**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to be treated with respect and dignity for one (Resident # 11) of eight residents reviewed for dignity. Resident # 11 waited 14 minutes staring at her meal tray before a staff member set down to assist with feeding Resident # 11. This failure placed residents at risk of not being treated with dignity. Findings included: A record review of Residents # 11's face sheet dated 7/31/24 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), traumatic subarachnoid hemorrhage (bleeding on the brain), wedge compression fracture of the T5-T6 vertebra (spinal fracture), major depressive disorder ( A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life.), cervicalgia (Neck pain),and anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities.) A record review of Resident # 11's care plan last revised on 5/09/2024 reflected she had ADL self-care performance deficit related to dementia, limited mobility, and terminal illness. Resident # 11's interventions reflected she needed total assistance by 1 staff to eat. An observation of meal service on 7/29/2024 at 1:00 pm revealed Resident # 11 lunch meal tray was sat in front of her. The Activity director came over and set up Resident # 11 meal tray without performing hand hygiene prior to touching meal tray and food items. After meal tray was set up the Activity Director walked away. Resident # 11 sat staring at her meal tray for 14 minutes before a staff member came over and sat down to assist with feeding Resident # 11 her meal tray. Interview with the Dietary Director on 7/29/2024 at 2:00 pm reflected the dining room trays are served after the hall trays go out. The Dietary Director said the meal tickets are in the order they are printed but they try to serve all residents at one table at a time. The Dietary Director said as for the trays of residents who need assistance those are not separated, they just come out in the normal order as they are printed. Record review of Meal Service policy dated 10/1/2018 reflected under heading policy: The facility believes that all residents should be always treated with dignity and respect. A respectful, positive dining experience is essential to the residents' quality of life and helps to identify residents' needs and improve their overall nutritional status. 7.Residents who require dining assistance will not have their trays delivered until a staff member is available to assist with dining.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 2 (Resident # 9 and Resident #47) out of 8 residents reviewed for call lights. The facility failed to ensure Resident #9 and Resident #47's call light was within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #9's Face Sheet, dated 07/31/2024, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of history of falling (balance issues or other health conditions that increase the risk of falling), unspecified lack of coordination (uncoordinated movement due to a muscle control problem that causes inability to coordinate movements), and abnormal posture ( rigid body movements and chronic abnormal positions of the body.). Record review of Resident #9's Annual MDS Assessment, dated 06/04/2024, reflected the Resident had a BIMS score of a 6 indicating her cognition was severely impaired. Resident #9 was assessed to require assistance with the following ADLs: eating, oral hygiene, toileting hygiene, showers, upper and lower dressing, putting on /taking off footwear, and personal hygiene. She also required assistance with transfers. Record review of Resident #9's Comprehensive Care Plan, dated 06/17/2024 reflected Resident #9 had an ADL self-care deficit related to cognitive loss and limited mobility. Intervention: Resident #9 required assistance with transfers, bed mobility, dressing, eating, toileting, dressing, and grooming. Resident #9 had actual falls with no injury related to poor balance and unsteady gait. Intervention: keep in highly visible areas. Record review of Resident # 47's face sheet dated 7/31/24 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of respiratory failure ( a condition that occurs when the lungs can't get enough oxygen into the blood or remove enough carbon dioxide from the body), traumatic brain injury ( brain dysfunction caused by an outside force, usually a violent blow to the head), dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus), quadriplegia (a type of paralysis that causes severe or complete loss of motor function in all four limbs and the body from the neck down), altered mental status (a general term for a change in mental function that can range from slight confusion to coma), chronic pain syndrome (persistent pain that lasts weeks to years), need for assistance with personal care, hypertension (high blood pressure), contracture to both left and right hands ( a permanent tightening of the muscles, tendons, skin, and surrounding tissue that causes the joints to shorten and stiffen and a decrease in ROM in both hands), muscle wasting and atrophy (the loss of muscle mass and strength), neuromuscular dysfunction of bladder (a urinary tract condition that occurs when the nerves and muscles of the urinary system don't work together properly due to damage to the nervous system), cognitive communication deficit (a communication problem that's caused by a cognitive deficit rather than a language or speech deficit), aphasia ( a comprehension and communication (reading, speaking, writing) disorder resulting from damage or injury to a specific area in the brain), complete amputation at right hip joint, and gastronomy status (the presence of a gastrostomy, which is a surgical opening into the stomach for nutritional support or gastric decompression) Record review of Resident # 47's care plan revised on 1/4/24 reflected the resident was a high risk for falls related to spasticity and traumatic brain injury interventions reflect to be sure resident's call light was within reach and encourage resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance. The care plan also reflected the resident had a communication problem related to head injury. Resident was nonverbal most of the time but will occasionally speak to staff and family. Will blink eyes yes and no and nod head no in response to questions. Interventions included anticipate and meet needs revised 5/6/24. Care plan reflected the resident has oxygen therapy PRN related to respiratory distress, decreased oxygen level revised 4/1/24 with interventions to include provide reassurance and allay anxiety. Have an agreed upon method for the resident to call for assistance (e.g. call light, bell). Stay with resident during episode of respiratory distress. Care plan reflected the resident had an ADL self-care performance deficit related to TBI interventions include resident to be totally dependent on staff for all aspects of ADL's revision on 2/16/24. Observation on 07/29/2024 at 9:41 AM to 9:47 AM Resident #9 was in her room sitting in her wheelchair. She had both feet propped up on her recliner. She had an overhead rolling table approximately 3 feet from where she was sitting. On the rolling table her call light was hanging over the table and the call button was not near her. The call button was hanging from the rolling table on the right side of the table and Resident #9 was sitting on the left side of the rolling table. Resident #9 attempted to reach for the call light. She was not able to reach the call light from where she was sitting in her wheelchair. Observation on 07/29/2024 at 9:45 AM Resident #9 attempted to reach for the call light and she was not able to reach it from where she was sitting in her wheelchair. Observation on 7/30/24 at 4:02 pm of Resident # 47's room revealed Resident # 47 to be in bed resting looking out the window. Further observation revealed Resident # 47's call light and soft pad call device both to be hung on the opposite wall not within reach of Resident # 47. Resident # 47 asked if he needed any assistance. Resident # 47 shook his head no. Resident # 47 asked if he was ok currently and Resident # 47 shook head yes as Resident # 47 is primarily nonverbal and this is his primary way to communicate. Interview on 07/29/2024 at 9:43 to 9:47 AM Resident #9 stated no when she was asked if she knew where her call light was located. She began to look for the call light in her wheelchair and she looked around the room and saw it on the overhead rolling table. She stated she could not reach it but she saw it on the table ( she pointed to the overhead rolling table and to the call light). Resident #9 stated she did use her light when she needed help. In an interview on 07/29/2024 at 9:50 AM CNA Q entered Resident #9's room and stated the call light was not within reach of Resident #9. She stated the resident would not be able to use the call light if she had an emergency or needed anything from the staff. CNA Q stated Resident #9 had fallen in the past attempting to get out of her chair. She stated there was a possibility Resident #9 could fall or have an emergency and would not be able to call out for help. She stated she had been in-serviced on call lights and to place the call light near the resident when in their room. She stated she did not recall when she received the in-service. Interview on 7/30/24 at 1:00 pm with CNA A revealed that residents should have their call lights within reach so they could have their needs met. CNA A said most residents have a regular call light except Resident # 47 who has a soft pad call device that he used be he has contractures of both arms. CNA A said Resident # 47 was mainly nonverbal so he needed frequent checks to make sure his needs were met. In an interview on 07/31/2024 at 9:08 AM the Administrator stated all call lights were expected to be within reach of the resident when the resident was in their room. He stated there was a possibility if the call light were not in reach the resident may need nursing assistance and would not be able to call out for help. In an interview on 07/31/2024 at 10:06 AM LVN P stated if a resident's call light was not within reach of the resident there was a possibility a resident may fall and break a hip or hit their head on the floor attempting to reach the call light. He stated if the resident had an emergency, the resident may be able to yell for help but there were some residents that would not be able to yell very loud. It would be difficult to hear those residents. LVN P stated Resident #9 would be difficult to hear if staff were not near their rooms. He stated it was the responsibility of all staff in the facility to check call lights when they entered a resident room to ensure the call light was attached where the residents had easy access to use the call light. He stated he had been in-serviced on call lights and placing the call light within reach of the resident when they were in their room. LVN P did not recall the last time he received the in-service. In an interview on 07/31/2024 at 11:09 AM the DON stated it was all the staff's responsibility when they entered a resident room to ensure the call light was within reach of the resident. She stated if the call light were not within reach, it would be difficult for a resident to obtain the help they may need in a timely manner. She stated some residents were able to yell for help and some residents would not be able to yell loud enough. She stated a resident had a potential to fall if the resident attempted to reach for their call light. She stated a resident may fracture their hip, break their leg, or arm. The DON stated it was safe practice for all staff to ensure call lights were within reach of all residents. She stated an in-service had been given to all staff on call light placement. She stated she did not recall the date when the in-service was given to the staff. In an interview on 07/31/2024 at 11:40 AM CNA B stated all staff were responsible to check call lights when they entered a resident's room. She stated if the call light was not in reach the resident may fall attempting to reach the call light or try to find the call light. CNA B stated a resident may break a bone or gain a laceration on their head if they fell. She stated all call lights were expected to be within reach of all residents when they were in their room. CNA B stated it would be difficult to hear Resident #9 if she attempted to yell for help and the staff were not standing near her room. She stated she had been in-serviced on call lights and attach call lights where residents can reach it when in their room. CNA B did not recall the date of the last in-service she had on call lights. Record review of the Facilities Policy on Call Lights: Accessibility and Timely Response, dated 10/13/2022 reflected the following: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. 2. Staff will ensure the call light is within reach of resident and secured, as needed. 3. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 4. The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor. 5. Ensure the call system alerts staff members directly or goes to a centralized staff work area. 6. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to provide a safe, clean, comfortable, and homelike environment; including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for one (Resident #1) of 8 residents reviewed for homelike environment. The facility failed to ensure two bedside tables were cleaned daily for three days observed during annual survey. This failure placed residents at risk for infections, injuries, and demoralization. The findings included: Review of the Face Sheet for Resident #1 reflected she was admitted on [DATE] with diagnosis of: hemiplegia to left side ( paralysis of limbs on the left side of body), metabolic encephalopathy (problem of the brain, history of traumatic brain injury (disruption in the normal function of the brain, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), epilepsy, unspecified convulsions ( a group of disorders marked by problems in the normal functioning of the brain), and need for personal care. Review of the Quarterly MDS assessment for Resident #1 dated 6/11/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she required substantial assistance for eating, hygiene, and dressing. She could accomplish some ADLs with one person assistance. She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #1 reflected interventions were in place for: full code status, ADL performance deficit, history of falls/hemiplegia, antidepressant medication, anticoagulant medication, chronic pain r/t pelvic fracture, and vertebrae fractures. Review of the Face Sheet for Resident #21 reflected she was admitted on [DATE] with diagnoses of: myopathy (disorder of the skeletal muscles), morbid obesity, hypothyroidism ( when the thyroid gland does not make enough thyroid hormones to meet your body's needs), congestive heart failure ( weakened heart condition that causes fluid buildup in the feet, arms, lungs and other organs), muscle wasting and atrophy ( decrease in size of muscles) and peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel. Review of the MDS assessment for Resident #21 dated 6/13/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she had impairment to both arms and legs, she required one person assist for eating and grooming, and extensive assistance in all other ADLs. She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #21 reflected interventions were in place for: her DNR status, ADL self- performance deficit, a history of falls, a urinary tract infection( infection in any part of the urinary system), Chronic back pain, and psych history related to sexual assault. In an interview on 7/30/24 at 8:20 am Resident #21 stated no one had ever cleaned the surface of her bedside table as far back as she could remember. She stated no one cleaned the table in between meals and incontinence care. She stated no one cleaned the table before setting her meal tray on it and no one helped to wash her hands. Observation of lunch service on 7/30/24, starting at 12:10 pm. At 12:15 pm Resident #21 stated her tray table or bedside table had not been cleaned. She also stated she had not been assisted to wash her hands. At 12:20 pm trays for 500 Hall exited the dining room and were checked by a nurse. At 12:22 pm trays were served to the first two rooms, Resident #10 and Resident #50 by Aides CNA M and CNA N. Neither resident was observed to be assisted with handwashing or cleaning their table. At 12:30 pm Resident #21 was not assisted to wash her hands and her tray table was not cleaned prior to being served her lunch tray. At 12:35 Resident #44 was served his lunch tray with a urinal containing approximately 300 mls of clear yellow urine sitting on the bedside table and left behind alongside his food. In an interview on 7/30/24 at 3:25 pm Housekeeper P stated each room in the facility was to be cleaned daily. He stated all touch surfaces were to be cleaned daily. He stated staff should be sure to follow policy during the current increase in Covid-19 infections in the facility . He stated there was a possibility if residents' rooms were not sanitized a resident may become ill with some type of virus. In an interview on 7/30/24 at 4:00 pm LVN L stated Residents should be assisted to wash their hands multiple times a day by aides and nurses. She stated caregivers should be wearing PPE when in Covid-19 rooms. She stated housekeeping was responsible for wiping down high touch surfaces once a day . She stated if not sanitized a resident may become ill. In an interview on 7/31/24 at 8:12 am Resident #21 stated no one cleaned her bedside table or helped her wash her hands before breakfast today. In an interview on 7/31/24 at 8:50am Resident #1 stated the staff did not help her wash her hands before breakfast today and did not help her wash her hands after getting up to the bathroom at 8:30 am. In an interview on 7/31/24 at 12:20 pm CNA A stated she assisted all the residents on 500 Hall to wash their hands this morning. She stated she can't speak for other aides, but she made sure everyone got help when they needed it. She stated tabletops and bedside tables were to be cleaned by housekeeping each day . She stated if a room was not sanitized a resident may become ill with breathing problems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the residents were free from abuse, neglect, misappropriation of resident property, and exploitation for one (1) of five (5) residents reviewed for abuse. The facility failed to protect Resident #1 from abuse when staff yelled at her when asking for assistance via call light. The noncompliance was identified as Past Noncompliance 07/30/24. The noncompliance began on 07/22/24 and ended on 07/29/24. The facility had corrected the noncompliance before the survey began. These failures placed residents at risk of experiencing and enduring abuse by facility staff causing decreased quality of life. Findings Included: Review of the Face Sheet for Resident #1 reflected she was admitted on [DATE] with diagnosis of: Hemiplegia to left side, Metabolic encephalopathy, Hx of Traumatic Brain Injury, Muscle wasting and atrophy, epilepsy, Unspecified convulsions, need for personal care. Review of the quarterly MDS assessment for Resident #1 dated 6/11/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she required substantial assistance for eating, hygiene and dressing. She could accomplish some ADLs with one person assistance. She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #1 reflected interventions were in place for: Full Code status, ADL performance deficit, History of Falls/Hemiplegia, Antidepressant medication, Anticoagulant medication, Chronic Pain r/t pelvic fracture and vertebrae fractures. Review of the Face Sheet for Resident #21 reflected she was admitted on [DATE] with diagnoses of: Myopathy, Morbid Obesity, Hypothyroidism, Congestive Heart Failure, Muscle wasting and atrophy and Peripheral Vascular disease. Review of the MDS assessment for Resident #21 dated 6/13/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she had impairment to both arms and legs, she required one person assist for eating and grooming and extensive assistance in all other ADLs. She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #21 reflected interventions were in place for: her DNR status, ADL self performance deficit, a history of falls, a UTI, Chronic back pain, Psych history related to sexual assault. In an interview on 7/29/24 at 9:10 am Resident #1 stated she felt fine, and she got along well with facility staff. She stated the one aide was the only one that had ever spoken badly to her. She stated she did not like to discuss the matter because the aide was disrespectful to her and talked to her like a child. In an interview on 7/29/24 at 9:15 am Resident #21 stated she had overheard the conversation between the CNA and Resident #1. She stated when Resident #1 first pushed her call light it was for assistance to the toilet. She stated the aide came in and said she would be right back. Resident #21 stated Resident #1 then pushed the call light about five more times. She stated the aide came back and yelled and cussed at Resident #1. She stated she didn't hear everything, but the aide was mean and warned Resident #1 not to push the call light anymore. In an interview on 7/30/24 at 1:36 pm the Administrator stated the employee named in the Abuse/Neglect allegation involving Resident #1 and her roommate Resident #21. The Administrator stated the employee was terminated for inappropriate behavior towards a resident. He stated he interviewed Resident #1, and she confirmed the staff was rude. The Administrator stated the Resident's room-mate Resident #21 stated she overheard and felt the aide had a bad attitude and was disrespectful. The Administrator stated no other reports of bad behavior were found in interviews with other residents. He stated in his interview with the can she denied speaking inappropriately or using cuss words. The Administrator stated no harm was assessed to either resident. In an interview on 7/30/24 at 3:15 pm the DON stated the incident involving Resident #1 and #21 had been investigated. She stated the facility had an aide who was not always polite with residents. She stated Resident #1 informed her the aide talked down to her like she was a child. The DON stated the roommate, Resident #21, confirmed the aide was grouchy with Resident #1. The DON stated no psychological harm was assessed. The DON stated the social worker did a Harm Survey with all able residents and no other residents had any complaints related to the allegations. In an interview on 7/30/24 at 4:00 pm LVN L stated neither Residents #1 nor #21, had any changes in behavior after the incident involving the aide. LVN L stated Resident #21 had complained about the aide stating she yelled at Resident #1 and cussed at her to stop using her call light. Review of the investigation report by the facility completed on 7/29/24 reflected the facility had substantiated the CNA was verbally inappropriate or abusive. The investigation started on 7/22/24 when Resident #1's family member reported via telephone that the Resident was treated ugly and disrespectfully by the CNA. The aide was suspended, and the physician, RP, and Sheriff department were notified. A head-to-toe assessment reflected no new injuries. Resident #1 denied any psychological stress. Interviews with other residents were conducted. Residents #1 and her roommate, Resident #21, were interviewed by the administrator. The interviews reflected the CNA was loud, inappropriate, and yelled at Resident #1 for putting her call light on too many times. The Administrator interviewed the alleged perpetrator who denied doing anything wrong. She stated Resident #1 put on her call light multiple times and she told her after getting her up she was going to keep her in her wheelchair. She stated she did not yell, the resident took it wrong. Review of the CNA's written statement dated 7/22/24 reflected she went to answer Resident #1's call light and she asked for a pain pill. She stated she would inform the nurse, and the nurse stated it would be 45 more minutes before she could have a pain pill per her physician's orders. The CNA stated Resident #1 put on the call light five more times asking for a pain pill. The CNA stated she took Resident #1 to the bathroom and placed her in a regular wheelchair as Resident #1's electric chair was still charging. Her statement also reflected she had informed Resident #1 the nurse wanted her to sit up in the wheelchair for a while after her lunch. Review of the Abuse Neglect and Exploitation Policy dated 8/15/22 reflected a definition of Verbal Abuse which included the use of disparaging or derogatory terms to residents. The CNA had completed training on abuse neglect at the time of her employment. Review of the facility policy Promoting Resident Dignity dated 1/13/23 reflected the employees were to protect and promote Resident rights and treat each resident with respect and dignity. Resident requests will be responded to in a timely manner. Staff were to speak respectfully to residents, discussions should not be overheard by others. The noncompliance was identified as Past Noncompliance 07/30/24. The noncompliance began on 07/22/24 and ended on 07/29/24. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to have sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for one cook (Cook G) of three dietary cooks reviewed for qualified dietary staff in that: Cook G had not received onboarding training with the appropriate competencies and skills to carry out the functions of the food and nutrition services department. This failure could place residents at risk of not having their nutritional needs met and place them at risk of food borne illness. Findings included: During an interview on 7/29/24 at 9:00 am the DD said all her staff including herself had the Texas Food Handlers License except for [NAME] G who was new and just started in the early part of July 2024. The DD said [NAME] G will be coming in to take her Texas Food Handlers course this week and get their food handlers license . The DD said [NAME] G had recently transitioned from the housekeeping department to dietary department. The DD said [NAME] G has worked several shifts since starting and was being trained by the DD, [NAME] E, and [NAME] F. The DD said [NAME] G has never prepared a meal by themselves and they have never been left in the kitchen without a team member present who has their Texas Food Handlers certification. During an observation and interview on 7/31/24 at 12:30 pm revealed [NAME] G to be in the DD office taking the Texas Food Handler online course. [NAME] G said they started in the dietary department on 7/11/24. [NAME] G said their normal shift was 12:00 pm-8:00 pm. [NAME] G said they have been receiving training from the DD, [NAME] E, and [NAME] F. [NAME] G said they have never worked in food service prior to this position. [NAME] G said they do not have a Texas Food Handlers certification, and which was why the DD requested they come in early today to be able to take the course today. [NAME] G said they have received Hands on training from the DD and the other cooks. [NAME] G said they have been allowed to assist in preparing the resident meals, wash dishes independently, serve tray line independently. [NAME] G said they have been trained on the different types of diets offered, menus and alternate meal options available. [NAME] G said they have not received or were unsure if they had received training on cross contamination, infection control, time temperature control, HACCP , recipes, and production records. [NAME] G said they had never received a job description to sign or nay other paperwork documents for this current position. Record review of dietary schedule for 7/15/24 - 8/12/24, revealed [NAME] G had worked 11 shifts in the dietary department as a cook. Record review of [NAME] G personnel file revealed a hire date of 3/1/24 with a job title of housekeeper signed by [NAME] G on 3/4/24. Job description of housekeeper in employee file dated 3/4/24. Interview on 7/29/24 at 9:00 am, DD was asked for the training documentation for [NAME] G. No training documents for [NAME] G provided prior to exit. Record review of the cook job description undated revealed under Licensing requirements: Texas Food Handler Certificate And under Experience requirements: Knowledge of food preparation, sanitation, and hygienic methods. Knowledge of Universal Precautions and rules that govern hazardous waste. Previous experience in skilled nursing facility is preferred. Ability to follow oral and written directions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of eight residents (Resident # 8, Resident #18, Resident #34, and Resident #50). 1. The facility failed to ensure Resident #18 and Resident #50's facial hair was removed. 2. The facility failed to ensure Resident # 8, and Resident # 34's nails were cleaned and did not have any rough edges. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Record review of Resident # 18's Face Sheet dated, 07/31/2024, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of muscle wasting and atrophy, not elsewhere classified, multiple sites ( thinning or loss of muscle tissue), lack of coordination (uncoordinated movement due to a muscle control problem that causes inability to coordinate movements), age-related physical debility (frail patients often present with symptoms including weakness and fatigue, medical complexity, and reduced tolerance to medical and surgical interventions), and type 2 diabetes mellitus without complications (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar levels to be abnormally high). Record review of Resident #18's Quarterly MDS Assessment, dated 06/21/2024, reflected the resident had a BIMS score of 1 indicating her cognition was severely impaired. Resident #18 did not reject care. She did require assistance with the following ADLs: eating, oral hygiene, toileting hygiene, showers, upper and lower dressing, and required maximum assistance with personal hygiene. Record review of Resident #18's Comprehensive Care Plan , dated 06/25/2024, reflected Resident #18 had ADL self -care performance deficit related to dementia (impairment of memory and abstract thinking, and often with personality change). Intervention: Resident #1 required limited assistance by one staff with personal hygiene and oral care. Observation on 07/29/2024 at 11:01 AM Resident #18 was sitting in her room. She had facial hair above her upper lip and had hair on the right side of her chin. The hair was approximately 1-2 inches long. Interview on 07/29/2024 at 11:03 AM Resident #18 was not interview able. Record review of Resident #50's Face Sheet dated, 07/31/2024, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of depression ( a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle wasting and atrophy, not elsewhere classified, multiple sites ( thinning or loss of muscle tissue), unspecified dementia, mild , with anxiety (impairment of memory and abstract thinking, and often with personality change and anxiety is often related to worries about coping with the condition and what the future holds). Record review of Resident #50's Quarterly MDS Assessment, dated 05/21/2024, reflected Resident #50 had a BIMS score of 7 indicating her cognition was severely impaired. Resident #50 required ADL assistance with eating, oral hygiene, toileting, upper and lower body dressing, putting on/ taking off footwear, and personal hygiene. Record review of Resident #50's Comprehensive Care Plan, dated 06/07/2024, reflected Resident #50 had an ADL self-care performance deficit related to dementia. Intervention: Resident #50 required assistance with personal hygiene. Observation on 07/29/2024 at 11:13 AM Resident #50 entered her room and was standing at the side of her bed. She had facial hair on the right and left side of her chin. The hair was approximately 1-2 inches long. Interview on 07/29/2024 at 11:14 AM Resident # 50 stated she was so embarrassed when asked if anyone had offered to remove hair on her chin. She stated she did not realize she had hair on her chin and if she did, she would have asked someone to remove it for her. She stated she was not able to remove hair from her chin anymore and needed help. She stated she had been visiting people and did not realize she had hair on her chin. She stated she never let anyone see her with hair on her chin. She stated it worried her. She stated she always wanted to look nice. Resident #50 stated she was worried other people would believe she did not take care of herself and it was embarrassing. 2. Record review of Resident #8's Face Sheet , dated 07/31/2024, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of other lack of coordination (uncoordinated movement due to a muscle control problem that causes inability to coordinate movements), age-related physical debility ( frail patients often present with symptoms including weakness and fatigue, medical complexity, and reduced tolerance to medical and surgical interventions), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (impairment of memory). Record review of Resident #8's Quarterly MDS Assessment, dated 05/22/2024, reflected the resident was not capable of completing BIMS assessment. The staff completed the Assessment for Mental Status. Resident #8 had poor short- and long-term memory recall, she did not know the current season, location of own room, staff names and faces, or that she was residing in a nursing facility. Her decision-making ability was severely impaired. She was also assessed to require assistance with the following ADLs: eating, oral hygiene, toileting hygiene, showers, upper and lower body dressing, and personal hygiene. Record review of Resident #8's Comprehensive Care Plan, dated 06/21/2024, reflected Resident #8 had an ADL self- care performance deficit related to dementia. Intervention: Resident required assistance with personal hygiene. She was at risk for signs/symptoms of depression related to dementia. Observation on 07/29/2024 at 8:59 AM Resident #8 was in her room sitting in her wheelchair. Her middle finger and ring fingernails were rough around the edges on her right hand. Resident #8 also had blackish/ brownish hard substance underneath the forefinger, ring finger and middle fingernails on her right hand. Interview on 07/29/2024 at 9:02 AM Resident #8 was not interview able. Record review of Resident # 34's Face Sheet dated, 07/31/2024, reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of lack of coordination (uncoordinated movement due to a muscle control problem that causes inability to coordinate movements), type 2 diabetes mellitus with diabetic neuropathy, unspecified (nerve damage caused by high blood sugar levels over time, leading to various complications in different parts of the body), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (impairment of memory), and chronic angle -closure glaucoma, unspecified eye, stage unspecified ( occurs when a portion of the angle is intermittently obstructed, resulting in scarring). Record review of Resident #34's Quarterly MDS Assessment, dated 04/30/2024, reflected the resident had a BIMS score of 11 indicating his cognition was moderately impaired. Resident #34 required assistance with personal hygiene, showers, and putting on and taking off footwear. Record review of Resident #34's Comprehensive Care Plan dated, 06/21/2024, reflected Resident #34 had an ADL self-care performance deficit. Intervention: Bathing/Showering: check nail length and clean on bath day and as needed. Report any changes to the nurse. Resident required assistance with bathing/showering. Resident was assessed to refuse showers and to be shaved. Record review of Resident #34's Shower record dated 07/02/2024 - 07/31/2024 reflected Resident #34 did not refuse shower from 07/12/2024 thru -7/31/2024. Observation on 07/29/2024 at 9:39 AM Resident #34 was sitting in his wheelchair in his room watching television. Resident #34 had blackish hard substance underneath the forefinger and middle fingernails on his right hand. His middle and right fingernails were rough around the edges. There was an odor of bowel movement on his right hand. Interview on 07/29/2024 at 9:42 AM Resident # 34 stated he asked someone to clean and trim his nails two or three days ago. The person stated she would report it to a nurse to clean and trim his nails because he was a diabetic. He stated a nurse never came to his room. Resident #34 stated he would try to clean and trim his nails, but with his vision issues he was reluctant due to being a diabetic and did not want to cut his finger and get it infected. He stated he did this one time, his finger became infected, and he quit doing his own nail care. Resident #34 stated he thought he had bowel movement in his fingernails and did not know how it got into his nails. In an interview on 06/27/2024 at 11:20 AM LVN P stated the nurses and the CNAs were responsible for nail care. He stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. LVN P stated it was the CNAs responsibility to clean and trim all other residents' nails. He stated if anyone refused nail care it would be documented on their shower record. He stated if there was a blackish substance underneath the residents' nails, there was a possibility the substance had bacteria underneath the residents' nails. He also stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea. He stated if a resident scratched themselves with rough nails there was a potential a resident may develop a skin tear. LVN P stated he was not aware of anyone refusing nail care. He stated he would need to refer to the shower record to know for certain if Resident # 8 or Resident #34 refused nail care. He stated if a female resident had facial hair on their chin there was a possibility the resident may become embarrassed with their appearance and may isolate themselves in their room. In an interview on 06/27/2024 at 11:09 AM the DON stated it was a joint effort between the CNAs and the nurses to complete nail care on the residents. She stated the nurses was responsible for residents with diagnosis of diabetes ( a disease in which the body's ability to produce or respond to the hormone insulin was impaired). The DON stated nail care was given during showers and as needed. She stated if a resident had blackish substance underneath their nails there was a possibility the substance may be some type of bacteria. The DON stated if the scent of feces was noticed underneath the residents' fingernails there was a potential this may be bacteria. She stated it was a possibility a resident may become physically ill such as vomiting or diarrhea if they ingested bacteria. She stated if a resident had rough fingernails there was a possibility the resident may scratch themselves and develop a skin tear. The DON stated if the female residents had facial hair on their chin or around the top lip of their mouth, it was a dignity issue. She stated the resident may become embarrassed and there was a possibility the resident may not want to interact with other residents. In an interview on 06/27/2024 at 11:30 AM CNA B stated the nurses completed all diabetic fingernails and the CNAs were responsible for all other residents' nails. She stated the CNAs were responsible to complete nail care such as trimming, filing, and cleaning the nails. CNA B stated if a resident's nails needed to be cleaned, trimmed, or filed and it was not their shower day the staff were expected to do any type of nail care as needed. She stated if a resident had blackish substance underneath their nails, it was probably some type of bacteria such as bowel movements. She stated if a resident swallowed bacteria it was a potential the resident may become ill with E. coli (a bacteria that is commonly found in the lower intestine of warm-blooded organisms) and may develop major stomach problems such as diarrhea. She stated she worked with Resident #8 and Resident #34, and she was not aware of them refusing nail care. CNA B stated sometimes Resident #34 would refuse to shave but she was not aware of him refusing nail care. She stated if a resident's nails were rough there was a possibility the resident may scratch themselves and develop a skin tear, or possibly scratch their eye and cause a tear on their eyeball. CNA B stated if a female resident had facial hair on their chin, a resident may become embarrassed over their appearance. She stated it would be a dignity issue and it was a possibility a resident may isolate themselves if they did not want anyone to see them with facial hair. CNA B stated it was the CNAs or nurses' responsibility to remove facial hair from the female's chin in the resident's room or during showers. She stated she was not aware of any female resident refusing to allow staff to remove unwanted facial hair from their face. Record review of the Facilities Policy on ADLs dated 05/26/2023 reflected A resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal, and oral hygiene.

Based on observations, interviews, and record review, the facility failed to provide the physician prescribed therapeutic diet to 11 of 13 residents (Resident # 3, Resident # 9, Resident # 10, Resident # 12, Resident # 13, Resident # 22, Resident # 23, Resident # 25, Resident # 36, Resident # 156, and Resident # 207) reviewed for therapeutic diets, in that: Resident # 3, Resident # 9, Resident # 10, Resident # 12, Resident # 13, Resident # 22, Resident # 23, Resident # 25, Resident # 36, Resident # 156, and Resident # 207did not receive a mechanical soft diet as ordered. This failure could place residents at risk for choking and causing further health issues. Findings included: A record review of Resident # 3's diet order dated 8/29/22 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # 9's diet order dated 8/29/22 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # !0's diet order dated 7/10/24 reflected an order for Regular diet mechanical sift texture, regular liquids consistency. A record review of Resident # 12's diet order dated 8/29/22 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # 13's diet order dated 12/14/23 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # 22's diet order dated 3/29/22 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # 23's diet order dated 4/22/24 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # 25's diet order dated 9/25/23 reflected an order for Reduced Concentrated Sweets mechanical soft texture, regular liquids consistency. A record review of Resident # 36's diet order dated 8/10/23 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # 156's diet order dated 7/16/24 reflected an order for Regular diet mechanical soft texture, regular liquids consistency. A record review of Resident # 207's diet order dated 7/16/24 reflected and order for Renal-Liberalized diet mechanical soft texture, regular liquids consistency. Observation of kitchen lunch preparation on 7/29/24 at 11:00 am revealed tray line to be set up with chopped lettuce for beef soft tacos. Observation of lunch tray line service on 7/29/24 at 12:00 pm revealed mechanical soft diets receiving chopped lettuce on meal trays. Observation of lunch meal tray on 7/29/24 at 12:45 pm of Resident # 13's meal tray and meal ticket with order of Regular diet mechanical soft texture. Resident # 13's meal tray consisted of ground beef and tortilla mixture with shredded cheese as garnish on top of beef mixture with a side of chopped lettuce. Observation of Resident # 13 to be eating some of the lettuce. Record review of week 2-day 8 recipe for soft beef taco reflected under notes: 3. For ground and puree texture modifications, omit lettuce and tomatoes. Record review of week 2-day 8 production records signed by Dietary Director and RD reflected mechanical soft texture to receive ½ cup of shredded lettuce. Interview on 7/29/24 at 12:33 pm the Dietary Director said the cooks follow the production records when preparing the meals and the production records stated mechanical soft diets can have chopped lettuce. The Dietary Director was asked about the recipe for soft beef tacos indicating to omit the lettuce and tomato and modify with substitution, the Dietary Director reiterated the staff follow the production records for meal preparation. The Dietary Director was unsure about the policy concerning diet texture modifications and stated they would ask the RD and Administrator about the policy. Interview on 7/30/24 at 9:22 am reflected the Registered Dietician (RD) said the company and the facility followed the National Dysphasia Diet Level 3: Advanced protocol for their mechanical soft diets. The RD said this protocol allowed for residents to receive shredded lettuce. The RD said this protocol was the policy the facility follows. The RD said the recipes come from their grocery supplier and the facility follows the facility procedure/protocol if the recipe has a discrepancy and states differently than the facility policy/protocol. Interview with Dietary Director on 7/31/24 at 9:15 am reflected Dietary Director said the facility received whole heads of lettuce and they chop it themselves as receiving pre-shredded lettuce in was more expensive and usually does not have a long shelf life. Record review of mechanical soft diet textures in-service dated 6/3/24 presented by Dietary Director reflected 5 staff members signatures of attendance. In-service training documentation reflected Under heading What is a Mechanical Soft diet texture? An altered diet texture for residents who cannot safely chew or swallow regular/hard food textures but may still chew softer foods. Foods should be soft, moist. Meats are ground or minced, moist, and no larger than ¼ inch pieces. Under heading Not approved foods: raw vegetables Record review of National Dysphagia Diet Level 3: Advanced policy provided by facility RD undated reflected mech soft to be handwritten in parenthesis at the top of the document next to the word advanced. Under heading considerations for specific food items: Raw fruits and vegetables-shredded lettuce is underlined, sliced tomatoes, and finely chopped tomatoes/salads as tolerated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive device when consuming meals and snacks for 1 resident (Resident # 2) of 8 residents reviewed for assistive devices. The facility failed to provide Residents# 2's physician ordered handled cup with lid for lunch. This failure put resident at risk for decreased fluid intake, dehydration, and decreased quality of life. Findings included: A record review of Residents # 2's face sheet dated 7/31/24 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral palsy (A congenital disorder of movement, muscle tone, or posture.), intellectual disabilities (A neurodevelopmental condition that affects a person's intellectual functioning and adaptive behavior.), muscle wasting and atrophy (The loss of muscle mass and strength), dysphagia (Difficulty swallowing foods or liquids, arising from the throat or esophagus.), ataxia (Impaired balance or coordination can be due to damage to the brain), need for assistance with personal care,, cognitive communication deficit (A communication problem that's caused by a cognitive deficit rather than a language or speech deficit), and age related physical debility. A record review of Resident # 2's care plan last revised on 1/26/2024 reflected she has potential nutritional problems related to cerebral palsy. Diet order RCS diet, mech soft, regular liquids consistency, Handled cup. Interventions reflected Resident # 2 will get a no spill handled cup with her meals to help aid with her drinking abilities. Provide serve diet as ordered. Monitor intake and record meal. A record review of Resident # 2's diet order dated 1/25/2024 reflected Reduced Concentrated Sweets diet, Mechanical Soft texture, Regular liquid consistency, handled cup with lid, divided plate, built up utensils, can have salads per speech therapy. Observation on 7/29/24 at 12:40 pm the Activity Director in dining room assisting Resident # 2 with their drink. Resident # 2 had a diet coke being poured into handled cup with lid by the Activity Director. The drink foamed over cup lid was applied to cup and given to Resident # 2. Cup slipped from Resident # 2's hands onto floor and spilled contents on floor. The Activity Director put Resident # 2 handled cup in the dirty dish area of dining room. The Activity Director went to Resident # 2's room got Resident # 2 another diet coke opened it then went to get straw to put inside can for Resident # 2. The Activity Director gave Resident # 2 the can of Diet coke with straw. A new clean handled spill proof cup was never provided to Resident # 2 during lunch meal service. Interview and observation on 7/29/24 at 2:00 pm with the Dietary Director reflected Resident # 2 has an order for a handled spill proof cup with all meals. The Dietary Director showed the kitchen had a quantity of 2 handled cups in the clean dish storage area that Resident# 2 used. Record review of Meal Service policy dated 10/1/2018 reflected under heading policy: The facility believes that all residents should be always treated with dignity and respect. A respectful, positive dining experience is essential to the residents' quality of life and helps to identify residents' needs and improve their overall nutritional status. 8. Assistive devices will be provided as ordered and documented in residents' care plans.

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 one of one kitchen reviewed for sanitation. 1. The facility failed to ensure all items were labeled and dated. 2. The facility failed to ensure all items were covered and stored properly. 3. The facility failed to ensure sanitation practices were occurring in kitchen. 4. The facility failed to ensure temperature logs were being completed. These failures placed residents at risk of foodborne illness. Findings included: Observation of the kitchen's ice machine on 7/29/24 at 7:00 am revealed the inside of the machine to have black debris and growth growing on the upper inside of the machine near the door. Observation of ice scoop receptacle on wall next to ice machine on 7/29/24 at 7:05 am revealed inside of receptacle to have dried brown appearing substance at the bottom of the receptacle. Observation of kitchen prep area worktable on 7/29/24 at 7:08 am revealed a staff member had a Styrofoam cup of coffee uncovered in work prep area near toaster, robot coupe blender, and block of butter unwrapped with butcher knife on wrapper next to it. Observation on 7/29/24 at 7:10 am in the clean dish storage area, there were steam table lids with dried particles on them. The lids were stored in bin with other clean steam table lids. Observation of walk-in refrigerator on 7/29/24 at 7:13 am revealed the following: *A cut unwrapped undated cucumber sitting on a tray with health shakes and chocolate syrup bottles. *A thawing brisket on bottom shelf on sheet pan undated. Observation of walk-in freezer on 7/29/24 at 7:16 am revealed the following: *A bag of frozen chicken breast that had been torn open with 1 single chicken breast remaining undated and unsealed. *A steam table pan of mixed vegetable blend with red peppers, green beans, broccoli, and mushrooms uncovered and undated on shelf. *A package with half of an angel food cake undated and unsealed. Observation of dry storage area on 7/229/24 at 7:20 am revealed the following: *A container of brown sugar with the lid sitting on top of container with a gap of approximately 2-centimeter opening. *A container of flour with lid sitting on top of container with a gap of approximately 1-centimeter. *A gallon Ziploc bag with penne pasta inside unlabeled and undated. *An open storage bin with individually wrapped saltine crackers unlabeled and undated on bin. *An open storage bin with individually packaged ketchup packets with a label stating contents were flour and date of 10/20/23. *An opened storage bin with individually packaged mustard packets undated and unlabeled. *An opened box of tea bags undated unlabeled and with box partially torn open with part of box missing. *An undated container of unopened oatmeal. *An undated container of parsley flakes. Observation of kitchen prep drink station on 7/29/24 at 7:30 am revealed the following: *An undated gallon container of orange juice without lid approximately ¼ full. *6 juice glasses full of orange juice without lids on table. A stack of lids were present next to glasses that had been filled. Observation of temperature logs on 7/29/24 at 7:33 am revealed the following: *The daily dish machine temperature and sanitizer log had not been completed for lunch on 7/10/24, breakfast on 7/25/24, and breakfast and lunch on 7/26/24. *The walk-in freezer temperature log had not been completed for 4/30/24, 7/27/24, and 7/28/24. *The walk-in refrigerator temperature log had not been completed for 7/27/24 and 7/28/24. *The pot/sink sanitizer test strip log had not been completed for dinner 7/25/24, breakfast 7/26/24, and lunch 7/26/24. *The daily meal/ food temperature log had not been completed for dinner 7/21/24 and breakfast 6/10/24. Observation of three-compartment sink on 7/29/24 at 7:38 am revealed dried particles, dirt, grime, and a single hair black in color on the dish drain side of the sink. Observation of dish machine rack storage dolly on 7/29/24 at 7:40 am revealed dirt, grime, dried particles, and paper scraps on storage dolly surface where dish machine racks are stored. Observation of lunch tray line on 7/29/24 at 12:15 pm revealed the 400 hall cart trays being loaded into meal cart with charro beans in bowls uncovered and bowls of soup uncovered. Observation of breakfast meal cart on 7/30/24 at 7:50 am revealed the 200 hall meal cart doors open in hallway with bowls of oatmeal on resident trays uncovered. Meal cart unattended at time of observation. Observation on 7/30/24 at 9:15 am Dietary Aide I was in kitchen with his beard guard down under chin not covering beard. Observation on 7/30/24 at 9:22 am of kitchen revealed large 55-gallon trash can in kitchen without lid. Observation on 7/30/24 at 12:05 pm Dietary Aide I was in kitchen working the lunch tray line with beard guard under chin not covering beard. Observation on 7/31/24 at 9:20 am of kitchen revealed large 55-gallon trash can in kitchen without lid. Observation on 7/31/24 at 9:21 am of kitchen revealed spatula hanging in clean utensil storage area with dried particles on surface. Observation on 7/31/24 at 9:24 am of kitchen revealed inside of juice dispenser nozzle to be caked with red and orange slimy buildup. Observation on 7/31/24 at 12:19 pm of Dietary Aide J in kitchen prepping mayonnaise cups for lunch meal service. Observation further revealed mayonnaise cups to be put on meal trays uncovered and loaded onto meal cart. Interview on 7/29/24 at 9:00 am the Dietary Director said the cleaning logs are posted on the cooler and each staff member has different parts of the kitchen they are responsible for cleaning. The Dietary Director said the cleaning schedule was posted on the cooler right next to the cleaning logs. The Dietary Director said all staff are trained in kitchen sanitation in part of their new hire onboarding training. The Dietary Director said everyone who comes into the kitchen was required to wear hair restraints and beard restraints for the males. The Dietary Director said when items are received, they are dated with the receipt date and stored using the First In First Out method. DD said once items are opened or prepared, they are dated with the open/preparation date and the discard date. Record review of dietary cleaning schedule posted for week of 6/24/24 revealed the following: *cleaning task of toaster completed 6/24/24, *cleaning task of microwave completed 6/24/24 by Dietary Aide K, *cleaning task of can opener completed 6/24/24 by Dietary Director and 6/25/24 by Dietary Aide K, *cleaning task of cook shelves and steam table completed by [NAME] F undated, *cleaning task of storeroom completed by [NAME] F undated, and *cleaning task of dish machine completed by [NAME] F undated. Record review of weekly dietary cleaning schedule posted for week of 7/1/24-7/8/24 with cleaning task of: *dry storage completed 7/1/24 by Dietary Aide I, *cleaning task of walk-in freezer completed on 7/1/24 by [NAME] E, * cleaning task of walk-in cooler completed on 7/1/24 by Dietary Director, *cleaning task of reach-in cooler completed 7/10/24 by Dietary Director, *cleaning task of mop under/between ovens, fryer and steamer completed on 7/1/24 by Dietary Director, and on 7/2/24 by Dietary Aide I, and *cleaning task of dish room completed on 7/1/24 and 7/2/24 by [NAME] F. Record review of general kitchen sanitation policy dated 10/1/2018 reflected under heading policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All nutrition and foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US food codes to minimize the risk of infection and food borne illness. Under heading procedure: 1. Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all food-contact surfaces of equipment. 4. Clean and sanitize all multi-use utensils and food-contact surfaces of equipment used in the preparation or storage of potentially hazardous food prior to each use. Clean and sanitize food-contact surfaces of equipment and multi-use utensils used for preparation of potentially hazardous foods on a continuous or production line basis at scheduled intervals throughout the preparation period based on food temperature, type of food and amount of food particle accumulation. 5. After cleaning and until use, store and handle all food-contact surfaces of equipment and multi-use utensils in a manner that protects the surfaces from manual contact, splash, dust, dirt, insects, and other contaminants 6. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. Record review of the dietary food handling policy undated under heading purpose: The purpose of this procedure is to provide guidelines for the d=safe preparation, handling, and storage of perishable food and proper environmental cleaning. Under heading general guidelines 13. Clean uniforms, hairnets or caps should be worn daily. All facial hair should be covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection control 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 4 of 8 (Resident #2, Resident #11, Resident #19 and Resident #44) residents reviewed for infection control practices. 1. Business Office Manager failed to don PPE according to the facility protocol prior to entering COVID isolation. 2. The CNAs serving food trays failed to ensure Resident #44 was served his meal under safe sanitary conditions. 3. Activity Director observed assisting Resident # 11 in dining room with meal set up touching ready to eat food items with ungloved hands and without performing hand hygiene in between residents. 4. CNA A observed passing hall tray for Resident # 2 and assisting Resident # 2 with meal tray set up with ungloved hands and without performing hand hygiene between residents. These failures could lead to the spread of infection to residents, residents' illness, and/ or distress. Findings included: 1. Observation on 07/30/2024 at 12:40 PM the BOM was in the dining room and volunteered to take Resident # 19 meal tray to her room on 400 hall. Business Office Manager exited the dining room with the meal tray and carried it to COVID Resident # Business Office Manager donned N95 mask ( personal protective equipment that are used to protect the wearer from particles of liquid from contaminating the face) and did not sanitize her hands. She entered Resident #19's room with meal tray. She exited Resident #19's room approximately nine minutes after entering the room. Observation on 07/30/2024 at 12:46 PM revealed the protocol of donning and doffing PPE was on the door of Resident #19's room and had instructions of the proper PPE to wear prior to entering the room. Observation on 07/30/2024 at 12:46 PM revealed the following was the protocol of PPE by CDC guidelines prior to entering Resident #19's room: 1. Use Personal Protective Equipment : PPE must be donned correctly before entering the patient area (e.g., isolation room, unit if cohorting). 2. Preferred PPE use N95 or higher respirator , face shield or googles, one pair of clean, non-sterile gloves, and isolation gown. 3. Acceptable Alternative PPE- use face mask, face shield or goggles, face mask N95 or higher respirators are preferred but facemasks are an acceptable alternative. One pair of clean , non-sterile gloves, and an isolation gown. Observation on 07/30/2024 at 12:46 PM revealed the following form on Resident #19's room, everyone must clean their hands, including before entering and leaving the room. In an interview on 07/30/2024 at 12:48 PM the BOM stated she did not sanitize her hands, place gloves on her hands, or wear a gown prior to entering Resident #19's room . She stated this was a COVID isolation room. She stated she thought she only needed to wear a mask and not anything else when entering an isolation room. She stated she did not sanitize or wash her hands prior to leaving the room. She was standing by Resident #19's room and stated she did not read the signs on the door and if she had read the signs she would have known the proper protocol she was to follow with wearing gloves, gowns, and sanitizing her hands. She stated she did bring cellophane and other container lids from the residents' meal tray out of the room. The BOM stated she was not to bring anything out of the room, and she did not discard these items prior to leaving the room. She stated she had been in-serviced on PPE, but she misunderstood the difference when it was COVID isolation and Non-COVID isolation. She stated she needed to read the signs or ask a nurse to ensure she was using the proper PPE. The BOM stated she did not follow facility protocol on wearing the proper PPE when she entered Resident #19's room . She stated both Residents in that room did have COVID. Observation on 07/30/2024 at 12:53 PM the BOM did not sanitize her hands when she exited Resident #19's room and during the interview. She walked down the end of the 400 hall to the front of the 400 hall and entered the therapy room, went into the restroom, washed her hands, and threw away the items she had in her hands when she exited Resident #19's room in the trash in the therapy bathroom. In an interview on 07/30/2024 at 1:15 PM the BOM stated she did enter the therapy room, wash her hands, and disposed of the lids and cellophane off of the meal tray she delivered to the COVID room Resident #19's room . She stated she was required to sanitize her hands prior to leaving the room and she should have sanitized her hands as soon as she exited the room. She stated there was a potential she could have contaminated her clothes and hands while around residents with COVID. The BOM apologized for touching the state surveyors' clothes and arm after she exited Resident #19's room . She stated, I was not to touch anyone or anything until I washed my hands. She stated there was a possibility she could contaminate other residents, staff, or visitors with COVID if she was not wearing the proper PPE when she entered a COVID isolation room. She stated there was protocol in place of the correct PPE to wear, to sanitize hands, and she did not follow the facility protocol. The BOM stated she had been in-service on the facility protocol of wearing the proper PPE. She stated it was recently but did not recall the date. In an interview on 07/31/2024 at 9:08 AM the Administrator stated the staff were expected to follow facility protocol for PPE when entering COVID isolation rooms. He stated the staff were expected to wear gown, face mask, face shield or goggles, and sanitize hands prior to donning gloves. He stated they had recent in-services for all staff on wearing PPE in COVID isolation rooms. The Administrator stated the forms on Resident #19 was the facilities protocol of what to wear prior to entering the room. He stated the BOM did not follow the facility protocol/policy on PPE when entering or exiting a COVID positive resident room. He did not reply when asked if there was a potential when a staff did not wear proper PPE in COVID room, that it could be spread to other staff or residents. In an interview on 07/31/2024 at 11:09 AM the DON stated the infection control forms on Resident #19's door was the facility protocol for the proper use of PPE and hand sanitation. She stated the facility was following CDC recommendations. The DON stated anyone including non- nursing staff were expected to sanitize their hands prior to donning gloves. The staff were required to Donn gown, N95 face mask, and face shield prior to entering any COVID isolation room. She stated all of the information of what to wear and how to Donn PPE was on the door of Resident #19's room . She stated if anyone did not follow the facility protocol of wearing PPE in a COVID isolation room there was a potential the person may contaminate other staff, residents, or visitors. She stated when someone exits a COVID isolation room the person was expected to wash their hands in the room prior to exiting. The DON also stated if the person did not wash their hands or sanitize their hands prior to exiting the COVID isolation room they were to sanitize their hands immediately after exiting the room. The DON stated both residents in Resident #19's room did have COVID. 2. Review of the Face Sheet for Resident #44 reflected he was admitted on [DATE] with diagnoses of: malignant neoplasm of renal pelvis ( the area at the center of the kidney), dementia with psychotic disturbance and anxiety, UTI ( infection in any part of the urinary system, pain to right arm/wrist, history of falling, high blood pressure, anemia, malignant skin cancer, and atrial fibrillation (irregular heart beat). Review of the quarterly MDS assessment dated [DATE] reflected: a BIMS score of 7 indicated severe cognitive impairment. His physical assessment reflected he was independent in eating and some oral hygiene, but needed at least one to two person assist for dressing, bathing, and other ADLs. He was assessed as occasionally incontinent of bladder and always continent of bowels. Review of the Care Plan for Resident #44 reflected interventions were in place for: DNR status, high risk of fractures or injuries r/t renal cancer untreated, ADL performance deficit r/t cancer and weakness, impulsive behavior problem, impaired cognitive function, lower extremity weakness, terminal prognosis r/t renal cancer, and the resident elected to be on palliative care. Review of the Face Sheet for Resident #1 reflected she was admitted on [DATE] with diagnoses of: hemiplegia to left side ( paralysis of limbs) , metabolic encephalopathy ( a problem of the brain) , history of traumatic brain injury ( happens when a sudden , external, physical assault damages the brain, muscle wasting and atrophy, epilepsy, unspecified convulsions, and need for personal care. Review of the quarterly MDS assessment for Resident #1 dated 6/11/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she required substantial assistance for eating, hygiene, and dressing. She could accomplish some ADLs with one person assistance. She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #1 reflected interventions were in place for: full code status, ADL performance deficit, history of falls/hemiplegia, antidepressant medication, anticoagulant (inhibiting the coagulation of the blood) medication, chronic pain r/t pelvic fracture, and vertebrae fractures. Review of the Face Sheet for Resident #21 reflected she was admitted on [DATE] with diagnoses of: myopathy , morbid obesity, hypothyroidism, congestive heart failure , muscle wasting and atrophy, and peripheral vascular disease . Review of the MDS assessment for Resident #21 dated 6/13/24 reflected a BIMS score of 15 indicating normal cognitive function. Her physical assessment reflected she had impairment to both arms and legs, she required one person assist for eating and grooming, and extensive assistance in all other ADLs. She was assessed as always incontinent of bowel and bladder. Review of the Care Plan for Resident #21 reflected interventions were in place for: her DNR status, ADL self-performance deficit, a history of falls, a UTI, chronic back pain, psych history related to sexual assault. In an interview on 7/30/24 at 8:20 am Resident #21 stated no one had ever cleaned the surface of her bedside table as far back as she could remember. She stated no one cleaned the table in between meals and incontinence care. She stated no one cleaned the table before setting her meal tray on it and no one helped to wash her hands. 3. A record review of Residents # 11's face sheet dated 7/31/24 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of dementia (a group of symptoms that affects memory, thinking, and interferes with daily life.), traumatic subarachnoid hemorrhage (bleeding on the brain), wedge compression fracture of the T5-T6 vertebra (spinal fracture), hypertension (high blood pressure), hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood), major depressive disorder ( a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life.), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone.), cervicalgia (neck pain), bullous pemphigoid (a rare skin condition causing large, fluid-filled blisters.), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities.) A record review of Resident # 11's care plan last revised on 5/09/2024 reflected she had an ADL self-care performance deficit related to dementia, limited mobility, and terminal illness. Resident # 11's interventions reflected she needed total assistance by 1 staff to eat. 4. A record review of Residents # 2's face sheet dated 7/31/24 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or posture.), intellectual disabilities (a neurodevelopmental condition that affects a person's intellectual functioning and adaptive behavior.), pain in left leg, muscle wasting and atrophy (the loss of muscle mass and strength), dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus.), ataxia (impaired balance or coordination can be due to damage to the brain), hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood.), major depressive disorder ( a mental health disorder characterized by persistently depressed mood or loss of interest in activities also called major depression or clinical depression), hypertension ( high blood pressure), need for assistance with personal care, type 2 diabetes ( adult onset diabetes a group of diseases that result in too much sugar in the blood), cognitive communication deficit (a communication problem that's caused by a cognitive deficit rather than a language or speech deficit), age related physical debility, and bilateral feet deformity. A record review of Resident # 2's care plan last revised on 5/10/2023 reflected she had an ADL self-care performance deficit related to impaired balance, cerebral palsy, ataxia, pain in left leg, age related physical debility, and bilateral feet deformity. Resident # 2's interventions reflected she needed supervision with setup assist of 1 staff to eat. Observation on 7/29/24 at 12:30 pm of the Activity Director in the dining room assisting Resident # 11 in setting up meal trays including touching ready to eat food of soft tacos without gloved hands and without performing hand hygiene in between residents. Observation of Activity Director providing clothing protectors to residents and touching residents' clothes without performing hand hygiene in between each resident. Observation of Activity Director getting residents in dining room, getting residents drinks, and straws without performing hand hygiene between residents. Observation on 7/29/2024 at 7:48 am of CNA A passing breakfast hall trays for 200 hall. CNA A went to pass tray to Resident # 2, assisting with meal tray set up with ungloved hands, and without performing hand hygiene between residents. The facility protocol/policy for following infection control prevention of wearing PPE was the CDC guidelines (not dated) listed during observations of the signs on the door of . Review of the facility policy Promoting Resident Dignity dated 1/13/23 reflected the employees were to protect and promote Resident rights and treat each resident with respect and dignity. Resident requests will be responded to in a timely manner. Residents personal space is to be respected and maintained in a clean sanitary manner. Record review of dietary hand washing policy dated 10/1/2018 reflected under heading policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All nutrition and food service employees will practice good hand washing practices to minimize the risk of infection and food borne illness. Under heading procedure: 2. Hands should be washed after the following occurrences: l. Assisting residents. Record review of hand hygiene policy dated 10/24/2022 reflected under heading policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Under heading definitions: Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub also known as alcohol-based hand rub. Review of the facility policy Infection Prevention and Control Program dated 5/13/24 reflected the facility has established and maintained a safe, sanitary, and comfortable environment to help prevent the spread and development of communicable diseases and infection per accepted national standards and guidelines. All staff are responsible for following policy and guidelines. Hand Hygiene shall be performed in accordance with established hand hygiene procedures. Environmental cleaning and disinfection shall be performed according to facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents has the right to be informed of, and participate in, their treatment for one (Resident #17) of four residents reviewed for resident rights. -The facility failed to ensure Resident #17'ss wishes to discontinue use of Estradiol (estrogen). This failure could place residents at risk of not being part of the decision-making process for their care. The findings included: Record review of Resident #17's admission record revealed a [AGE] year-old resident admitted on [DATE]. Resident #17 diagnoses included cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood), unspecified dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (decrease in size or wasting away of a body part or tissue arrested development), lack of coordination, type 2 diabetes mellitus (a condition results from insufficient production of insulin, causing high blood sugar), polyneuropathy (damage to multiple peripheral nerves), hypertension (high pressure in the arteries), hemiplegia (paralysis of one side of the body) and hemiparesis (is weakness on one side of the body) of the right side, dysphagia (difficulty in swallowing food or liquid difficulty in swallowing food or liquid), and chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes and fluids). Record review of Resident #17's quarterly MDS dated [DATE] with an ARD of 5/12/2023 revealed a BIMS of 11 indicating minimal cognitive impairment. The MDS revealed he had no indications of psychosis, behaviors affecting others, or wandering or elopement behaviors, and he rejected care between one and three days in the seven days prior to the assessment. The MDS documented Resident #17 required extensive assistance from one or more caregivers with bed mobility, transfers, locomotion, dressing, personal hygiene, and toileting, and minimal assistance with set-up for eating. The MDS noted he was always incontinent of bladder and bowel, but he was not on a toileting program. The MDS revealed he was at risk of developing pressure ulcers or injuries, had two venous (typically shallow with irregular sloping edges) and/or arterial (deep and has a 'punched out' appearance) ulcers (an open sore on an external or internal surface of the body, caused by a break in the skin or mucous membrane that fails to heal) of the feet, and was receiving treatment for the injuries. The MDS documented Resident #17 received anticoagulant and diuretic medication seven days of the seven days prior to the assessment. The MDS noted he received no therapeutic services. Record review of the Resident #17's care plan, updated 3/7/2023, revealed a focus on his propensity to curse at staff and make inappropriate comments to female staff members with interventions including anticipation of his needs, positive interactions, discussion of inappropriate behaviors. Record review of Resident #17's medication record revealed he was prescribed Estradiol (a female hormone that regulates many functions in the body, such as reproduction, mood, and bone health) 1mg tablet, one tablet daily, for inappropriate sexual behaviors. The prescription was ordered on 4/11/2023 and initiated on 4/12/2023. Record review of Resident #17's medication record revealed prescriptions for Estradiol 1mg tablet one time daily for inappropriate sexual behaviors. Record review of a nurse's note dated 4/11/2023 documented Resident #17 was being sexually inappropriate with CNA's during bed bath today. Record review of a nurse's noted dated 4/11/2023 revealed Resident #17 was prescribed Estradiol 1mg for inappropriate sexual behaviors. Record review of a nurse's note dated 5/24/2023 created by the DON revealed Resident #17 refused to sign a consent for Estradiol and informed the nurse he did not want to take it. Record review of Resident #17's May 2023 MAR revealed he had been administered Estradiol 5/25/2023 through 5/31/2023 daily at 9:00 AM. Record review of Resident #17's June 2023 MAR revealed he had been administered Estradiol 6/1/2023 through 6/8/2023 daily at 9:00 AM. Observation on 6/6/2023 at 9:09 AM of Resident #17 revealed he was lying in his bed watching television. Resident #17 appeared clean and appropriately groomed. Interview on 6/7/2023 at 8:02 AM with Resident #17, he said he did not know the names of all the medications he took. Resident #17 said he did not know if he was prescribed, administered, or took Estradiol. Resident #17 said he did not know what Estradiol would treat. Interview on 6/8/2023 at 12:18 PM with Resident #17, he said he had spoken with the Admin regarding his Estradiol on 6/8/2023. Resident #17 said he wanted to take the estradiol because it calmed him down. Resident #17 said he had not known he was taking it in the past. Resident #17 said the facility and staff had not informed him of the medications he takes. Resident #17 said the staff would administer the medication and tell him to take it without explaining what he was taking. Interview on 6/7/2023 at 1:14 PM with CNA A, she said she had been employed as a CNA since December of 2022. CNA A said her primary duties as a CNA were to assist residents with showers, other ADL's, weigh the residents, and assist the residents with what they needed. CNA A said Resident #17 did not appear to have a problem with her. CNA A said Resident #17 preferred specific CNA's and nurses. CNA A said Resident #17 routinely refused care. CNA A said Resident #17 had acted inappropriately with her. CNA A said he had made inappropriate jokes and had attempted to touch her bottom. CNA A said she had informed the facility management about her concerns. CNA A said Resident #17's inappropriate behaviors had decreased since she informed management of the issues. Interview on 6/8/20 at 8:14 AM with The MDS, she said Resident #17's Estradiol was not on his care plan. The MDS said it was not on his care plan because he had come to the facility with the prescription. The MDS said she thought the Estradiol was controlling Resident #17's inappropriate sexual behaviors and that was why she had not included it as an intervention on the care plan. The MDS reviewed the EHR and said the Estradiol was prescribed on 4/11/2023. The MDS said the Estradiol should have been included on the care plan as an intervention for the Resident #17's focus on inappropriate sexual behaviors. The MDS said she was unsure if Resident #17 had received any psychiatric or social work intervention to address the inappropriate sexual behaviors. Telephone interview on 6/8/2023 with Resident #17's PCP at 10:34 AM, he said he thought he was aware Resident #17 was prescribed Estradiol. Resident #17's PCP said Estradiol was not a common medication, but it may have been used for sexually inappropriate behaviors. Resident #17's PCP said if Resident #17 was his own responsible party, he could choose to refuse and/or discontinue the medication. Telephone interview on 6/8/2023 with Resident #17's NP at 10:42 AM, she said Resident #17 was prescribed Estradiol for inappropriate sexual behaviors. Resident #17's NP said she had prescribed Estradiol in the past to residents with inappropriate sexual behaviors and it had decreased the behaviors. Resident #17's NP said the estradiol could decrease Resident #17 grabbing behaviors. Resident #17's NP said the estradiol helps the nurses to work with Resident #17 and would stop him from grabbing their lady parts. Resident #17's NP said she had not been informed Resident #17 had refused to take the Estradiol. Resident #17's NP said he could refuse his medication if he was his own responsible party. Interview on 6/8/2023 at 11:17 AM with the DON, she said if a resident had inappropriate verbal behaviors, she would address the concern and move on. She said if the behaviors were physical, she would move the resident's hand, speak to the resident, and move on. The DON said if the behaviors continued or became invasive the facility progress to medication reviews, possible referral to an inpatient geriatric psychiatric hospital, or obtaining physician's orders for medication to address the behaviors. The DON said it was not her decision to determine if Resident #17 should have begun the medication after what was documented as a one-time occurrence, it was the prescribers. The DON said she did speak to Resident #17, on 5/24/2023, where he expressed a desire to discontinue his use of Estradiol. The DON said she did not discuss the discontinuation of the orders with the physician. The DON said at that time there was another interim DON who would have contacted the physician. The DON said if Resident #17 verbally refused to take the Estradiol a discontinuation of orders should have been obtained from the physician. Interview on 6/8/2023 at 12:05 PM with the Admin, he said he had spoken to Resident #17 regarding his prescription for Estradiol. The Admin said he had chosen to continue taking the medication. Record review of the facility's Medication Administration policy date 10/1/2019 read in part medications are administered as prescribed in accordance with good nursing principles and practices ., .the patient has the right to know exactly what they are taking, people taking medication have the right to refuse medications ., .residents may actively refuse medications ., and medication refusal must be reported to the prescriber or mid-level practitioner after every vital medication is refused and after every 3rd dose of a nonvital medication and there must be documentation of prescriber notification of such .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 6 residents (Resident#17) reviewed for unnecessary drugs. The facility failed to ensure Estradiol (a female hormone that regulates many functions in the body, such as reproduction, mood, and bone health) was appropriate for Resident #17. Estradiol was prescribed for one documented incident of sexualized behavior which is an off-label use. This failure could place residents receiving medications at risk of a possible inappropriate drug use or adverse drug reaction. hospitalization. Findings included: Record review of Resident #17's admission record revealed a [AGE] year-old resident admitted on [DATE]. Resident #17 diagnoses included cerebral infarction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood), unspecified dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), muscle wasting (loss of muscle leading to its shrinking and weakening) and atrophy (decrease in size or wasting away of a body part or tissue arrested development), lack of coordination, type 2 diabetes mellitus (a condition results from insufficient production of insulin, causing high blood sugar), polyneuropathy (damage to multiple peripheral nerves), hypertension (high pressure in the arteries), hemiplegia (paralysis of one side of the body) and hemiparesis (is weakness on one side of the body) of the right side, dysphagia (difficulty in swallowing food or liquid difficulty in swallowing food or liquid), and chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes and fluids). Record review of Resident #17's quarterly MDS dated [DATE] with an ARD of 5/12/2023 revealed a BIMS of 11 indicating minimal cognitive impairment. The MDS revealed he had no indications of psychosis, behaviors affecting others, or wandering or elopement behaviors, and he rejected care between one and three days in the seven days prior to the assessment. The MDS documented Resident #17 required extensive assistance from one or more caregivers with bed mobility, transfers, locomotion, dressing, personal hygiene, and toileting, and minimal assistance with set-up for eating. The MDS noted he was always incontinent of bladder and bowel, but he was not on a toileting program. The MDS revealed he was at risk of developing pressure ulcers or injuries, had two venous (typically shallow with irregular sloping edges) and/or arterial (deep and has a 'punched out' appearance) ulcers (an open sore on an external or internal surface of the body, caused by a break in the skin or mucous membrane that fails to heal) of the feet, and was receiving treatment for the injuries. The MDS documented Resident #17 received anticoagulant and diuretic medication seven days of the seven days prior to the assessment. The MDS noted he received no therapeutic services. Record review of the Resident #17's care plan, updated 3/7/2023, revealed a focus on his propensity to curse at staff and make inappropriate comments to female staff members with interventions including anticipation of his needs, positive interactions, discussion of inappropriate behaviors. Record review of Resident #17's medication record revealed he was prescribed Estradiol (a female hormone that regulates many functions in the body, such as reproduction, mood, and bone health) 1mg tablet, one tablet daily, for inappropriate sexual behaviors. The prescription was ordered on 4/11/2023 and initiated on 4/12/2023. Record review of Resident #17's medication record revealed prescriptions for Estradiol 1mg tablet one time daily for inappropriate sexual behaviors. Record review of a nurse's note dated 4/11/2023 documented Resident #17 was being sexually inappropriate with CNA's during bed bath today. Record review of a nurse's noted dated 4/11/2023 revealed Resident #17 was prescribed Estradiol 1mg for inappropriate sexual behaviors. Observation on 6/6/2023 at 9:09 AM of Resident #17 revealed he was lying in his bed watching television. Resident #17 appeared clean and appropriately groomed. Interview on 6/8/2023 at 12:18 PM with Resident #17, he said he had spoken with the Admin regarding his Estradiol on 6/8/2023. Resident #17 said he wanted to take the estradiol because it calmed him down. Resident #17 said he had not known he was taking it in the past. Resident #17 said the facility and staff had not informed him of the medications he takes. Resident #17 said the staff would administer the medication and tell him to take it without explaining what he was taking. Resident #17 did not recall any psychiatric care services. Interview on 6/7/2023 at 1:14 PM with CNA A, she said she had been employed as a CNA since December of 2022. CNA A said her primary duties as a CNA were to assist residents with showers, other ADL's, weigh the residents, and assist the residents with what they needed. CNA A said Resident #17 did not appear to have a problem with her. CNA A said Resident #17 preferred specific CNA's and nurses. CNA A said Resident #17 routinely refused care. CNA A said Resident #17 had acted inappropriately with her. CNA A said he had made inappropriate jokes and had attempted to touch her bottom. CNA A said she had informed the facility management about her concerns. CNA A said Resident #17's inappropriate behaviors had decreased since she informed management of the issues. Interview on 6/8/20 at 8:14 AM with the MDS, she said the Estradiol should have been included on the care plan as an intervention for the Resident #17's focus on inappropriate sexual behaviors. Telephone interview on 6/8/2023 with Resident #17's PCP at 10:34 AM, he said he thought he was aware Resident #17 was prescribed Estradiol. Resident #17's PCP said Estradiol was not a common medication, but it may have been used for sexually inappropriate behaviors. Telephone interview with on 6/28/2023 Resident #17's NP at 10:42 AM, she said Resident #17 was prescribed Estradiol for inappropriate sexual behaviors. Resident #17's NP said she had prescribed Estradiol in the past to residents with inappropriate sexual behaviors and it had decreased the behaviors. Resident #17's NP said the estradiol could decrease Resident #17 grabbing behaviors. Resident #17's NP said the estradiol helps the nurses to work with Resident #17 and would stop him from grabbing their lady parts. Interview on 6/8/2023 at 11:17 AM with the DON, she said if a resident had inappropriate verbal behaviors, she would address the concern and move on. She said if the behaviors were physical, she would move the resident's hand, speak to the resident, and move on. The DON said if the behaviors continued or became invasive the facility progress to medication reviews, possible referral to an inpatient geriatric psychiatric hospital, or obtaining physician's orders for medication to address the behaviors. The DON said it was not her decision to determine if Resident #17 should have begun the medication after what was documented as a one-time occurrence, it was the prescribers. The DON said she did not know Resident #17's history with the prescriber, but in general the least restrictive approach should be utilized for inappropriate behaviors, and medication may not be the least restrictive. Record review of the FDA's medication label for estradiol revealed it's typical uses included treatment of moderate to severe vasomotor symptoms associated with the menopause, treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with the menopause, treatment of hypoestrogenism due to hypogonadism, castration or primary ovarian failure, treatment of breast cancer (for palliation only) in appropriately selected women and men with metastatic disease, treatment of advanced androgen-dependent carcinoma of the prostate (for palliation only), and prevention of osteoporosis. The label documented estradiol was contraindicated for undiagnosed abnormal genital bleeding, known, suspected, or history of cancer of the breast, known or suspected estrogen-dependent neoplasia, active deep vein thrombosis, pulmonary embolism or history of these conditions, active or recent (e.g., within the past year) arterial thromboembolic disease (e.g., stroke, myocardial infarction), and liver dysfunction or disease. The label further documented estradiol should not be used in patients with known hypersensitivity to its ingredients, and estradiol 2 mg, contain FD&C Yellow No. 5 (tartrazine) which may cause allergic-type reactions (including bronchial asthma) in certain susceptible individuals. Record review of the FDA's boxed warnings for Estradiol revealed estrogen therapy has been associated with an increased risk of cardiovascular events such as myocardial infarction and stroke, as well as venous thrombosis and pulmonary embolism, and should any of these occur or be suspected, estrogens should be discontinued immediately. The boxed warnings documented an increase in the risk of gallbladder disease requiring surgery in postmenopausal women receiving estrogens had been reported. The boxed warning further revealed estrogen administration may lead to severe hypercalcemia in patients with breast cancer and bone metastases. Per the boxed warnings retinal vascular thrombosis had been reported in patients receiving estrogens.

Based on observation, interviews and record review the facility failed to ensure all drugs and biologicals were stored securely for three (Nurse Cart 2B Hall, Med Aide Cart 1A Hall, Nurse cart 2A Hall) of four medication carts reviewed for storage of medications. Nurse Cart 2B Hall, Med Aide Cart 1A Hall and Nurse cart 2A Hall had punctured protective seals on the back of multiple narcotic medication blister pill cards. This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion. Findings included: Nurse Cart 2B Hall: Observation on 05/31/2023 at 10:00am revealed the narcotic storage of Lorazepam 0.5mg tablets #5 and #6 of 9 tablets had torn protective seals. A second blister card of Lorazepam 0.5mg, tablet #3 of 4 tablets had a torn protective seal. A third blister card of Lorazepam, tablet #6 of 30 tablets had a torn protective seal. In an interview on 05/31/2023 at 10:00AM, LVN E stated if the resident needed a dose of Lorazepam, he would use the tablets with the broken seal first. LVN E stated if the seal was broken there would be an infection control issue, or someone could remove the pills. LVN E stated he will waste the tablets with another nurse. Med Aide Cart 1A Hall: Observation on 05/31/2023 at 10:43AM revealed the narcotic storage of Lorazepam 0.5mg, tablet #10 of 10 tablets had a torn seal that was taped over with paper tape. In an interview with RN B and DON on 05/31/2023 at 10:43AM, RN B stated the Lorazepam tablet may fall out, get lost and the resident will not have any pills available when needed. RN B stated it should not have been taped, it should be wasted. The DON stated it should not have tape and will be wasted. Nurse Med Cart 2A Hall: Observation on 06/01/2023 at 12:45PM revealed the narcotic storage of Tramadol 50mg (1/2tabs), tablets #2, #3, #5 of 6 tablets had torn protective seals. A blister card of Lorazepam 0.5mg, had 16 tablets; blister seal #3 was torn, #15 had a puncture, #6 and #8 were torn and taped over with paper tape. A second blister card of Lorazepam 0.5mg tabs had 14 tablets and seal #8 was torn. A third Lorazepam 0.5mg blister card had 34 tablets and blister seal #6 was torn. In an interview on 06/01/2023 at 12:45PM, LVN D stated it was not correct to tape up the seals that were broken. LVN D stated the risk would be infection, loss of the drug, depletion of the resident's supply and the tablet may not be the same that was originally in the package. LVN D stated she would notify the ADON, waste the meds with another nurse and place reorders. In an interview on 06/01/2023 at 12:50PM, LVN E said all nurses in charge of medication carts were responsible for checking the integrity of blister seals on all packaging. In an interview on 06/01/2023 at 4:40PM, the Administrator stated she expected the nurses to be responsible for checking the integrity of the packaging since they are the ones who count it daily. The Administrator stated she expected nurses to waste the meds if the seals are broken as the tablets could fall out and picked up by anyone. The Administrator then stated, I don't know, I would probably tape it if the seal was broken only slightly then label it, do not use, or waste it later. Record review of the facility policy for storage of medications, revised April 2007 read in part: Policy Statement: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received .2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe and sanitary manner. 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing Record review of the facility policy for Controlled Substances, revised December 2012 read in part: Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances Record review of the undated facility policy for Drug Diversion revealed in part: .Goal, to support the health and safety of its employees, patients and visitors. Policy: Drug diversion (theft) is prohibited. Suspected drug diversion will be investigated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 8 residents reviewed for infection control (Resident #30). The facility failed to ensure the needle used on Resident #30, remained sterile during the procedure for intramuscular injection of the antibiotic Ceftriaxone. This failure could place residents at risk of infection, decline in health and hospitalization. Findings included: Record review of Resident #30's face sheet revealed a [AGE] year-old male admitted to the facility 02/21/2021 and initially admitted on [DATE]. His diagnoses included atrial fibrillation (abnormal heart rhythm), Parkinson's disease, muscle wasting, pain in joints, age related debility, behavioral and emotional disorder, depression, non-cancerous tumor of the salivary gland, HTN and contractures of the hips and of the knees. Record review of Resident #30's quarterly MDS dated [DATE] revealed he had short term and long term memory problem. He had moderately impaired cognitive skills for daily decision making. He required extensive assistance with ADLs and was always incontinent of bowel and bladder. Further review revealed he was receiving antibiotics and IV medications. Record review of Resident #30's undated care plan revealed the resident had an infection of swollen lymph nodes to the right cheek/jaw area, date initiated was 06/05/2023. The goal was for resident to be free of complications related to infection. Interventions included nurses to administer antibiotics as per MD orders. Record review of Resident #30's active physician orders revealed an order to start Ceftriaxone sodium solution reconstituted 1gm, inject 1 gm IM every 24 hours for swollen lymph nodes with fever on start date 06/07/2023 and end date of 06/10/2023. Observation and interview on 06/07/2023 at 9:10AM, RN A prepared Ceftriaxone 1gm vial. RN A reconstituted the Ceftriaxone 1gm by adding 2.1 ml of Lidocaine 1%. RN A put on clean gloves, cleansed the stopper on the Ceftriaxone vial with an alcohol prep pad, removed the cap of the needle, set the cap down on the med cart, withdrew the liquid using a 3ml syringe and 22 g needle. RN A walked to Resident #30's bedside, explained the procedure to Resident #30, opened a small alcohol prep pad, placed the pad on top of the outer package of the prep pad and placed the syringe with exposed needle on top of the alcohol pad. RN A removed gloves and donned clean gloves then disinfected Resident #30's dorsogluteal site (left hip area) with an alcohol prep pad. RN A picked up the syringe with needle and wiped the needle using the alcohol prep pad. RN A injected the content of the syringe and needle into Resident #30's dorsogluteal site, swabbed the site with a new alcohol pad and disposed of the syringe with the needle in a sharps container. RN A stated he did not recap the needle d/t the potential of a needle stick. RN A stated he wiped the needle with alcohol to clean and disinfect it. RN A was asked if wiping the needle with alcohol was facility policy. RN A stated it was the way he learned how to do injections. Interview on 06/07/2023 at 4:30PM, the DON stated after drawing up the injectable medication she expected the nurse to cover the needle with the cap in a way to prevent a needle stick. The DON stated the cap did not necessarily need to be tightly secured. The DON stated it was not policy to wipe down the needle. The DON stated the risk would be an infection control issue and potential needle stick. The DON stated she would monitor Resident #30's injection site for infection keeping in mind the Ceftriaxone may cause redness by itself. Interview on 06/08/2023 at 8:30AM RN A stated he had been working at the facility about 1.5 years now and had an inservice regarding administration of medication about one week ago. Interview on 06/08/2023 at 8:35AM, the DON stated the DON or the corporate nurse was responsible to conduct nursing staff inservices for medication administration. Interview on 06/08/2023 at 10:10AM, the DON stated the records for Nursing Administration of Medications inservices were completed through the online learning courses provided by the facility. The DON stated RN A had signed an inservice on 2/6/2023. Record review of the online learning transcript included RN A's completion of the one-hour course for Medication Administration in Acute Care on 2/06/2023, with a final score of 100. Record review of the facility policy and procedure manual, section: Medication Administration, Injectable Administration revised on 10/01/2009 read in part: Policy: to administer medications via subcutaneous, intradermal and intramuscular routes in a safe, accurate and effective manner. Equipment Required .2. Sterile syringe capable of holding the medication volume. 3. Sterile safety needle .Procedure .Sites for Administration: .Intramuscular .withdraw the medication; create air lock. Do not recap needle, remove air bubbles .Sanitize hands with approved sanitizer .put on gloves .prepare skin for injection, remove air from syringe and insert the needle .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for four (Resident #1, Resident #2, Resident #3, and Resident #4) out of five residents reviewed for ADLs, in that: The facility failed to provide showers to Resident #1, Resident #2, Resident #3, and Resident #4 in compliance with their shower schedules. This deficient practice placed residents at risk of a decline in hygiene, at risk of skin breakdown, and reduced feelings of self-worth. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral palsy (a group of disorders that affect movement and muscle tone or posture), major depressive disorder, age-related physical debility, and muscle wasting and atrophy. Review of Resident #1's quarterly care plan, dated 03/01/23, reflected she had an ADL self-care performance deficit related to impaired balance and cerebral palsy with an intervention of requiring assistance of two staff members with bathing/showering. Review of Resident #1's quarterly MDS assessment, dated 12/06/22, reflected a BIMS of 5, indicating a severe cognitive impairment. Section G (Functional Status) reflected she required physical help with bathing. Review of Resident #1's bathing tasks in her EMR, from 02/13/23 - 03/13/23, reflected she had not received a shower/bath. No refusals were documented. During an observation and interview on 03/13/23 at 11:55 AM, Resident #1 was laying in her bed. Her face and hair were greasy. She stated she could not remember the last time she had been showered, but it had been a long time. She stated it made her feel bad and gross. Review of Resident #2's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, muscle wasting and atrophy, and unspecified pain. Review of Resident #2's quarterly care plan, dated 01/04/23, reflected she had an ADL self-care performance deficit related to activity intolerance, fatigue, and limited mobility with an intervention of requiring extensive assistance with 1-2 staff with bathing/showering. Review of Resident #2's quarterly MDS assessment, dated 01/04/23, reflected a BIMS of 11, indicating a moderate cognitive impairment. Section G (Functional Status) reflected she required physical help with bathing. Review of Resident #2's bathing tasks in her EMR, from 02/13/23 - 03/13/23, reflected she had received a shower on 02/23/23 and 02/25/23. No refusals were documented. During an observation and interview on 03/23/23 at 12:05 PM, Resident #2 was sitting in the dining room waiting for lunch to be served. She stated it had been forever since she had been showered. She stated she always felt so good when she did receive one. She stated when she asked for one, she was always told they were too short staffed. She stated she almost had not gone to the dining room for lunch that day because she felt dirty. Review of Resident #3's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including major depressive disorder, dementia, and muscle weakness. Review of Resident #3's initial care plan, dated 03/09/23, reflected no mention of assistance required for ADL care /bathing. Review of Resident #3's admission MDS assessment, dated 03/10/23, reflected a BIMS had not been conducted. Section G (Functional Status) reflected the activity of bathing had not occurred over the entire 7-day period. Review of Resident #3's bathing tasks in her EMR, from 03/06/23 - 03/13/23, reflected she had not received a shower/bath. During an observation and interview on 03/13/23 at 12:11 PM, Resident #3 was pacing in her room. The front of her shirt had brown stains on it. She stated she had not been bathed since she was admitted to the facility (03/06/23). She stated she felt dirty, and the staff kept putting off giving her a shower day after day and she just could not live like that. Review of Resident #4's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including muscle weakness, tremors (a type of involuntary movement of the body, distinct from a muscle spasm or twitch), major depressive disorder, and muscle wasting and atrophy. Review of resident #4's quarterly care plan, dated 02/27/23, reflected he had an ADL self-care performance deficit related to generalized weakness, seizures, tremors, hypertension (high blood pressure), incontinence, vertigo, impaired cognition, and impaired mobility with no interventions in regard to bathing. Review of Resident #4's quarterly MDS assessment, dated 02/26/23, indicated a BIMS of 6, indicating a severe cognitive impairment. Section G (Functional Status) reflected the activity of bathing had not occurred over the entire 7-day period. Review of Resident #4's bathing tasks in his EMR, from 02/26/23 - 03/13/23, reflected he had received a shower on 02/27/23 and 03/08/23. A refusal was documented on 03/03/23. During an observation and interview on 03/13/23 at 12:16 PM, Resident #4 was in bed watching television with his FM sitting in a chair next to him. Resident #4's face was greasy, and his hair was matted on the back of his head. Resident #4 stated he rarely got showered and he hated it. Resident #3's FM stated he went at least a week without receiving a shower and she normally had to go ask an aide herself for it to get done, and she did not feel like that was okay. During an interview on 03/13/23 at 2:20 PM, the DON stated it was her expectation that residents received at least three showers a week. She stated it was ultimately up to her to ensure they were being done regularly. She stated the aidesaide's documented showers in their care tracker (which was reflected in the residents' EMR). The DON stated she had not looked at showers in the EMR's recently but had not heard any complaints of not receiving them. She stated not receiving showers regularly could lead to skin break down and infections. During an interview on 03/13/23 at 2:00 PM, the ADM stated the residents had the right to be cleaned appropriately and as often as they wanted. He stated not receiving regular showers could lead to bad hygiene. Review of the facility's Activities of Daily Living Policy, dated 10/24/22, reflected the following: Care and services will be provided for the following activities of daily living: 1. Bathing . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.