Based on observation, interview and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure that all food items being served to residents, were within their expiration or best by dates. This failure could place residents at risk of food-borne illness and a diminished quality of life. Findings included: On 6/11/24 beginning at 9:31AM an initial observation of the kitchen was conducted. An observation of the dry panty revealed: (3) 5-ounce cans LaChoy Chow Mein Noodles with expiration date 3/23/24. (1) 5-ounce can LaChoy Chow Mein Noodles with expiration date 12/2/23. (4) 3-ounce cans LaChoy Asian-style Crunchy Noodles with expiration date 12/18/23. (1) 19-ounce can Progresso Chicken and Sausage Gumbo Soup with expiration date 3/23/24. (2) partial 15-ounce bottles of Lime Juice with exp. date of 11/16/23. Refrigerate after opening stamped on both bottles by manufacturer. Both were in dry pantry. (1) 2-pound bag Honey Nut Cereal Rounds-no date received. 2 loaves white bread with no date received and a best by date of 6/5/24. 2 loaves white bread with no date received and a best by date of 6/10/24. An observation of the freezer revealed: (1) partial 3-pound bag of frozen triple berry blend fruit-open to air. (1) partial 2-pound zip seal bag of tortilla quarters-no label/no date. An observation of the refrigerator revealed the following: (5) 30 count fresh eggs-with no date received or use by date. (1) partial 12-ounce bottle of brown mustard with exp. date 6/7/24. An interview with the Dietary Manager on 6/12/24 at 1:13PM revealed the negative outcome of serving residents expired food would be sickness, interaction with medications and possible food aversions, if residents were aware of which food(s) made them sick. Record review of the facility's Sanitation and Food Handling Policy and Procedure dated 2012 revealed: o All unused food must be securely covered. All items are to be labeled and dated as to their content. o Stock is to be rotated on a first in, first out basis. Record review of the facility's Food Safety Policy and Procedures dated 2012 revealed: o Food is to be tightly wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated, and stored properly. o Do not keep potentially hazardous foods in refrigerator past the labeled expiration date. Record review of the facility's undated Recommended Maximum Storage Period of Unopened Food revealed: o Eggs in shell: Follow expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 5 Residents (Resident #1) reviewed. The facility failed to complete a baseline care plan within 48 hours of admission for Resident #1. This failure could place all newly admitted patients at risk for lack of care, needs not being met, and goals not targeted towards the individual needs of the resident. Findings Included: Record review of Resident #1's face sheet, undated, revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included but are not limited to Systemic Lupus (autoimmune disease), Rheumatoid Arthritis (chronic inflammatory disorder that can affect more than just your joints), and Diabetes Mellitus (body has high sugar levels for prolonged periods of time) with unspecified complications. Record review of Resident #1's care plans, undated, showed a care plan beginning on 10/31/23. Further review revealed no baseline care plan completed. Record review of care plan assessments completed for Resident #1 since admission did not show a baseline care plan. An interview with ADON on 10/31/23 at 1:39 PM revealed that everyone does the care plans, but MDS C was who was in charge of the assessments and submitting the care plans. MDS C scheduled the meetings. ADON stated that baseline must be done withing 24 hours of admission and the admission nurse oversees completing the baseline care plans. ADON stated a negative outcome can be quality of care. In an interview with MDS C on 10/31/23 at 1:42 PM revealed that she (MDS C) oversees the MDS assessments and care plans. MDS C stated that the baseline care plan had to be completed within 24 hours and they were part of the admission process. Entry MDS was done and sent in, then they had 14 days to complete the MDS assessment and then 7 days after that to finish the care plan. They had a regional nurse above them that reviews the assessments and care plans all the time; above her there was a whole team of people who were constantly auditing them. MDS C stated that the regional nurse comes in one to two times a quarter and she was always in their charts. They sent a report once a week and her (Resident #1) care plan was not triggered. MDS C stated she did it today. MDS C confirmed the care plan was not done within 48 hours of admission and stated a negative outcome was not knowing much about the resident, what type of food they like, any injuries, and could be on the wrong diet. Baseline care plan policy was not obtained prior to exiting facility.

The facility failed to establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for one of one room observed for infection control precautions. HK A did not follow transmission-based precautions for a resident under contact precautions by not utilizing PPE while in the room. This failure could place all residents in the facility by exposing them to care that could lead to infection, communicable diseases, and feelings of isolation related to poor hygiene. Findings included: An observation on 10/31/23 at 11:12 AM revealed a resident sitting in Contact Isolation Room on C Hall that had transmission base precautions posted on door for contact precautions. A plastic, 3 drawer container was beside the door with PPE in each drawer. An observation and interview on 10/31/23 at 2:44 PM showed HK A was cleaning the room with contact precautions sign on the door. HK A did not don PPE while in room with transmission-based precautions posted. HK A indicated that housekeeping was to wear PPE when transmission-based precautions were placed on door. HK A stated a negative outcome was that infection can spread to the rest of facility. An interview on 10/31/23 at 2:48 PM, HK B stated that rooms were cleaned one time a day or as needed. HK B confirmed that PPE must be worn if precautions are posted. HK B stated that HK Sup reminds staff if there were any issues. HK B stated a negative outcome was that it was not good for the residents. An interview on 10/31/23 at 2:53 PM, HK Sup stated that infection control training was annually or as needed. Last training was approximately one month ago. HK Sup confirmed contact precautions were posted on the door located in Contact Isolation Room on C Hall. HK Sup stated all staff were required to use PPE and it includes housekeeping. HK Sup stated a negative outcome was the spread of infection. Record review of in-service training report, dated 8/22/23, showed HK A received training for PPE use. Handout for training of donning and doffing PPE included with in- service. Record review of policy titled Infection Control Plan, updated 03/2023, under heading 11- Preventing Infections Related to the Use of Specific Devices, section 5, line 2 stated gowns are also worn by personnel during the care of patients infected with the epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from residents or items in their environment to other residents or environments; when gowns are worn for this purpose, they are removed before the personnel leave the resident's environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review; the facility failed to ensure residents remained free of any significant medication errors for 1 of 6 residents reviewed for medication errors (Resident #1). RN A incorrectly administered another resident's Metoprolol Tartrate Oral tablet 25mg to Resident #1. The significant medication error caused Resident #1 to have an altered blood pressure requiring transfer to the local hospital for further evaluation. The facility's failure could place residents at risk for adverse reactions, health complications and hospitalization and death. Findings include: Record Review of Resident #1's facility clinical record revealed: Resident #1 was a [AGE] year-old female with an admission date of 8/16/23. She was admitted to the facility for rehabilitation services after a diagnosis of pneumonia in the community. Resident #1 had diagnoses of pneumonia, unspecified protein calorie malnutrition, chronic pain, unsteadiness on feet, muscle wasting, major depression, single episode. Resident #1 was discharged home on 9/15/23 after the emergency room visit. Record Review of Resident #1's MDS, dated [DATE], indicated the following: Resident #1 had adequate vision and hearing; BIMS-14, was independent in bed mobility, transfers, dressing, and toileting, independent in mobility; had no upper or lower extremity impairment; was occasionally incontinent of bowel and bladder; had some complaints of pain requiring medication; and was at risk for falls. Record Review of the care plan for Resident #1, dated 8/16/23, indicated: Resident #1 was independent in activities of daily living, had pain, and was at risk for falls. Record Review of the Physician's Orders for Resident #1 dated 8/16/23 to 8/31/23 and 9/1/23- 9/30/23, revealed no orders for Metoprolol. Record Review of Resident #1's facility progress notes dated 9/15/23 at 12:03 pm stated: Blood pressure medication Metoprolol administered in error by RN A. Immediate assessment completed. Resident was alert, oriented and has no signs of lethargy or distress. Manual blood pressurewas 82/58. NP notified, and orders received to send resident to the emergency room for closer evaluation. Record Review of the facility, Medication Error Forms, for Resident #1's medication error dated 9/15/23 at 12:04 pm stated: Blood pressure medication Metoprolol administered in error by nurse. Immediate assessment completed. No signs of lethargy or distress. Manual blood pressure 82/58. NP notified and orders received to transfer resident to emergency room. Record Review of the facility incident report for Resident #1's medication error dated 9/15/23 at 12:05 pm indicated: Blood pressure medication Metoprolol administered in error by nurse. Immediate assessment completed and resident showed no signs or symptoms of distress or lethargy. Resident had a history of hypotension. Manual blood pressure 82/58. NP notified and orders received to transfer resident to hospital. Resident #1 was alert and oriented. Resident #1 stated she did not feel any different than normal. Resident was oriented to time place and person. Predisposing physiological factors- hypotensive. During an interview on 9/20/23 at 10:00 a.m., RN A stated she was the nurse that committed the medication error while caring for Resident #1. RN A stated she was completing med pass when she was distracted and overwhelmed with other residents asking for her attention and a resident wandering into the covid rooms. She stated was redirecting the wandering resident and trying to assist the other residents with their requests and was not thinking when she gave the Metoprolol to Resident #1 instead of the correct resident. She stated shortly after giving the medication to Resident #1 she realized she had given the medication to the wrong resident. During an interview on 9/20/23 at 1:00 pm, Resident #1's family member (Family Member #2) stated there was no significant problem to Resident #1 after the wrong medication was given. She stated the hospital told her Resident #1 's vital signs were normal, and she did not have any aftereffects of being given the medication. Family Member #2 stated RN A was a good nurse, and she did not give Resident #1 the medication on purpose. During an interview on 9/20/23 at 2:00 pm, the MD stated he was aware of the wrong medication being administered to Resident #1. He stated her blood pressure did go down to the 80's and she was sent to the hospital emergency room. MD stated she did not require any treatment at the emergency room because of this. The MD stated the metoprolol has a 12-hour half-life and within 6 hours we would not expect her to have any ill effects. During an interview on 9/20/23 at 2:45 pm, the DON stated she was notified immediately after the medication error and an assessment was started. The DON stated Resident #1's blood pressure was 82/58. The NP was contacted, and the resident was sent to the emergency room. The DON stated she believed this happened because the nurse was on the way to give the medication and was interrupted with a situation involving another resident needing immediate attention. The DON stated she was responsible for the actions of the nurses and has in-service and trained all the nurses in medication administration. The DON stated the consequences of this incident could be death, confusion, or an allergic reaction of a resident to the wrong medication. During an interview on 9/20/23 at 2:55 pm, the ADM stated she was notified immediately after the medication error and an assessment was started on Resident #1. The ADM stated she thought RN#1 was overwhelmed accidentally gave the medication to the wrong resident. The ADM stated to ensure this does not happen again, all nurses were in-serviced on medication administration and felling overwhelmed. The ADM stated the DON was also doing med pass monitoring for the next month. The ADM stated the consequences of a resident getting the wrong medication was death, or an allergic reaction to the wrong medication. Record Review of the facility policy titled, Medication Administration Procedures, dated 2003, stated: Before administering the dose, the nurse must make certain to correctly identify the resident to whom the medication is being administered. Medications prescribed for one resident are not to be administered to any other resident. Medication errors are immediately reported to the resident's physician. In addition, the DON should be notified of any medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #4 Advance Directives Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 3 (Resident #4, #11 and #13) of 16 residents reviewed for advanced directives. Resident #4 had a DNR is her record that had no information in the Physicians Statement Section and no second signature for the physician. Resident #11 had a DNR in her record with no information in the Two Witnesses Section. Resident #13 was listed in her chart as a full code with a correctly completed DNR present in her medical records. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings include: Resident #4 Record review of the face sheet dated 5-9-2023 in the clinical record for Resident #4 revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), hypertension (a condition in which the foresee of the blood against the artery walls is too high), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), and aortic stenosis (narrowing of the valve in the large blood vessel branching of the heart), Under the section Advanced Directives Resident #4 was listed as a DNR. Record review of the clinical record for Resident #4 revealed the last MDS completed was a quarterly dated 2-2-2023 with a BIMS 0f 9 indicating she was moderately cognitively impaired, and she required set-up assistance with all her activities of daily living. Record review of the clinical record for Resident #4 revealed a care plan (date initiated 7-29-2022) with an admission date 7-28-2022 with the following: Focus: Resident had an order for Do Not Resuscitate (DNR)-Date initiated 7-29-2022 Interventions: All aspects of the DNR will be explained to the resident or responsible party-date initiated 2-9-2023 In the absence of b/p, pulse, respirations, CPR will not be initiated -date initiated 2-9-2023 Record review of the clinical record for Resident #4 revealed an Order Summary with active orders as of 5-9-2023 with the following order: DNR (with a start date of 7-29-2022) Record review of the clinical record for Resident #4 revealed a DNR dated 7-28-2022 (by Resident #4's adult child) with the following: Section-Physician Statement-there was no physicians signature, no printed physician name, no date of signature, and no printed license number. There was no second signature for the physician in the All person who have signed above must sign below, acknowledging that this document has been properly completed section. Resident #11 Record review of the face sheet dated 5-8-2023 in the clinical record for Resident #11 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), Parkinson's (a disorder of the central nervous system that affects movements to include tremors), malignant neoplasm of the right and left lung (a fast-growing cancer that spreads to other areas of the body), and malnutrition (lack of proper nutrition). Under the section Advanced Directives Resident #11 was listed as a DNR. Record review of the clinical record for Resident #11 revealed the last MDS completed was a quarterly dated 3-22-2023 with a BIMS of 13 indicating she was cognitively intact, and she had a functionality of requiring one to two-person assistance with activities of daily living. Record review of the clinical record for Resident #11 revealed a care plan (date initiated 2-9-2023) with an admission date 12-16-2022 with the following: Focus: Resident had an order for Do Not Resuscitate (DNR)-Date initiated 2-9-2023 Interventions: All aspects of the DNR will be explained to the resident or responsible party-date initiated 2-9-2023 Focus: Resident requires hospice as evidenced by terminal illness. She has been diagnosed with lung cancer. -Date initiated 2-15-2023 Interventions: -there were no interventions listed related to the DNR process. Record review of the clinical record for Resident #11 revealed an Order Summary with active orders as of 5-8-2023 with the following order: DNR (with a start date of 2-9-2023) Admit to hospice services (with a start dated of 2-6-2023) Record review of the clinical record for Resident #11 revealed a DNR dated 2-8-2023 (by Resident #11's Medical Power of Attorney) with the following: Section-Two Witnesses-there was no information Section-All person who have signed about must sign below, acknowledging that this document has been properly completed-there was a signature on the Notary line and a notary stamp. Resident #13 Record review of the face sheet dated 5-8-2023 in the clinical record for Resident #13 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), malnutrition (lack of proper nutrition), Lymphoma (a cancer of the lymph system), and schizophrenia (a disease that affects a person's ability to think, feel, and behave clearly. Under the section Advanced Directives Resident #13 was listed as a Full Code. Record review of the clinical record for Resident #13 revealed the last MDS completed was a quarterly dated 1-30-2023 with a BIMS of 6 indicating she was severely cognitively impaired, and she had a functionality of requiring one-person assistance with all her activities of daily living. Record review of the clinical record for Resident #13 revealed a care plan with admission date 6-28-2022 with the following: Focus: Resident is a full code-Date initiated 6-29-2022 Intervention-Initiate BLS CPR if the resident is without a heartbeat or not breathing. Notify EMS -Date Initiated: [DATE] Record review of the clinical record for Resident #13 revealed an Order Summary with active orders as of 5-8-2023 with the following order: Full code (with an order date 0f 6-28-2022) Record review of the clinical record for Resident #13 revealed a DNR dated 5-3-2023 (by Resident #13's Medical Power of Attorney) that was completed correctly. During an interview on [DATE] at 02:36 PM LVN F reported that if a resident was a DNR and she assessed that resident to not have a heart rate and/or pulse then she would not start CPR, she would notify the family, hospice if they were involved with the resident's care, and notify the physician. LVN F attempted to verify Resident #4, Resident #11, and Resident #13's DNR status by the markings placed on each Residents door. LVN F reported that a green sticker will be placed on the resident's door if that resident is a DNR, but the door markings were inconsistent and LVN F reported that she would have to verify each resident's DNR status by the resident information kept at the nurse's station. LVN F checked the master file at the nurse station and reported that the information had not been updated since [DATE] so she would have to check each resident's chart in the computer system. LVN F checked Resident #13's electronic record and reported that Resident #13 was listed as a full code and that she would immediately start CPR and have another staff member contact 911, Resident #11 and Resident #4 were both listed as a DNR on their face sheet in their electronic record and therefor LVN F would not start CPR and would notify family and the physician for Resident #4 and family, physician, and hospice for Resident #11. LVN F was asked to check each resident's DNR form in the electronic record. LVN F reviewed Resident #11's DNR form and reported that it was missing the witness's signature, therefore it was invalid, not a legal document, and that the resident would have to be changed to a full code until the DNR form could be corrected with the right document. LVN F then checked Resident #4 and reported that the DNR form did not have any physician information and therefore was not a legal document and would have to be handled the same as Resident 11's DNR. LVN F then checked Resident #13's electronic record and reported that Resident #13 was a full code. When asked to check the document section of Resident 13's electronic record LVN F found the DNR form, reported that it was filled out correctly as of 5-3-2023, and that Resident #13 would have to be changed to a DNR status. LVN F reported that it was the Social Workers responsibility to ensure that the DNR's were correct and that if the DNR's were not correct then the resident wishes would not be followed. During an interview on [DATE] at 02:52 PM the DON and CN verified that Resident #11 was missing the witness signatures and was not a valid DNR, Resident #4 was missing all the physician information and was not a valid DNR, and Resident #13 was listed as a full code with a valid DNR in her record. Both the DON and CN verified that the social worker was responsible for making sure the DNR's were correct. The DON reported that it would cause problems for the staff, and it could result in the resident, or the families wishes not being followed if the DNR process was not followed correctly. During an interview on [DATE] at 03:21 PM the SW went to the medical records office an pulled the original DNR form for Resident #11 and verified it was missing the witness signature, pulled Resident #4's DNR form and verified it was missing the physician information, and reported that she did not know why both DNR forms were not signed. The SW reported that she would try to do a monthly review of all resident DNR's, and she again reported that she did not know Resident #4 and Resident #11's DNR's were not signed. The SW did report that if the DNR form process is not complete and accurate then it can be a mess because the process will not be followed correctly. The SW reported that she would get both DNR forms corrected immediately. During an interview on [DATE] at 09:17 AM the CN reported that they did an audit of the original medical record charts kept in the medical records office the previous evening and was able to find the original DNR forms for Resident #11 that had the second witness signature that was a notary but when it was copied the witness signature did not copy correctly in the Resident #11's electronic chart or the hospice record which would be the records that staff would access when completing a code and they found the original DNR form for Resident #4 that when copied cut off the bottom of the form to include the physicians signature section and that is the reason why the physicians signature section was missing in the copy placed in Resident #4's electronic chart which would be the record that staff would access when completing a code. The CN reported that the facility was going to implement an immediate in-service with staff to reeducated on the DNR/Code process and implement a monthly audit of all DNR forms to ensure that they are complete and accurate. Record review of facility provided policy titled Do Not Resuscitate Order, revised 10-12-2013, revealed the following: Out of Hospital DNR Form The Out of Hospital DNR form was designed by the Texas Department of Human Services to comply with the requirement as set forth in the Health and Safety Code for the purpose of instructing Emergency Medical personnel and other health care professionals to forgo resuscitation attempts. 5. In all cases the form must be signed and dated by two witnesses 11. All validly executed DNR orders will be honored by the facility. Record review of the facility provided policy titled Self Determination End of Life Measures and Advanced Directives, undated, revealed the following: 8. The residents right to execute and advanced directive or make changes to an existing advanced directive .will be recognized an applicable under Texas state law. 11. There are two witnesses required for all advance directive documents . Residents who have completed a valid OOH (Out of Hospital) DNR (Do Not Resuscitate) form will have their wishes be honored. Record review of OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #16) of 16 residents reviewed for respiratory care. Resident #16 had orders for oxygen at 5 liters per minute and was receiving oxygen at lower concentrations. This failure could place residents who receive oxygen at an increased risk for receiving oxygen at the wrong rate which could lead to hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organ), shortness of breath, and hypoxia (insufficient levels of oxygen in the tissues of the body for normal life functions). Findings included: Record review of Resident #16's face sheet, dated 05/09/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), anxiety disorder, congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), emphysema (a lung disease which results in shortness of breath). Record review of Resident #16's Quarterly MDS, dated [DATE], revealed a BIMS score of 7 out of 15 which indicated severely impaired cognition. He required limited to extensive one-person assistance with bed mobility, transfer, bathing, walking, locomotion and personal hygiene. He was independent in eating and toilet use. The MDS documented a need for oxygen therapy while a resident. Record review of Resident #16's care plan, dated 03/13/23, revealed he had congestive heart failure, emphysema, and chronic obstructive pulmonary disorder with a history of low O2 [oxygen] saturations. The care plan listed an intervention of continuous oxygen at 2-5 liters per minute via nasal cannula. It further noted, Give oxygen therapy as ordered by the physician. The care plan noted the resident had oxygen therapy and medications were to be given as ordered by physician. The care plan noted hospice provided a second concentrator to be kept in the dining room for Resident #16 to use during meals. The care plan again noted the resident was to take oxygen at 2-5 liters per minute via nasal cannula. The care plan noted the resident had altered respiratory status/difficulty breathing/ shortness of breath. Record review of Resident #16's active orders revealed an order by his primary physician, dated 02/24/23, for oxygen via N/C [nasal cannula] at 5 LPM [liter per minute] continuously. Record review of Resident #16's oxygen saturation summary, dated 05/09/23 revealed his oxygen levels were checked between two and five times per day. His oxygen levels dropped below 90% 14 times in the last 3 months. Ten of those times Resident #16 was not receiving oxygen via nasal cannula as ordered but was breathing room air. During an observation on 05/08/23 at 12:26 PM Resident #16 was sitting at a table in the dining room taking oxygen via nasal cannula hooked to a concentrator near his table set at 4.5 liters per minute. He appeared alert and oriented as he ate his lunch. During an observation on 05/08/23 at 01:58 PM Resident #16 was observed sitting in his w/c in the hallway taking oxygen via nasal cannula from a tank on the back of his w/c set to 4 liters per minute. During an observation on 05/08/23 at 02:01 PM Resident #16 was sitting in his w/c in his room taking oxygen via nasal cannula at 4 liters per minute. He was fully dressed and appeared to be sleepy but willing to talk. During an observation on 05/08/23 at 02:25 PM Resident #16 walked from his room to the drink station in the hall without oxygen. During an observation on 05/09/23 at 12:06 PM Resident #16 stood in front of his closet with no oxygen looking for a new shirt to wear. During an observation on 05/09/23 at 12:21 PM Resident #16 was sitting in the dining room with his oxygen via nasal cannula hooked to the oxygen tank on the back of his w/c. The oxygen tank was set to 0 liters per minute. The oxygen concentrator near his table was not on. During an observation on 05/09/23 at 01:29 PM Resident #16 was sitting in his w/c in the hallway. He was taking oxygen via nasal cannula hooked to the tank on his w/c which was set to 3 liters per minute. During an observation on 05/09/23 at 02:42 PM Resident #16 was lying in his bed on his back under a blanket with his eyes closed taking oxygen via nasal cannula hooked to the concentrator near his bed which was set to 3.75 liters per minute. During an observation on 05/10/23 at 08:22 AM Resident #16 was sitting at a table in the dining room eating his breakfast taking oxygen via nasal cannula hooked to the concentrator near his table which was set to 4 liters per minute. During an interview on 05/10/23 at 09:32 AM CNA E stated the nurses were responsible for setting the oxygen concentration levels for residents. She stated if a resident complained to her or showed signs of struggling to breathe, she would get a nurse. During an interview on 05/10/23 at 09:32 AM LVN D stated the nurses were responsible to set the oxygen concentration levels for residents based on the physician's orders. She stated the physician's orders were found in the chart of the resident. LVN D stated a possible negative outcome of a resident taking oxygen at a lower concentration than ordered by the physician was the resident would not be able to breathe well, they would not get the right amount of oxygen. During an interview on 05/10/23 at 09:44 AM RN A stated the nurses were responsible for physically setting the oxygen concentration levels for residents. She stated she knew what level to set a resident's oxygen concentration to by reading the physician's orders in the resident's chart. She stated if a resident took oxygen at a lower concentration than ordered by the physician it could lead to shortness of break and decreased oxygen saturation. RN A stated she cared for Resident #16. When asked why his oxygen concentration levels did not match his orders for 5 liters per minute, RN A got online and looked at Resident #16's orders. She stated he had a new order dated 05/10/23 for oxygen at 4 liters per minute. During an interview on 05/10/23 at 09:49 AM the DON stated the nurses were responsible for setting the oxygen levels for residents to the correct concentration. She stated the nurses found the physician's orders regarding oxygen in the resident's chart. The DON stated a resident receiving oxygen at a lower concentration than ordered by the physician might experience oxygen desaturation. She stated the nurses were responsible for entering physician's orders into the electronic health record. When asked why Resident #16 was not receiving oxygen at the concentration ordered she stated she changed his order that morning because he had an order for 2-5 liters per minute and she knew they were not allowed to have orders with ranges, so she changed it to 4 liters per minute. Record review of facility's policy titled Medication Orders and dated 2003 revealed the following: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Record review of a facility's policy titled Oxygen Administration and dated 2007 revealed the following: Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. 7. Place nasal cannula .in the nares . 9. Turn on oxygen after properly setting volume .

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in one of one kitchen reviewed for proper food storage. 1. The facility failed to ensure refrigerated foods were properly labelled and dated. 2. The facility failed to ensure pantry foods were properly labelled, dated, and stored in airtight containers. 3. The facility failed to ensure expired foods and leftovers past the use by date were removed from the refrigerator, pantry, and spice shelf. These failures could place residents at risk for food-borne illness. Findings included: Observation of the upright refrigerator on 05/08/23 at 09:57 AM revealed the following: -a white plastic tub of chicken base with no date -a resealable plastic bag of what appeared to be slices of ham dated 04/28/23 -a bag of celery with no date -a resealable plastic bag of what appeared to be tortillas dated 02/16/23 -a resealable plastic bag of what appeared to be half a green pepper dated 03/28/23 -mango slices in rectangular plastic package with a use by date of 04/28/23 -a grocery store produce bag with what appeared to be two nectarines, one of which had two black fuzzy spots the size of dimes on one side -two kiwi in square plastic package dated 03/28/23 -a resealable plastic bag of what appeared to be half a red onion dated 04/21/23 -a resealable plastic bag of what appeared to be 4 limes dated 04/10/23 -a resealable plastic bag of what appeared to be 5 garlic cloves which were orange in color and slimy, dated 04/10/23 Observation of the spice shelf in the kitchen on 05/08/23 at 10:06 AM revealed a small opaque white storage tub with lid labelled caramel sauce with a use by date of 04/05/23. Observation of the pantry on 05/08/23 at 10:07 AM revealed the following: -a bag of powdered sugar with no date -an open bag of chocolate chips with no date -a bag of chocolate chips with no date -an open bag of grape drink mix with no date -a bag of lemon gelatin with no date -a 5-gallon opaque white storage tub with lid approximately ¼ full of a crumb-like substance no label or date -a large bag of Japanese breadcrumbs open to air with no date -three gallons of lemon juice with expiration dates of 04/26/23 -4 gallons of mustard in a box with no date -3 cans of cooking spray in a box with no date -2 large cans of mandarin orange slices with dents on the sides of the cans near the top During an interview on 05/08/23 at 10:18 AM [NAME] B stated pantry foods should be dated on the top of the packaging. Observation of the chest refrigerator on 05/08/23 at 10:20 AM revealed a gallon of lemon juice 2/3 full had an expiration date of 04/26/23. Observation of the freezer on 05/08/23 at 10:25 AM revealed a foil wrapped package labelled cilantro with a use by date of 12/08/22. During an interview on 05/09/23 at 02:21 PM the ADM stated canned goods that are not dented are assumed to be good for consumption indefinitely. During an interview on 05/09/23 at 03:24 PM the DM stated she and the cooks were responsible for throwing out expired food or food past it's use by date. She stated a possible negative outcome of not throwing out said food was residents could get sick or vomit. During an interview on 05/09/23 at 03:26 PM [NAME] C stated part of her job responsibility was to throw out expired food. She stated a possible negative outcome of serving expired food to residents was they could get food poisoning or get sick. During an interview on 05/10/23 at 09:54 AM the DM stated she and the cooks were responsible to label and date food that comes into the kitchen. She stated a possible negative outcome of having undated and unlabeled food was the food could be spoiled. She stated leftovers were to be dated the date they were made and the date they should be thrown away. The DM stated leftovers were to be thrown away 7 days after they were made. She stated produce was good for two to three weeks. The DM stated she had trained her staff on throwing away expired food and leftovers as well as labelling and dating food properly. During an interview on 05/10/23 at 09:50 AM [NAME] C stated the cooks were responsible for labelling and dating food. She stated a possible negative outcome of not labelling and dating food was, We wouldn't know when it was opened or if it is fresh to serve out and people could get sit from that. [NAME] C stated produce is good for 6-7 days. She stated leftovers are dated the date they were made and 7 days after that. [NAME] C stated she had been trained on how to date and label food as well as on throwing out expired food from the pantry, refrigerator, and freezer. Record review of an in-service training report dated 05/08/23 listed the DM as instructor and revealed the following: Make sure everything it [sic] labeled and dated. Items in fridge must have labels and dates. When it was put in fridge and 7 days out. Record review of facility's policy titled, Storage Refrigerators and dated 2012 revealed the following: .5. Food must be covered, when stored, with a date label identifying what is in the container. Record review of facility's policy titled Dry Storage and Supplies and dated 2012 revealed the following: .3. Dry bulk foods are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. 4. Open packages of food are stored in closed containers with tight covers, and dated as to when opened. Record review of facility's policy titled Food Storage and Supplies and dated 2012 revealed the following: .8. On perishable foods, microorganisms such as molds, yeasts, and bacteria can multiply and cause food to spoil.If a food has developed such spoilage characteristics it should not be eaten.if possible food spoilage is observed prior to the best by date, the product will be discarded. 9. Perishable and non-perishable foods are classified based on their pH and water content.Perishable items that are refrigerated are dated once opened and used within 7 days .but non-perishable items that are refrigerated once opened should be dated when opened . Record review of facility's policy titled Food Safety and dated 2012 revealed the following: . 2. Food is to be tightly wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated and stored properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 out of 16 residents (Resident #131) whose care plans were reviewed. The facility failed to implement the care plan of Resident #131 in that they did not monitor for and/or document monitoring for complications related to the resident's anticoagulant therapy as called for in the resident's care plan. This failure could place residents at risk of not receiving the care required to meet their medical, nursing, and/or mental and psychosocial needs; and place them at an increased and unnecessary risk for complications such as excessive bleeding. Findings Include: Record review of Resident #131's face sheet, dated 04/13/2022, revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease (buildup of fats, cholesterol, and other substances in and on arterial walls) and history of pulmonary embolism (blood clot that develops in a blood vessel and travels to a lung, suddenly blocking blood flow). Record review of Resident #131's active physician orders, dated 04/13/2022, revealed an order with a start date of 04/08/2022 that read Xarelto Tablet 20 mg (Rivaroxaban) Give 20 mg by mouth at bedtime for blood thinner. Record review of Resident #131's care plan, not dated, revealed a focus area titled The resident is on Anticoagulant therapy that had the goal of The resident will be free from discomfort or adverse reactions related to anticoagulant use and interventions for that goal that included Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. Record review of Resident #131's TAR for the month of April 2020, dated 04/01/2022 through 04/30/2022, revealed no documentation or evidence of monitoring for complications related anticoagulant therapy. During an interview on 04/14/2022 at 11:30 AM, ADON was asked to help surveyors locate evidence of anticoagulant complication monitoring and documentation for that monitoring for Resident #131. ADON reported she would attempt to locate such evidence. During an interview on 04/14/2022 at 1:26 PM, ADON reported that Resident #131 takes Xarelto, which is an anticoagulant blood thinner, and that the resident's care plan indicates that monitoring for complications of the medication should be done and documented. ADON reported that such documentation should be present in the resident's TAR, but it was not present because it was not being documented. ADON reported that it was not being documented in the TAR because the monitoring order was not put into the system by the admitting nurse, which was herself. ADON reported that the admitting nurse, which in this case was her, is responsible for putting a section in the TAR for that type of monitoring for staff to document it. ADON reported that the potential consequences of not performing and/or documenting this type of monitoring include that the resident could experience bruising or excessive bleeding. During an interview on 04/14/2022 at 1:32 PM, DON reported that she was familiar with Resident #131 and that the resident received Xarelto, which is an anticoagulant medication. DON reported that the resident's care plan contained an intervention for staff to monitor for side effects of the medication and document that monitoring. DON reported that documentation of that monitoring was not getting done and should have been. DON reported that she did not know why it was not being done, and that potential consequences of it not being done could include DIC (a serious disorder affecting the blood's ability to clot and stop bleeding), bruising, and bleeding. During and observation and interview on 04/15/2022 at 10:02 AM, Resident #131 reported that she takes blood thinner medication and has for years. Resident #131 reported that she bruises easily and currently had bruising but denied having a recent bloody noses or other problems related to bleeding. Resident #131 rolled up her sleeve and presented her left arm on which there was a large area of bruising on the inside of the arm located in the area opposite to her elbow (antecubital space). The resident had no concerns about the bruise stating that it was just something that happens at my age. Record review of facility provided policy titled Comprehensive Care Planning, not dated, revealed in part: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Record review of facility provided policy titled Anticoagulation - Clinical Protocol, dated November 2018, revealed in part: Monitoring and Follow-Up 2. Staff will monitor for symptoms of abnormal bleeding or clotting.

**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 incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #6) reviewed for incontinence and catheter care. -Resident #6 was left in her room for 2 hours with her catheter bag on the floor. These deficient practices could place residents at risk for the spread of viral/bacterial infections, and poor hygiene. Findings include: Record review of Resident #6's face sheet dated 4-13-2022 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Coronary Artery Disease (blockage of the arteries of the heart), fracture of the right femur, malnutrition (lack of poor nutrition), history of falling, depression, pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), hypertension (a condition in which the force of the blood against the artery wall is too high), muscle weakness, difficulty walking, lack of coordination, need for assistance with personal care, and chronic pain, Record review of Resident #6's last MDS was a significant change in status completed 4-6-2022 listing her with a BIMS of 9 indicating she was moderately cognitively impaired, and she had a functionality of requiring one-to-two-person assistance with activities of daily living. Record review of Section H titled Bowel and Bladder of Resident #6's 4-6-2022 MDS revealed the following: H0100 Appliances: A, Indwelling Catheter-Resident #6 was marked as having this appliance. During an observation on 04/13/22 at 10:22 AM, Resident #6 was in bed sleeping under her covers. Resident #6 did not wake to knocking or introduction. Resident #6 had her catheter hanging off the left side of the foot of her bed. This surveyor noted 200 cc of amber colored urine in the bag and there was no bag cover. During an observation on 04/14/22 at 08:37 AM, Resident #6 was in her bed sleeping with her catheter bag laying on the floor at the foot of the left side of her bed. During an observation on 04/14/22 at 09:38 AM, Resident #6 was in her bed sleeping with her catheter bag laying on the floor at the foot of the left side of her bed. During an observation on 04/14/22 at 10:06 AM, Resident #6 was in her bed sleeping with her catheter bag laying on the floor at the foot of the left side of her bed. During an observation on 04/14/22 at 10:28 AM, Resident #6 was in her bed sleeping with her catheter bag laying on the floor at the foot of the left side of her bed. During an observation on 04/14/22 at 10:37 AM, MS entered Resident #6's room and picked Resident #6's catheter bag up off the floor and placed it on Resident #6's bed frame. The Maintenance Supervisor then washed her hands and exited the room. The Maintenance Supervisor reported that the catheter bag should not be on the floor the urine cannot flow right and it's an infection control issue. The Maintenance Supervisor reported that floor staff round every two hours. The Maintenance Supervisor reported that she is the officer for Champion Rounds for this hallway is the reason why she was checking the resident rooms. The Maintenance Supervisor reported that she is a Certified Nurse Aide. During an interview on 04/14/22 at 11:02 AM, CNA A reported that CNAs are supposed to do rounds every two hours and they attempt to do them at 6, 8, 10, 12, 2, etc. CNA A verified that she is currently assigned to Resident #6's hallway and that Resident #6's catheter should not have been on the floor. CNA A reported that a catheter bag left on the floor can get stepped on, it could leak out, and it could not drain right. During an observation and interview on 04/14/22 at 12:46 PM, Resident #6 was up sitting at the side of her bed eating her lunch. Resident #6's catheter was noted hanging from the foot of her bed in a privacy bag. Resident #6 became confused and replied Ok to this surveyor's introduction and questions. Resident #6 was unable to effectively respond to any questions concerning her care, stay, or her catheter care. During an interview on 04/14/22 at 01:21 PM the DON reported that all CNA staff should make rounds every two hours. That a catheter should be stored in a privacy bag that will allow flow to gravity. When advised that a catheter was left on the floor for two hours, the DON reported that a catheter should not be left on the floor. When asked why the DON stated that it could get stepped on, it could be tripped over, and it could cause contamination. The DON verified that all facility direct care staff have been trained on catheter care to include Foley bag storage. The DON then stated, we will do an immediate retraining of all our staff. During an interview on 4/15/2022 at 09:30 AM the DON provided the policy titled Catheter Care and stated, We have looked, and this is the only policy we have that addresses the use of catheter bags. Record review of the facility provided policy titled Catheter Care undated, revealed the following: General Guidelines: 10. Be sure the catheter tubing and drainage bag are kept off the floor.