure), History of urinary tract infection (an infection in any part of the urinary system). Record review of Resident #62's Quarterly MDS assessment, dated 09/18/2024, revealed Resident #62 has a BIMS score of 11, which indicated mild to moderate cognitive impairment. Further review revealed Resident #62 required extensive assistance to total care with ADLs and was indicated to occasionally be incontinent of bladder and frequently incontinent of bowel. Record review of Resident #62's care plan, dated 02/17/2022, revealed a problem of I have bladder incontinence related to overactive bladder at risk for skin breakdown, with a goal of I will remain free from skin breakdown due to incontinence and brief use through the review date. Observation on 12/12/24 at 1:35 p.m. revealed, while providing incontinent care for Resident #62, CNA C did not clean the rectal area of the resident and did not clean the groin areas and upper thighs of the resident. During an interview on 12/12/2024 at 1:47 p.m. CNA C stated she did not clean between the resident's buttocks' cheeks area or the groin area. CNA C stated she should have cleaned the rectal area and groins areas. CNA C stated she was nervous. CNA C stated she received training for infection control and incontinent care within the last year. During an interview with the DON on 12/12/2024 at 2:20 p.m., the DON stated the rectal and groins areas had to be cleaned. The DON stated the ADONs and herself were the one training the staff for infection control and incontinent care and that the ADONs and herself would check the staff skills annually and as needed if a problem was noted. During an interview with the DON on 12/13/2024 at 10 a.m., the DON stated they did not have a policy/procedure describing the steps the staff had to execute during incontinent care for a female. Review of Peri-care: What Every Caregiver Needs to Know By mmLearn.org on Fri, Jun 14, 2019 revealed Moving from front to back, use warm water and a clean washcloth (or disposable wipes) to clean the perineal area. For females, this involves cleaning the inner legs, labia, and groin area while for men it requires cleaning the tip and shaft of the penis, along with the scrotum. Both men and women require cleaning of the anal area, which will involve turning the patient on his/her side.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnnel to have access to the keys for 1 of 4 medication carts ([NAME] Unit Nurse's medication cart) reviewed for storage. The facility failed to ensure LVN-F secured Resident #62's Fiasp Insulin, when it was left unattended on top of the Nurses medication cart. This failure could place residents at risk for drug diversion and accidents and hazards. Findings include: Observation on 12/12/2024 at 11:03 a.m. revealed LVN-F prepared Resident # 62's medications, which included drawing up 16 units of Fiasp Insulin into a syringe, locked the medication cart, and left the vial of Fiasp insulin on top of the medication cart, and entered Resident #62's room to administer her medications. The medication cart was out of sight from LVN-F. During an interview with LVN-F on 12/12/2024 at 11:12 a.m., LVN-F stated the vial of insulin was left out unsecured on top of the medication cart, noting she had left it out for the State Surveyor to view, but then forgot to put it back inside the medication cart before locking it. LVN-F stated medications should always be kept locked up to prevent theft of drugs, and to keep it from being accidently pushed off the cart, breaking on the floor and causing a hazard with broken glass. Interview on 12/12/2024 at 3:23 p.m. with the DON revealed she was aware of the insulin vial being left out on top of medication cart unsecured during medication administration with Resident #62, and stated each Nurse was responsiible for ensuring all medications were secured inside the medication cart unless directly supervised by the Nurse. She stated not keeping medications locked and secured could result in theft of medications. Record review of the facility policy titled Medication Cart Use and Storage revised January 2023 revealed under Guidelines 1. Security- The medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use. During administration of medications avoid placing medications of top of the cart unless pulling medications from the cart. The only exception would be if the cart and medications are within the direct line of sight of the authorized personnel. Note: Best practice is to avoid leaving medication on top of the cart. .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to properly store a 16-oz. bag of chips in the dry storage room. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 12/12/2024 at 10:10 AM revealed a 16-oz. bag of chips that had been opened, was rolled down, and stored inside a bag with a zip lock that was not closed. During an interview on 12/12/2024 at 10:11 AM, the DM stated the bag with the zip lock should have been sealed and failure to ensure it was sealed could lead to pests in the dry storage room and potential food borne illness. Record review of the facility's policy number 03.003, Food Storage, revised 06/01/2019, revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Code and HACCP guidelines. Procedure: 1. Dry storage rooms. d. to ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination.

Based on observation, interview and record review, the facility failed a to dispose of garbage and refuse properly for 1 of 2 Dumpsters (Dumpster #1) reviewed for disposal of garbage. The facility failed to ensure the sliding doors on both sides of the dumpster was completely closed. This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings were: Observation on 12/12/2024 at 10:19 AM revealed the sliding doors on both sides of Dumpster #1 were open, leaving an approximate 6 gap between the door and wall of the dumpster on both sides. During an interview on 12/12/2024 at 10:21 AM, the DM stated the doors on the sides of Dumpster #1 were both open and should not have been. It was important for the doors to be completely shut to prevent rodents from entering the dumpsters and potentially spreading foodborne illness. Record review of the facility's policy number 04.015 Garbage Receptacles, revised 06/01/2019, revealed, This facility will maintain garbage receptacles in a clean and sanitary manner to minimize the risk of food hazards. Outdoor receptacles: It shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insects and rodents with doors/lids kept closed and no waste outside of the receptacle. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (B) With tight-fitting lids or doors if kept outside the food establishment. 5-501.114 Using Drain Plugs. Drains in receptacles and waste handling units for refuse, recyclables, and returnables shall have drain plugs in place.

Based on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy for 1 of 5 residents (Resident #3) reviewed for resident rights, in that: The facility failed to ensure CNA A and LVN B completely closed Resident #3's privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #3's face sheet, dated 12/12/2024, revealed an admission date of 05/28/2007 and, a readmission date of 05/07/2014, with diagnoses which included: Dementia (decline in cognitive abilities), Epilepsy (Neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions), Moderate intellectual disabilities, and Psychosis (Difficulties determining what is real and what is not real). Record review of Resident #3's Quarterly MDS assessment, dated 09/10/2024, revealed the resident had a BIMS score of 00, which indicated he was severely cognitively impaired. Resident #3 was always incontinent of bladder and bowel and, required total care with his ADLs. Record review of Resident #3's care plan, dated 02/09/2022, revealed a problem of I have bowel/bladder incontinence related to Disease Process and at risk for skin breakdown, with an intervention of INCONTINENT: provide incontinent care as needed for incontinent episodes. Observation on 12/12/24 at 10:25 a.m. revealed CNA A and LVN B did not completely close the privacy curtains while they provided incontinent care for Resident #3, exposing the resident who could be seen from the room's door. During an interview with CNA A and LVN B on 12/12/2024 at 10:40 a.m., they confirmed the privacy curtains was not completely closed while they provided care for Resident #3 but it should have been. They stated they received resident rights training within the year. During an interview with the DON on 12/12/2024 at 2:20 p.m., the DON confirmed privacy must be provided during nursing care and Resident #3's privacy curtains should have been closed completely. She stated the staff had received training on resident rights within the year and the training was provided by the ADONs and herself. They also checked the staff skills annually and as needed. Review of Facility's policy titled Certified Nurse Aide Standards of Clinical Practice dated January 2023, revealed we believe that each resident has the right to be treated with dignity and respect and that privacy be maintained during procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 5 residents (Resident #88) observed for nursing care and 3 of 19 (residents #10, #88 and #89) reviewed for infection control, in that: 1. The facility failed to ensure CNA E washed or sanitized her hands or changed her gloves, before touching the resident #88's clean brief and after touching the soiled resident's chuck and brief. 2. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented or used while staff provided high-contact resident activities, including: catheter care for Resident #88, wound care for Resident #10, and medication administration via G-tube for Resident #89. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1. Record review of Resident #88's face sheet, dated 12/12/2024, revealed an admission date of 10/23/2023, and a readmission date of 06/01/2024, with diagnoses which included: Hypertension (high blood pressure), Need for assistance with personal care, Injury of urethra (thin tube connected to the bladder that carries urine out of the body), Chronic osteomyelitis (bone infection) right ankle and foot, History of urinary tract infection (an infection in any part of the urinary system), Obstructive uropathy (urine cannot drain through the urinary tract). Record review of Resident #88's Significant change MDS assessment, dated 10/21/2024 revealed Resident #88 had a BIMS score of 3, indicating severe cognitive impairment. Resident #88 was coded as always incontinent of bowel and had an indwelling catheter. Resident #88 required total care with his ADLs. Review of Resident #88's care plan, dated 12/22/2023, revealed a problem of I require an Indwelling Catheter, with a goal of I will not experience any complications associated with my catheter to include trauma, infection or pain, dignity concerns through my next review date. Observation on 12/12/2024 at 9:40 a.m. revealed while providing incontinent care for Resident #88, CNA E removed soiled chucks and brief from Resident #88 and, without changing her gloves or sanitizing her hands, placed and fasten new clean brief on Resident #88. During an interview with CNA E on 12/12/2024 at 9:53 a.m., CNA E verbally confirmed she did not wash or sanitize her hands or change her gloves, before touching the clean brief and fastening the brief to the resident. CNA A stated she should have changed her gloves and wash or sanitize her hands prior to placing the new brief on Resident #88. She stated the staff received infection control training regularly. During an interview with the DON on 12/12/2024 at 2:20 p.m., the DON confirmed the CNA should have washed or sanitize her hands and changed her gloves, prior to placing the clean brief under the resident to prevent risk of cross contamination and prevent infection for the resident. She stated the staff received infection control training frequently and their skills were checked yearly. The DON revealed she and her ADONs were doing spot checks to check the skills of the staff. Review of facility's policy, titled Hand washing/hand hygiene, dated January 2023, revealed Use an alcohol-based hand rub [ .] for situations such as this [ .] before moving from a contaminated/soiled to clean care or procedures [ .] after contact with blood or bodily fluid; After handling use dressing, contaminated equipment, etc. 2a. Record review of Resident #88's face sheet dated 12/13/2024 revealed he was an [AGE] year-old man, with an initial admission date of 10/23/2023 with re-admission on [DATE], with diagnoses which included: Cerebral infarction (stroke), Obstructive and reflux uropathy (blockage in urinary tract), unspecified injury of urethra and retention of urine. Record review of Resident #88's Order Summary dated 12/13/2024 revealed orders for: Foley Catheter 14-16 Fr 5-30cc, change monthly and as needed with order date of 06/03/2024; and EBP (Enhanced Barrier Precautions): Practice EBP as indicated (foley care) every shift for foley care with order date of 12/13/2024. Observation by Health Surveyor-I on 12/12/2024 at 9:40 a.m. of catheter and incontinent care being provided to Resident #88 by LVN-B and CNA-E, revealed neither staff wore a gown, just gloves, while providing catheter care, and there was no sign for EBP posted on his door or PPE supply outside Resident #88's room. b. Record review of Resident #10's face sheet dated 12/13/2024 revealed a [AGE] year-old woman with an initial admission date of 05/22/2025 and a re-admission date of 10/13/2023 and diagnoses which included: Dementia (loss of cognitive functioning that interferes with daily life) and Type 2 Diabetes Mellitus (chronic condition leading to high blood sugar levels). Record review of Resident #10's order summary dated 12/13/2024 revealed an order for Right foot 5th: cleanse with wound cleanser apply skin prep and cover with dressing daily and PRN removal /soiling. Observation by Health Surveyor-I on 12/12/2024 at 1:27 p.m. of wound care being provided to Resident #10 by LVN-F revealed LVN-F did not wear a gown, just gloves while providing wound care to Resident #10, and there was no sign for EBP on the door and no PPE supply available outside her room. c. Record review of Resident #89's face sheet dated 12/13/2024 revealed she was an [AGE] year-old woman with an initial admission date of 11/17/2024 and re-admission on [DATE], with diagnoses that included: Hemiplegia and hemiparesis (one-side paralysis or weakness) following cerebral infarction (stroke) affecting left non-dominant side, dysphagia (inability to swallow safely); and artificial opening status (feeding tube into small intestine to for medication administration and nutrition) Record review of Resident #89's Care Plan initiated 11/18/2024 revealed a focus area for feeding tube r/t [related to] dysphagia. Observation on 12/13/2024 at 7:11 a.m. revealed LVN-H did not wear a gown, just gloves while administering medications via a -tube to Resident #89. There was no EBP sign posted on Resident #89's door, and no PPE supply available outside her room. During an interview with LVN-H on 12/13/2024 at 7:39 a.m., LVN-H revealed she had never heard of or had been trained on EBP and did not know what these precautions entailed. LVN-H stated she had received training on medication administration and had passed a competency check done by the ADON on medication administration including via G-tube. This training did not include training on EBP. Record review of LVN-H's competency checklist dated 9/20/2024 revealed she had been checked off as meeting criteria on infection control, which included isolation techniques, and Medication Administration including by feeding tube. During an interview with ADON-G on 12/13/2024 at 7:45 a.m., ADON-G stated they had not yet implemented Enhanced Barrier Precautions at the facility, and stated she would immediately be getting EBP signs posted, and PPE supply units placed outside all residents room's who require EBP. Interview on 12/13/2024 at 10:40 a.m. with the DON revealed she confirmed that EBP was included in the facility Infection Control Policy to be used during high-contact activities for residents with wounds or in-dwelling devices. The DON also confirmed that there were no EBP signs or PPE supplies available outside resident's room who had wounds or in-dwelling devices, and that staff had not been trained on EBP, but had no answer other than it just fell through the cracks for why EBP precautions had not been implemented at the facility. Record review of the facility policy titled Infection Prevention and Control revised April 2024, Under Section II. Categories: Types of Isolation Precautions revealed EBP may be indicated as a recommendation by the CDC (when contact precautions do not otherwise apply) for residents with the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Further review revealed: Resident/Patients with the following clinical indication should be under EBP: Significant Wounds such as chronic wounds, ulcers, open PUI or complicated/non-healing surgical incisions or wounds, and/or open wounds requiring a dressing .and Indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. Record review of CMS Memorandum dated 3/20/2024 from Director, Quality, Safety and Oversight Group (QSOG), Subject: Enhanced Barrier Precautions in Nursing Home revealed that CMS was issuing new guidance for State Survey Agencies and LTC facilities on use of [NAME] to align with nationally accepted standards. The Memorandum included: EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact care activities regardless of their multidrug-resistant organism status. The new guidance related to EBP is being incorporated into F880 Infection Prevention and Control. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure 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 3 of 5 residents (Resident #6, #7 and #8) reviewed for respiratory care. 1. The facility failed to ensure Resident #6's oxygen tubing was not on the floor. 2. The facility failed to ensure Resident #7's oxygen tubing was not on the floor. 3. The facility failed to ensure Resident #8's nasal canula was not on the floor. These deficient practices could place residents at risk of receiving incorrect or inadequate oxygen support, possible contamination/cross contamination/infection and could result in a decline in health. The findings were: 1. Record review of Resident #6's face sheet reflected she is a [AGE] year-old female with an original admission date of 06/19/2018 and a readmission date of 12/17/2021. Resident #6 had diagnoses which included Chronic Obstructive Pulmonary Disease (a group of lung diseases causing constriction of the airways and difficulty breathing) and type II diabetes mellitus (causes high blood sugar due to the pancreas not producing enough insulin). Record review of Resident #6's consolidated physician orders for March 2024 reflected orders for Oxygen at 2-4 Liters per N/C PRN (order date 08/04/2021). Further review of the consolidated orders reflected an order to change O2 and /or nebulizer tubing Q week, every night shift every Sunday (order date 08/04/2021). Record review of Resident #6's care plan, revised 12/26/2023, reflected Resident #6 has oxygen therapy related to ineffective gas exchange related to COPD. The goal was will have no s/sx of poor oxygen absorption through the review date with a target review date of 05/01/2024. The interventions reflected administer oxygen per order. Record review of Resident #6's Quarterly MDS, dated [DATE], reflected a BIMS score of 12, indicating mild impaired cognition. Resident #6 was on oxygen therapy for COPD. Observation on 03/29/2024 at 11:48 am revealed Resident #6's oxygen tubing on the floor. Resident #6 was in the dining room seated at a table. Her oxygen concentrator was plugged into the wall and her concentrator was 6 feet away from the resident. Her oxygen tubing was stretched across the floor from the concentrator to the resident. During an interview on 03/29/2024 at 11:49 am with Resident #6, she stated the staff bring her oxygen into the dining room and set it up for her. She said she has asked them to not let the tubing touch the floor but they do not care. During an interview with CNA C on 3/29/24 at 11:55 am, CNA C acknowledged Resident #6's tubing on the floor. She stated the staff are responsible for setting up Resident #6's oxygen and stated the oxygen should not be touching the floor. CNA C stated this deficient practice could result in cross contamination or the tubing getting run over or bent, causing the resident to not get as much oxygen. CNA C stated she had received training regarding oxygen tubing not touch the floor. 2. Record review of Resident #7's face sheet reflected she is a [AGE] year-old female with an admission date of 03/02/2023. Resident #7 has diagnoses which included Chronic Obstructive Pulmonary Disease (a group of lung diseases causing constriction of the airways and difficulty breathing) Dependence on Supplemental Oxygen and Dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #7's consolidated physician orders for March 2024 reflected oxygen at 2-3 liters per n/c PRN and change O2 and/nebulizer tubing Q week every night shift every Sunday (order date 11/28/2023). Record review of Resident #7's Quarterly MDS, dated [DATE], reflected a BIMS score of 5 indicating severe cognitive impairment and oxygen therapy with a diagnosis of COPD. Record review of Resident #7's care plan, revised 09/26/2023, reflected oxygen therapy related to CHF, ineffective gas exchange, COPD. The goal was to have no s/sx of poor oxygen absorption through the next review date of 04/18/2024. The interventions reflected monitor for s/sx of respiratory distress and report the MD PRN. Observation on 03/29/2024 at 11:47 am revealed Resident #7's oxygen tubing on the floor while Resident #7 was seated at the dining room table. Resident #7's oxygen tubing was connected to an oxygen cylinder attached to the back of Resident #7's wheelchair. During an interview with CNA C on 3/29/24 at 11:55 am, CNA C acknowledged Resident #7's oxygen tubing was on the floor. CNA C stated the staff are responsible for the placement of the oxygen and oxygen tubing and stated the oxygen tubing should not be touching the floor. 3. Record review of Resident #8's face sheet reflected she is an [AGE] year old female with an original admission date of 01/19/2016 and a readmission date of 03/01/2024. Resident #8 has diagnoses which include Acute Respiratory Failure (caused by a disease or injury that effects breathing). Record review of Resident #8's consolidated physician orders for March 2024 reflected orders for continuous oxygen 2-4 liters per n/c every shift (order dated 03/01/2024). Record review of Resident #8's Quarterly MDS, dated [DATE], reflected a BIMS score of 08, indicating moderate cognitive impairment. Resident #7 is on oxygen therapy for respiratory failure. Record Review of Resident #8's care plan, revised 10/05/2023, reflected Resident #8 is on oxygen therapy r/t ineffective gas exchange, respiratory illness, resident wears CPAP at HS. The goal was she would have no s/sx of poor oxygen absorption through the review date of 04/01/2024. The interventions reflected monitor for s/sx of respiratory distress and report to MD PRN. Observation on 04/01/24 at 1:30 p.m. revealed Resident #8's oxygen nasal canula on the floor in the bathroom. Resident #8 was sitting in a recliner in her room. An oxygen cylinder was in the bathroom with the oxygen tubing nasal cannula lying on the floor in front of the toilet. During an interview with Resident #8 on 04/01/24 at 1:30 p.m., Resident #8 stated she was unaware of the nasal canula being on the floor in the bathroom. During an interview with LVN B on 04/01/2024 at 11:10 am she stated oxygen tubing should not touch the floor because it can get dirty and cause cross contamination. She stated it can cause a resident to get a respiratory infection or other sicknesses. Furthermore, LVN B stated she had received training on oxygen tubing placement. During an interview with LVN B on 04/01/2024 at 1:32 p.m. she acknowledged the oxygen nasal canula on the floor and stated, it should not be there, I am going to change it out right now. During an interview with the Administrator 04/01/2024 at 1:45 p.m. he stated nasal canula oxygen tubing should not touch the floor because it can become contaminated and introduce germ into the nose. For the oxygen tubing itself, it is going to touch the floor if the resident moves around. The tubing has to be long enough for them to move around the room. The Administrator stated staff have received training on oxygen and tubing. During an interview with the DON on 04/01/2024 at 2:00 p.m. the DON was asked why is it important that oxygen tubing not be on the floor in the dining room or a resident room, she stated if it is a long tubing and the resident is going to and from the bathroom, the tubing could be on the floor She also stated I do not think the tubing itself is an issue but the nasal cannula itself could introduce germs. Furthermore, the DON stated staff had received training on changing and labeling tubing and where to place tubing when not in use. Record review of the facility's policy on Oxygen-Respiratory Tubing/Equipment Management, revised 01/2022, states the guideline is to maintain properly functioning equipment and decrease the potential for the spread of infection by maintaining clean equipment and tubing bottles and mask. A procedure is to change tubing weekly and provide storage receptacle for proper storage when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 2 of 7 residents (Residents #2 and #56) reviewed for privacy, in that: 1. CNA A and CNA B did not close Resident #2's window curtain while providing incontinent care for the resident. 2 LVN M did not completely close Resident #56's privacy curtain while providing wound care for the resident. These failures could place residents at-risk of loss of dignity due to lack of privacy. The findings include: 1. Record review of Resident #2's face sheet, dated 10/19/2023, revealed an admission date of 08/15/2015, with diagnoses which included: Peripheral vascular disease (Abnormal narrowing of arteries), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Hypertension (High blood pressure) and, Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 3, indicating she was severely impaired. Resident #2 required extensive assistance and was always incontinent of bladder and frequently incontinent of bowel. Record review of Resident #2's care plan, dated 09/13/2023, revealed a problem of I have incontinence r/t (related to) Activity and a goal of I will remain free from skin breakdown due to incontinence and brief use through the review date. Observation on 10/19/23 at 1:24 p.m. revealed CNA A and CNA B did not close the window curtain while providing incontinent care for Resident #2. Anybody walking outside would have been to see the resident fully exposed. During an interview with CNA A and CNA B on 10/19/2023 at 1:30 p.m., CNA A and CNA B confirmed the window curtain was not closed while they provided care for Resident #2 but it should have been. They revealed they forgot to lose it. They confirmed receiving training for residents rights within the year. During an interview with the DON on 10/19/2023 at 3:34 p.m., the DON confirmed the window curtain should have been closed to protect the privacy of the resident. She confirmed the staff were trained in resident rights 2. Record review of Resident #56's face sheet, dated 10/23/2023, revealed an admission date of 05/13/2015 and, a readmission date of 09/20/2015, with diagnoses which included: Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypothyroidism (under active thyroid) and, Dementia (decline in cognitive abilities) Record review of Resident #56's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 0, indicating she was severely impaired. Resident #56 required extensive assistance to total care and was always incontinent of bladder and bowel. Record of Resident #56's care plan, dated 07/10/2023, revealed a problem of My skin is fragile and I am at risk for skin injury--new or worsening skin condition. 0/10/23 pressure ulcer to Sacrum. with an intervention of Apply treatment as ordered. Observation on 10/20/2023 at 9:03 a.m. revealed LVN M provided wound care for Resident #56, exposing the end of the resident's bed which could be seen from the door if someone had entered the room during care. Further observation revealed LVN M did not pull the curtains completely around Resident #56's bed to offer privacy to the resident during care because the privacy curtain was not long enough During an interview with LVN M on 10/20/2023 at 9:16 a.m., LVN M confirmed the privacy curtain was not completely closed while she provided care for Resident #56, but it should have been. She confirmed receiving training for residents' rights within the year. During an interview with the DON on 10/20/2023 at 12:52 p.m., the DON confirmed the privacy curtain should have been closed to protect the privacy of the residents. She confirmed the staff was trained in resident rights The DON revealed The ADON would annually check the skills and knowledge of the staff and sport check were done if a concern was noted. Review of facility policy, titled Standards for clinical procedures, dated January 2022, revealed [ .] g. Pull the privacy curtain between the residents, even if the roommate is not present. close windows blinds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report alleged violations related to neglect or abuse, including injuries of unknown source, are reported immediately, but not later than 24 hours after the allegation is made to the administrator of the facility and to other officials (including to the State Survey Agency), for 1 of 39 residents (Resident #9) reviewed for abuse and neglect, in that: The facility failed to report to the State Survey agency (HHSC) when Resident #9 alleged a dietary cook hit her on the arm on 08/16/2023. This failure could place residents at risk for abuse and neglect. The findings were: Record review of Resident #9's face sheet, dated 10/19/2023, revealed the resident was re-admitted on [DATE] (original admission on [DATE]) with diagnoses that included: major depressive disorder, age-related physical debility, and muscle weakness. Record review of Resident #9's quarterly MDS assessment, dated 03/11/2023, revealed the resident had a BIMS score of 15, which indicated intact cognitive impairment. Record review of the Grievance/Concern Report - Residents and Families, dated 08/21/2023, revealed Room Name: Resident Council. [ .] Concern/Details: Resident #9 claimed [name of Dietary [NAME] C] from kitchen hit her on the arm. Resident did speak to [name of Administrator] about incident. [ .] Action Taken: on 8/16/23 resident approached this writer [Administrator] in hallway & stated [name of Dietary [NAME] C] in the kitchen hit her on the arm. Resident [#9] stated she got me my food & then hit me on the arm. I [Administrator] asked if she did it to be mean or like she was patting her to say here you go. She [Resident #9] stated she didn't know. I [Administrator] asked her [Resident #9] if she believed she [Dietary [NAME] C] was trying to hurt her, if so I [Administrator] would call the police & notify the state & her family. Resident [#9] started laughing & stated no she [Resident #9] just didn't want her [Dietary [NAME] C] to do that anymore. I [Administrator] assured resident [#9] that I [Administrator] would speak with [name of Dietary [NAME] C] & this wouldn't happen again. Conversation held with [name of Dietary [NAME] C] & documented. [name of Dietary [NAME] C] is aware that Resident [#9] does not want to be touched. Record review of Tulip, on 10/19/2023, revealed no incident report for Resident #9, during 08/2023, of Resident #9's alleged staff complaint. During an interview on 10/18/2023 at 2:25 p.m., Resident #9 stated she told an unknown staff member that she wanted cottage cheese and then Dietary [NAME] C came to her and hit her on her arm, while motioning to her upper left arm. She stated she believed it was last month. She stated she felt bad because all she did was ask for something and then was hit by staff. Resident #9 stated she told the Administrator and he had told her he would contact the police and correct it but she never saw anything done. Resident #9 stated that Dietary [NAME] C didn't even come apologize to her or anything. During an interview and record review, of written grievance dated 08/21/2023, on 10/20/2023 at 10:55 a.m., Activity Assistant stated she remembered the incident and that Resident #9 first brought up the incident during resident council on 08/16/2023. She stated that Resident #9 told her that she had asked someone for something (believed it was cottage cheese but couldn't remember) and that Dietary [NAME] C had swatted her on the arm. During an interview and record review, of written grievance dated 08/21/2023, on 10/20/2023 at 11:00 a.m., the Administrator stated he remembered the incident. He stated he contacted Resident #9's family about this incident and he said they laughed and stated Resident #9 was not a touchy feely person and did not like to be touched. The Administrator stated he believed it was not abuse and therefore was not reported because the resident stated she was not wanting it reported and that the resident stated she believed the staff was not being hurtful. During an interview and record review, of written grievance dated 08/21/2023, on 10/20/2023 at 11:21 a.m., Dietary [NAME] C stated Resident #9 asked for cottage cheese and she placed it on the table and then tapped the resident on the shoulder to say here you go. She stated Resident #9 had no response afterward. Dietary [NAME] C stated the Administrator spoke with her about the incident and asked her what happened and for her not to touch Resident #9 anymore. She stated that she was not aware of what should be reported but if a resident was claimed abuse, then maybe it should be reported. During an interview and record review, of written grievance dated 08/21/2023,on 10/20/2023 at 12:31 p.m., the DON stated she believed she was on PTO at the time and only recalled the incident upon her return to work. She stated she believed it was not a reportable because of the resident's statements and it was probably just a tap [instead of a hit]. Record review of facility's Abuse Guidance: Preventing, Identifying, and Reporting, dated 02/2017, revealed Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. [ .] Report any alleged or suspicions of abuse to HHSC by telephone reporting or via TULIP reporting with the designated time frames in accordance with HHSC's PL 19-17 (Replaces PL 17-18)[a] are reported immediately, [b] but not later than 2 hours after the allegation is made, if the events cause the allegation involve abuse or result in serious bodily injury; [c] or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, [ .].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 27 residents (Resident #81) whose assessments were reviewed, in that: Resident #81's Annual MDS incorrectly documented the resident as receiving an insulin injection. This failure could place residents at-risk for inadequate care due to inaccurate assessments. The findings were: 1. Record review of Resident #81's face sheet, dated 10/18/2023, revealed an admission date of 08/17/2022, with diagnoses that included: Hemiplegia(Paralysis of one side of the body), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood) and, Cerebral infarction (Stroke). Record review of Resident #81's Physician orders and Medication administration record for August 2023 revealed orders for: Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous Solution Peninjector 2 MG/3ML (Semaglutide) Inject 1 milliliter subcutaneously one time a day every Mon related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) Wipe pen prior to applying needle Record review of Resident #81's Annual MDS, dated [DATE], revealed the assessment indicated Resident #81 received an injection of insulin. During an interview with MDS nurse D on 10/20/23 at 12:05 p.m., the MDS nurse confirmed she had completed the MDS. The MDS nurse confirmed Resident #81's Annual MDS was coded as the resident having received an insulin injection when Resident #81 had only received Ozempic (medication used for the treatment of type 2 diabetes in combination with diet and exercise) . The MDS nurse revealed she did not know why she had coded Ozempic as an insulin. She confirmed Ozempic was a non-insulin injection pen and should not have been coded as an insulin injection. The MDS nurse revealed the RAI was used as reference for the MDS and she had access electronically to the RAI on her computer. Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 2019, revealed, Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the comprehensive person-centered care plan to reflect the current condition for 1 of 20 residents (Resident #86) reviewed for care plan revisions The facility failed to update Resident #86's care plan to reflect his risk for elopement This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: Record review of Resident #86's face sheet, dated 10/20/2023, revealed he was admitted to the facility on [DATE] with diagnoses which included: Dementia (decline in cognitive abilities), Heart disease, Insomnia (Sleep disorder), Dysarthria (Speech sound disorder) and, Ataxic gait (lack of voluntary coordination of muscle movement) Review of Resident's 86 quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 8 which indicated moderate cognitive impairement. Resident #86 was coded as no behavior for the look back period. Record review of Resident #86's care plan with a review date of 09/14/2023 revealed there was no risk for elopement care plan. Review of Resident #86's nurse's progress note, dated 08/09/2023, revealed Resident ambulating again by pushing his wheelchair towards middle of building -and trying to go outside again-- voicing he was going outside to sit down-- three staff members redirecting him back to his room and he did. Review of Residnet #86's nurse's progress note, dated 09/28/2023, revealed Resident has been redirected back to room from nearest exit doors X 3 by CNA. Resident is having hallucinations. States someone is coming to pick him up. Offered snack and a drink. Redirected resident back to room. No questions or concerns at this time During an interview on 10/20/23 at 12:52 p.m., the DON confirmed Resident #86 was trying to exit the building and confirmed that no care plan for elopement or exit seeking had been created. The DON Confirmed a care plan should have been created and that they had apparently forgotten to create a care plan. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, Version 1.18.11, October 2023 revealed Therefore, facilities are responsible for assessing and addressing all care issues that are relevant to individual residents, regardless of whether or not they are covered by the RAI (42 CFR 483.20(b)), including monitoring each resident ' s condition and responding with appropriate intervention

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were accurately documented for 1 of 39 Residents (Resident #302) reviewed for medical records, in that: The facility failed to ensure Resident #302's Full Code status was included in his physician orders. This failures could place residents at risk for improper care due to inaccurate records. The findings were: Record review of Resident #302's face sheet, dated 10/19/2023, revealed the resident was admitted [DATE] with diagnoses that included: dementia, fracture of left femur, vitamin deficiency, and history of falling. Record review of Resident #302's MDS assessment, dated 10/13/2023, revealed the resident had a BIMS score of 01, which indicated severe cognitive impairment. Record review of Resident #302's care plan, dated 10/19/2023, revealed Resident/Family/RP does not have advance directives and elects Full Code status. Record review of Resident #302's physician orders, dated 10/19/2023, revealed no mention of resident's code status. During an interview and record review, of Resident #302's physician orders, on 10/20/2023 at 10:40 a.m., MDS D confirmed resident's code status was not included in his orders. MDS D was not able to state why his code status was not included. She stated the potential harm to the resident was staff would not know his code status. During an interview and record review, of Resident #302's physician orders, on 02/2017 at 11:50 a.m., the DON confirmed there was not a code status entered in his physician orders. She was not able to state why there was not a code status in his orders. The DON stated she believed there was not a potential harm to the resident because he would automatically be considered full code, being there was nothing specified. Record review of facility policy titled Medical Records, revised 04/2008, which read A medical record is maintained for every person admitted to a community in accordance with accepted professional standards and practices. The administrator has ultimate responsibility for the maintenance of medical records but may delegate this responsibility to another team member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 (Resident #47) reviewed for hospice services, in that: The facility failed to obtain Resident #47's most recent hospice Plan of Care, Hospice Election Form and Physician Certification of Terminal Illness. This failure could place the resident who received hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings included: Record review of Resident #47's face sheet, dated 10/19/2023, revealed the resident was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included: neurocognitive disorder with Lewy bodies, dementia, dysphagia, and Parkinson's disease with dyskinesia. Record review of Resident #47's admission MDS, dated [DATE], revealed the resident had a BIMS score of 03, which indicated severe cognitive impairment. Further review revealed the resident had a life expectancy of less than 6 months and had received hospice care while a resident at the facility. Record review of Resident #47's Care Plan last review completed 10/06/2023, revealed a focus area, Advanced care planning choices for end-of-life: Lewy Body Dementia-no weight monitoring. Further review revealed interventions with visit frequencies for nurse and CNA, coordinate care with all hospice team members and name of hospice agency and contact information. Record review of Resident #47's electronic medical record Order Summary Report of Active Orders as of 10/19/2023, revealed an order on 09/19/2023 for: Admit to [Hospice] DX- Lewy body Dementia: Please contact at [phone number] for any changes in condition. Record review of Resident #47's electronic medical record, miscellaneous documents, revealed no Hospice Election of Benefits form, Certificate of Terminal Illness, or Plan of Care. In an interview with the MR staff on 10/19/2023 at 2:35 p.m., the MR staff confirmed there were no paper charts kept at the facility. She stated all records were in the facility's electronic system. The MR staff revealed the DON had access to the portal for [Hospice Company B] for any information not found in the electronic system. The MR staff was not sure if portal access for [Hospice Company A] records were available. In an interview with the DON on 10/19/2023 at 3:10 p.m., the DON stated she had access to both hospices currently used for all needed information. However, at the time of interview the DON was unable to access the portal for [Hospice Company A] and revealed the Election form, Certificate of Terminal Illness, and Plan of Care would be in Resident #47's hospice binder at the nurse's station. An observation and interview with the DON on 10/19/2023 at 3:23 p.m., revealed the DON was unable to locate Resident #47's hospice binder at the nurse's station. The DON stated the SW was responsible for making referrals for hospice services for families. The DON further revealed that as the DON she was the designated staff responsible to coordinate services after a resident was on hospice services to ensure all documentation was in place and that the resident's hospice plan of care is coordinated with the facility plan of care. During an interview and record review with the MR staff on 10/19/2023 at 5:08 p.m., the MR staff provided a white binder with [Hospice Company A] and Resident #47's name on the front cover. Further review of the binder revealed a hospice admission consent, election of Medicare hospice benefits, Certificate of Terminal Illness with Recertification, and physician orders. The MR staff stated the hospice binder was found in a drawer in the secure unit. Further review of the binder revealed the documents were printed on 10/19/2023 between 3:46 p.m. and 4:52 p.m. In an interview with the DON on 10/19/2023 at 5:14 p.m., the DON stated she did not know when the hospice binder had arrived at the facility however stated she had been coordinating with [Hospice Company A] earlier that day to ensure all documentation was in place. Record review of the facility's hospice services agreement with [Hospice Company A], with effective date May 14, 2021, revealed, in Agreements: 2. Responsibilities of Facility, (e) Coordination of Care, (v) Designated Facility Member; Facility shall designate a member of Facility's interdisciplinary team who is responsible for working with Hospice representatives to coordinate care to each Hospice Patient provided by Facility and Hospice. Facility's designated interdisciplinary team member shall be responsible for: (iv) obtaining patient specific information from Hospice as required by applicable laws and regulations. 3. Responsibilities of Hospice. (e) Provision of Information; At a minimum, Hospice shall provide the following information to Facility's designated interdisciplinary team member for each Hospice Patient residing at Facility: (i) Hospice Plan of Care, Medications and Orders, (ii) Election Form, (iii) Certifications, (iv) Contact Information, and (v) On-Call System. Record review of the facility's policy titled, End of Life Hospice Type Care & Coordination, date implemented 3/13/19, revealed, To provide supportive care for residents and their families during the end stages of life by enabling them to participate in interactions of their choice in a supportive environment with the assistance of compassionate caregivers and interdisciplinary teams.

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 10 residents (Residents #81, #93 and, #31) reviewed for infection control, in that: 1. Medication Aide F did not sanitize the blood pressure cuff between Resident #81 and Resident #93 2. While providing incontinent care for Resident #31, CNA G did not wash her hands after touching the trash can and, LVN H did not change her gloves or wash her hands before touching a pair of clean briefs These failures could place residents at-risk for infection due to improper care practices. The findings include: 1. Record review of Resident #81's face sheet, dated 10/18/2023, revealed an admission date of 08/17/2022, with diagnoses that included: Hemiplegia (Paralysis of one side of the body), Type 2 diabetes mellitus (high level of sugar in the blood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Cerebral infarction (Stroke). Record review of Resident #81's physician orders for October 2023 revealed an order for amlodipiine Besylate Tablet 5 MG Give 1 tablet by mouth in the morning related to HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE (I11.9) hold if sbp (Systolic blood pressure) under 100, or dbp (Diastolic blood pressure) under 60, or pulse under 60 Record review of Resident #93's face sheet, dated 10/19/2023, revealed an admission date of 09/01/2022 with diagnoses which included: Dementia (decline in cognitive abilities), Atrial fibrillation (Abnormal heart rhythm), Insomnia (Sleep disorder), Malignant neoplasm of female breast (Breast cancer) Record review of Resident #93's physician orders for October 2023 revealed an order for amlodipiine Besylate Tablet 5 MG Give 1 tablet by mouth in the morning related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) hold if sbp (Systolic blood pressure) under 100, or dbp (Diastolic blood pressure) under 60, or pulse under 60 Observation on 10/19/23 at 8:52 a.m revealed, while administering medications, Medication Aide F took the blood pressure and pulse of Resident #81. Further observation at 8:58 a.m. revealed, Medication Aide F took the blood pressure and pulse of Resident #93 with the same blood pressure/pulse cuff that was used for Resident #81. Medication aide F did not sanitize the blood pressure/pulse cuff between the two residents. During an interview with Medication aide F on 10/19/2023 at 9:15 a.m. the medication aide confirmed she forgot to use a wipe to clean the blood pressure/pulse cuff between use. She revealed it was causing a risk of cross contamination. She received infection control training within the year. During an interview on 10/19/2023 at 3:34 p.m., the DON confirmed the medication aide should have sanitized the blood pressure/pulse cuff in between resident to avoid cross contamination. She revealed infection control training was provided to the staff multiple times a year. She revealed the staff's skills were checked annually. She also stated the ADON and herself would do spot check of the staff for skills and infection control knowledge. Review of the facility's policy, titled Infection prevention and control program, dated 10/2022, revealed 10 Disinfecting multi-patient use equipment or supplies after each use and stored appropriately 2. Record review of Resident #31's face sheet, dated 10/19/2023, revealed an admission date of 11/27/2019 and, a readmission date of 01/02/2020, with diagnoses which included: Chronic atrial fibrillation (heart rhythm disorder), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Chronic kidney disease (gradual loss of kidney function), Hemiplegia (Paralysis of one side of the body) and, Urinary tract infection (an infection in any part of the urinary system). Record review of Resident #31's MDS quarterly assessment, dated 07/27/2023, revealed the resident had a BIMS score of 7, indicating moderate cognitive impairment. Resident #31 required extensive assistance and was always incontinent of bowel and bladder. Record review of Resident #31's care plan revealed a care plan revised 08/30/2023 with a problem of I am at risk for significant infections and/or recurrent infections r/t compromised medical condition: Actual Infections: UTI (urinary tract infection) and a goal of I will not experience any complications to include distress throughout the course of my treatment of infection until resolved and/or next revision Observation on 10/19/23 10:20 a.m., revealed while providing incontinent care for Resident # 31 CNA G, after washing her hands, touched the trash can with her gloved hands. She did not change her gloves or wash her hands, then, started providing care for Resident #31. LVN H touched the door and privacy curtain to close them and without changing her gloves or washing her hands, touched the resident to position her and the clean brief and fasten it on the resident, During an Interview on 10/19/2023 at 10:30 a.m., CNA G confirmed she touched the trash can after washing her hands and putting her gloves one. She did not realize the trash can was considered contaminated and that she should have changed her gloves and clean her hands. She confirmed receiving infection control training within the year. During an interview on 10/19/2023 at 10:30 a.m., LVN H confirmed not changing her gloves and cleaning her hands after touching the door and privacy curtain. She confirmed she needed to clean her hands and change gloves, but she forgot. She confirmed receiving infection control training within the year. During an interview with the DON on 10/19/2023 at 3:34 p.m., the DON confirmed the staff should change gloves and wash their hands after touching the environment directly around the resident She confirmed the staff was trained in infection control within the year. She revealed the staff's skills were checked annually by the ADON and they would spot check skills in case of concerns with infection control. Review of the facility's policy, titled Infection prevention and control program, dated 10/2022, revealed Educating staff and ensuring that they adhere to proper infection prevention and control practices when performing resident care activities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed, through past non-compliance, to implement an intervention to reduce the risk of a fall for 1 of 17 Residents (Resident #1) in that: Resident #1 sustained a fall with injuries while being transferred by CNA-C who did not use a gait belt during the resident transfer. This failure could place residents at risk for their safety needs not being met with unsafe transfers. The findings included: Record review of Resident #1's face sheet, dated 10/5/23 ,revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease unspecified (a group of lung diseases that block air flow and make it difficult to breathe), heart failure unspecified (a condition in which the heart is unable to pump blood correctly), and acute kidney failure unspecified (a disease in which the kidney is unable to remove waste and balance fluids). Record review of Resident #1's care plan, dated 2/5/23, revealed the resident was a fall risk for gait and mobility. Record review of Resident #1s MDS assessment, dated 2/8/23, revealed the resident's transfers required a one person assist with extensive assistance needed. Record review of the most recent CNA competencies skills checklist for CNA-C dated 4/25/22 revealed competency attainment in resident transfers using a gait belt. Record review of fall incident report dated 3/17/23, completed by ADON-B, for Resident #1 who was being transferred into her wheelchair by CNA-C noted Resident #1 sustained injuries as a result of the fall including: laceration on her scalp, an abrasion on her right upper arm, a skin tear on the back of her left hand, and a skin tear on her left lower leg. The size parameters of the various injuries was not noted. Record review of undated statement from CNA-C regarding the fall of Resident #1 on 3/17/23 revealed Resident #1 was being transferred from her recliner to the wheelchair by CNA-C who was completing the transfer without the use of a gait belt. During an observation on 10/5/23 at 1:25pm revealed CNA-D transferring Resident #2 in her room from bed to wheelchair using a gait belt with proper technique. During an observation on 10/5/23 at 1:36pm revealed CNA-E transferring Resident #3 in her room from bed to wheelchair using a gait belt with proper technique. During an interview on 10/5/23 at 2:15pm the DON revealed that CNA-C did not use a gait belt during the transfer of Resident #1 on 3/17/23 from her recliner to her wheelchair. The DON stated that the gait belt should have been used to help prevent the fall. She stated that nursing administration does random checks on all shifts for gait belt usage compliance; she stated that staff have been in-serviced on gait belt usage and showed surveyor a storage room which contained new gait belts for staff use. The DON stated that gait belts are used by CNA staff on all resident transfers. The DON stated that CNA-C was suspended at the time of the resident fall on 3/17/23 and did not return to work due to termination. During an interview on 10/5/23 at 2:30pm the Administrator stated that CNA staff use gait belts on resident transfers and that CNA-C did not return to work after the 3/17/23 fall incident and was terminated. During an interview on 10/6/23 at 2:20pm CNA-I hired 10/13/22 stated that gait belts were used for resident transfers for fall prevention and was aware of where they were stored. During an interview on 10/6/23 at 2:30 pm NA-H, hired on 9/2/21, stated that gait belts were used for resident transfers for fall prevention and was aware of where they were stored. During an interview on 10/6/23 at 2:35pm CNA-G, hired 11/1/10, stated gait belts were used for resident transfers for fall prevention and was aware of where they were stored. During an interview on 10/6/23 at 2:45pm CNA-F, hired 3/7/23, stated gait belts were used for resident transfers for fall prevention and was aware of where they were stored. Record review of staff training forms dated 8/9//22 and 3/18/23 revealed staff in-service on gait belt usage for resident transfers. Record review of Conduct and Workplace notice dated 3/24/23 revealed employee termination action for CNA-C. Record review of facility policy named Safe Resident Handling/Transfers dated 12/1/21 revealed the need for gait belts to be used on resident transfers.

Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable home like environment for 1 of 1 chair utilized for obtaining residents weights reviewed for clean and homelike environment, in that: The facility failed to ensure the chair used to weigh residents was clean. This deficient practice could place residents who utilized the chair for weights at-risk of illness and infection due to contact with unclean surfaces. Findings Include: During observations of Hall 200 B portion of the facility on 8/29/2022 at 9:00 a.m. and again at 9:40 a.m. revealed there was a blue chair, with a varied degree of white and gray colored stain in the seat portion of the chair which covered approximately seventy percent of the bottom seat portion of the chair, sitting in a doorway of room behind and near the nurse's station. During an interview on 8/29/2022 at 9:50 a.m. CNA B stated the dark blue chair sitting in the doorway facing the hallway was a weight chair. CNA B stated there was a stain in the seat portion of the chair and stated it was a hard water stain. When asked if residents utilized the chair, CNA B stated residents do sit in the chair and get weighed either weekly, monthly or when a weight is ordered. CNA B further stated residents did comment about the stain in the seat portion of the chair and stated, 4 residents she could remember have told her the chair looks dirty and they did not want to sit in it, they do eventually but I have to explain each time that it is not dirty. When asked how she believed sitting in the blue weight chair with the stained seat made the residents feel, she replied I think it makes them feel upset. CNA B would not reveal the names of the four residents. When asked if the condition of the chair had been reported CNA B said everyone knows it is like that. During an interview with the DON on 8/29/2022 at 3:09 p.m., the DON stated she was unaware the weight chair was stained, and further stated, a lot of residents walk to the other side of the facility to be weighed, there is a different scale on the other side of the building. During an interview with the Administrator on 8/30/2022 at 12:56 p.m., the Administrator stated the chair was clean and the stain in the chair would not come out of the seat. The Administrator explained the chair was cleaned by all staff that used it for residents. No policy was provided regarding cleaning of weight chairs prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure CNAs have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 2 CNAs (CNA A) observed for incontinent care, in that: CNA A failed to use appropriate techniques while cleaning Resident #144's rectal area during wound/incontinent care. This deficient practice place residents identified for incontinent care at risk for cross contamination resulting in infections. The findings include: Record review of Resident #144's face sheet, dated 08/31/2022 revealed an admission date of 08/27/2022 with diagnoses which included: acute respiratory failure with hypoxia (hypoxemic respiratory failure means that you don't have enough oxygen in your blood, but your levels of carbon dioxide are close to normal), sepsis (the body's extreme response to an infection), pneumonia (an infection that inflames the air sacs in one or both lungs), high blood pressure (a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease), osteoarthritis (when the protective cartilage that cushions the ends of the bones wears down over time), atrial Fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), acute kidney failure (when your kidneys stop working suddenly) and pulmonary embolism (occurs when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung). Record review of Resident #144's most recent admission MDS assessment, dated 08/23/2022, revealed the resident was incontinent of both bowel and bladder and was totally dependent upon 1 staff member to provide incontinent care. Observation on 08/31/2022 at 11:05 a.m., during wound care for Resident #144, revealed the resident was incontinent of bowel movement (BM), resulting in CNA A, needing to provide incontinent care. As CNA A was cleaning the rectal area, CNA A took a wet wipe and wiped back and forth without changing the surface of the wet wipe or obtaining a clean wet wipe X 2 to on Resident #144. Further observation revealed as LVN A and CNA A began to turn Resident #144 on his left side, he became incontinent of BM again. Again, CNA A began to provide incontinent care to Resident #144 and as she was cleaning the rectal area, CNA A took a wet wipe and wiped back and forth without changing the surface of the wet wipe or obtaining a clean wet wipe X 2. During an interview on 08/31/2022 at 11:09 a.m., CNA A confirmed she had wiped Resident #144's rectal area X2 each time with a wet wipe and wiped back and forth without changing the surface of the wet wipe or obtaining a clean wet wipe During an interview on 08/31/2022 at 11:40 p.m., the ADON stated CNA A had performed incontinent care before. Record review of CNA A's Personnel Files revealed CNA A was hired on 09/13/2021 and review of CNA A's training record CNA Skills Checklist dated 11/24 (no year), revealed on the second page, Personal Care: Pericare/Incontinent Male and was checked off by the instructor, the initials of the employee and date completed (11-24). During an interview with the DON on 08/31/2022, the DON stated the facility used [NAME] and [NAME] as their policy and procedure for perineal care. Record review of the Facility Procedural Guideline #21 for Perineal Care/Incontinent Care-Male (no date) used to train CNA A and the [NAME] & [NAME] on Perineal Care (also used by the facility) stated in part: 12. After cleansing genital area, turn to side, then wash and rinse the rectal area moving from front to back using a clean area of washcloth for each stroke . (Facility uses wet wipes instead of a washcloth).

Based on observation, interview, and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment requirement, for 1 of 1 kitchen staff (Dietary Manager) reviewed for qualifications, in that: The Dietary Manager did not have the appropriate license, certification, or qualifications to function as the food service supervisor. This failure could place all residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition. Findings include: During an interview on 8/28/2022 at 4:05 p.m., Dietary Aide A stated the Dietary Manager was not available as she was out on leave. During an interview on 8/29/2022 at 8:30 a.m., the Administrator explained the facility did not have a Certified Dietary Manager employed at this time and further stated the staff currently identified by kitchen staff as the current Dietary Manager was not certified. Record review of employee records and licensure revealed the Dietary Manger was hired 12/12/2017 as an employee with the facility. No documentation provided by the facility revealed the date the current Dietary Manager assumed that role in the facility. Record review of the USDA Food Code 2017 indicated the following: Based on the risks inherent to the Food Operation, during inspections and upon request the Person in Charge shall demonstrate to the Regulatory Authority knowledge of food borne disease prevention application of the Hazard Analysis of foodborne disease prevention, application of the Hazard Analysis and Critical Control Point principles, and the requirements of this Code. The Person in Charge shall demonstrate this knowledge by: (A) Complying with this Code by having no violations of priority items during the current inspection; (B) Being a certified food protection manager who has shown proficiency of required information through passing a test that is part of an accredited program; Record review of Texas Food Establishment Rules 228.33 Certified Food Protection Manager and Food Handler Requirements 228.33(a) states: At least one employee that has supervisory and management responsibility and the authority to direct and control food preparation and service shall be a certified food protection manager who has shown proficiency of required information through passing a test that is part of an accredited program.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and storage, in that: 1. The facility failed to properly store food in the walk-in refrigerator. 2. The facility failed to properly store food in the walk-in freezer. 3. The ceiling in the dry storage area had water stains and water was leaking on a box. These deficient practices could place residents who eat food from the kitchen at-risk of foodborne illness. Observation of the walk-in refrigerator on 8/28/2022 at 4:10 p.m., with Dietary Aide C, revealed the following: - One 3-pound container or sour cream opened and approximately 75 percent used was not labeled with an open date, - Cheese removed from the manufacturer's packaging was not labeled or dated, - One quarter silver pan of what was identified by kitchen staff as possibly beef stew was not labeled, - One quarter silver pan of what was identified by kitchen staff as possibly eggs was not labeled, - One quarter silver pan of what was identified by kitchen staff as possibly sausage and bacon was not identified, - One quarter pan of an unknown substance tan in color was not labeled in the walk- in refrigerator, - and One full sheet carrot cake was partially used and stored in the walk- in freezer with no open date. Observation of the walk-in freezer on 08/28/2022 at 4:13 p.m., with Dietary Aide C, revealed the following: - One 3-gallon container of ice cream had a torn lid exposing the ice cream to other possible containments, - One package of an unknown substance identified as possibly some type of meat in the freezer with no date or label, - One item wrapped in foil, approximately the size of standard house brick, was unlabeled or dated, - One 2.5 pound fully cooked sliced ham with no manufacturers date visible on the packaging, - and two 40-ounce bags of frozen green peas with no manufacturer's date visible on the packaging. Observation on 08/29/2022 at 4:15 p.m., with Dietary Aide C, revealed the ceiling in the dry storage area was peeling and appeared to have a small hole in it and to be leaking, there was a brown closed cardboard box labeled store in a cool dry area beneath the hole which appeared to be wet. During an interview with Dietary Aide C on 8/28/2022 at 4:20 p.m., Dietary Aide C stated the items in the walk-in refrigerator and walk in freezer should have been labeled and were supposed to be labeled and dated so staff knew which items were able to be used. Dietary Aide C further stated the kitchen staff was supposed to make sure the food was good before it was served to the residents, and dating and labeling were important to keep residents from getting items they were not supposed to be served. Dietary Aide C stated she was not aware if the cardboard box of food items in the dry storage area was wet prior to the observation on 08/29/2022. During an interview with the Administrator on 8/28/2022 at 5:20 p.m., the Administrator stated he was unaware there were unlabeled and undated items anywhere in the kitchen. The Administrator further stated he was unaware there was an area in the ceiling possibly leaking onto items in the dry storage area prior to today, and further stated the facility's Dietary Manager was on leave. Record review of the facility's policy titled, Food Storage Policy, dated 2018, revealed, 1. Dry Storage Rooms: Keep the storage room well-ventilated with humidity controls to prevent mold growth. 2. Refrigerators: (d) Date, label and tightly seal all refrigerated food using clean, nonabsorbent, covered containers that are approved for food storage. 3. Freezer: (e) Store frozen foods in moisture-proof wrap or containers that are labeled and dated.