**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 4 of 4 resident hallways (Hallway A, Women's Unit, Hallway C, and Men's Unit) reviewed for environmental concerns. 1. The facility failed on 8/13/25 to ensure the ceiling lights were replaced and the ceiling vent cleaned in the therapy bathroom located at the end of the A- hallway.2. The facility failed on 8/13/25 to ensure the ceiling vents/panels were cleaned/repaired and a shower room in room # 32 cleaned on the Women's Unit.3. The facility failed on 8/13/25 to repair a bedroom light in room [ROOM NUMBER] and clean a shower room in room # 70 on the C-hall.4. The facility failed on 8/13/25 to repair a bathroom floor molding in room # 89 on the Men's Secure Unit. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that was unpleasant, unsanitary, and unsafe. Findings Included: During observation rounds with the Maintenance Director and Administrator on 08/13/25 from 9:30am- 9:55am revealed the following: a. In the therapy dept bathroom located at the end of the A- Unit-hallway there was 2 missing overhead light bulbs which measured approximately 3 ft in length and the bathroom ceiling air vent had visible dirt and dust particles on the vent surface.b. In the A-Unit hallway the ceiling vent fan in front of room [ROOM NUMBER] had signs of rust particles on the surface.c. In the A-Unit hallway the ceiling vent panel which measured approximately 2x2 ft besides room [ROOM NUMBER] was not attached to the ceiling on one corner.d. In the Women's Unit the ceiling vent panel which measured approximately 2x2 ft in front of room [ROOM NUMBER] had visible dirt particles on the surface.e. In the Women's Unit in the general activity room [ROOM NUMBER] ceiling panels which each measured approximately 2x2 ft had visible brown water/dirt stains on the surface.f. In the Women's Unit the ceiling vent which measured approximately 2x2 ft in front of room [ROOM NUMBER] was not attached to the ceiling on one corner.g. In the Women's Unit the shower floor which measured approximately 3x2 ft in room [ROOM NUMBER] had visible mold on the floor surface.h. In the C-hall the A-side bedside light in room [ROOM NUMBER] was not working.I. In the C-hall the shower floor which measured approximately 3x2 ft in room [ROOM NUMBER] had visible mold on the floor surface.j. In the Men's Unit the floor molding which measured 3 ft in length in the bathroom of room [ROOM NUMBER] was not attached to the wall surface. During an interview with the Maintenance Director and Administrator on 8/13/25 at 10.00am the Administrator stated that making the noted repairs would improve the homelike environment for the residents. The Maintenance Director stated staff communicate the need for repairs on the work order TELS system and he had not received a work order for the needed repairs noted on the resident hallways. The Maintenance Director stated that making the noted repairs would improve the homelike environment for the residents. Record review of the facility's Maintenance Policies and Procedures which was undated revealed the Maintenance Director will make a routine inspection of the Center to ensure all fixtures are securely fastened, that the Center is clean and in good repair, and that all systems are working properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected his bowel incontinence and included a care plan regarding how to take care of his bowel incontinence. These deficient practices could place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included: Record review of Resident #1’s face sheet, dated 07/09/2025, revealed Resident #1 was [AGE] years old male, admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with the diagnosis of major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities), urinary tract infection (infection to the bladder), dysuria (discomfort, pain, or burning when urinating), neuromuscular dysfunction of bladder (the nerve that carry messages back and forth between the bladder and the spinal cord and brain do not work the way they should), and paraplegia (inability to voluntarily move the lower parts of the body). Record review of Resident #1’s quarterly MDS, dated [DATE], revealed the resident’s BIMS was 15 out of 15, which indicated the resident’s cognition was intact, and the resident needed to have substantial/maximal assistance (Helper does MORE THAN HALF the effort) to sit to stand and chair to bed transfer, and for toilet transfer, the resident did not attempted due to medical condition or safety concerns. Further record review of the MDS indicated Resident #1 had urinary indwelling catheter and was always bowel incontinent. Record review of Resident #1’s comprehensive care plan, dated 03/10/2025, revealed the resident had the care plan regarding how to care for the resident’s bladder, indwelling catheter, but there was no care plan regarding how to care for the resident’s bowel incontinence. Observation on 07/10/2025 at 9:05 a.m. revealed two CNAs were providing catheter care and perineal care to Resident #1. Interview on 07/10/2025 at 11:50 a.m. Resident #1 said he could not go to the bathroom for a bowel movement by himself, and he had bowel incontinence. The resident stated the facility staff should clean the resident. Interview on 07/10/2025 at 9:17 a.m. CNA A stated Resident #1 was always incontinent of bowel , and staff should check and clean the resident. Interview on 07/09/2025 at 11:13 a.m. the MDS nurse acknowledged there was no care plan regarding how to care Resident #1’s bowel incontinence. The resident was readmitted recently, and the MDS nurse missed it when developing the resident’s care plan. The MDS nurse stated Resident #1’s care plan should have addressed the resident’s bowel incontinence care because the resident was always bowel incontinent, and staff should clean the resident. Interview on 07/10/2025 at 3:45 p.m. the DON stated Resident #1’s care plan should have addressed the resident’s bowel incontinence care because the resident was always incontinent of the bowel, and staff should clean the resident. No care plans regarding how to care Resident #1’s bowel incontinence might cause improper care because the care plan looked like a blueprint. Record review of the facility policy, titled “Care Plans, Comprehensive Person-Centered,” revised 12/2020, revealed “… 9. Areas of concerns that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident’s problem areas and their causes, and relevant clinical decision making. a. When possible, interventions address the underlying sources of the problem areas, not just addressing only symptoms or triggers. b. Care planning individual symptoms in isolation may have little, if any, benefit for the resident.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #1) reviewed for incontinence care. When CNA-A was providing incontinent and bladder indwelling catheter care to Resident #1 on 07/10/2025, CNA-A did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region), left groin area, right groin area, and scrotum. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections. The findings included: Record review of Resident #1's face sheet, dated 07/09/2025, revealed Resident #1 was [AGE] years old male, admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with the diagnosis of major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities), urinary tract infection (infection to the bladder), dysuria (discomfort, pain, or burning when urinating), neuromuscular dysfunction of bladder (the nerve that carry messages back and forth between the bladder and the spinal cord and brain do not work the way they should), and paraplegia (inability to voluntarily move the lower parts of the body). Record review of Resident #1's quarterly MDS, dated [DATE], revealed the resident's BIMS was 15 out of 15, which indicated the resident's cognition was intact, and the resident needed to have substantial/maximal assistance (Helper does MORE THAN HALF the effort) to sit to stand and chair to bed transfer, and for toilet transfer, the resident did not attempted due to medical condition or safety concerns. Further record review of the MDS indicated Resident #1 had urinary indwelling catheter and was always bowel incontinent. Record review of Resident #1's comprehensive care plan, dated 03/10/2025, revealed the resident had the care plan regarding how to care for the resident's bladder, indwelling catheter, but there was no care plan regarding how to care for the resident's bowel incontinence. Observation on 07/10/2025 at 9:05 a.m. revealed CNA-A washed her hands with water, put on gloves and a gown, opened the old and dirty brief of Resident #1, then cleaned only the resident's penis with a circular motion. CNA-A did not clean the resident's suprapubic area, left groin area, right groin area, and scrotum. CNA-A cleaned Resident #1's indwelling catheter gently, then rolled the resident to the left side and cleaned the resident's rectal and buttock areas. Further observation revealed CNA-A changed her gloves after sanitizing her hands and put a new and clean brief under the resident, then closed the brief. Interview on 07/10/2025 at 9:17 a.m. CNA-A acknowledged she did not clean Resident #1's suprapubic area, left groin area, right groin area, and scrotum, then she cleaned only Resident #1's penis, indwelling catheter, and buttock areas. Further interview revealed CNA-A said she was very nervous, so she forgot to clean Resident #1's suprapubic area, left groin area, right groin area, and scrotum. CNA-A stated she should have cleaned those areas to prevent possible infection. Interview on 07/10/2025 at 3:45 p.m. the DON stated CNA-A should have cleaned Resident #1's suprapubic area, left groin area, right groin area, scrotum per the facility policy to prevent possible infection. Record review of the facility policy, titled Perineal Care, revised 12/2020, revealed 01/20/2023, revealed B. For a male resident: . (6) Continue to clean the perineal area including the penis, scrotum, inner thighs. (12) Clean the rental area thoroughly, including the area under the scrotum, the anus, and the buttocks, change the cleansing wipe as needed.

Based on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for residents 1 of 1 secure unit reviewed for activities, in that: The facility failed to ensure there were organized activities available to residents. The failure placed residents at risk for a diminished quality of life, isolation, and lack of stimulation. Findings included: During observation of men's secure unit (MSU) on 3/4/2025 at 1:30 PM, the centrally located group activities board was observed to have a large print February 2025 calendar posted with red themed decorations. There were no additional postings to include activities for March on the activities board. On 3/5/2025 as observed at 1:30 PM, the group activities board contained new decorations in a green theme but did not have a calendar or notes of daily or monthly activities. The activities board remained the same during observation on 3/6/2025 at 09:05 AM. No calendars were observed in resident rooms. Observation of MSU on 3/4/2025 during times of 4 scheduled events (10:00 AM morning melodies, 11:30 AM coffee and daily chronicle, 2:00 PM mardi gras art, 3:00 PM coffee and chat) did not reveal any formal group activity. During these times, residents were observed sitting quietly in the dining area watching television or resting in their rooms watching television or sleeping.The nursing staff was not aware of any planned activities for the day during brief interview on initial observation of unit on 3/4/2025 at approximately 10:00 AM. Observation of MSU on 3/5/2025 during time of scheduled event (10:00 morning melodies) did not reveal scheduled activity occurrence. An interview was conducted with CNA B on 3/4/2025 at 11:22 AM. CNA B was asked what helped to prevent residents from having altercations with each other. She answered that the residents played bingo on Monday/Wednesday/Friday and they really liked that activity. She explained that when the residents were busy, it kept them from fighting and getting upset. CNA B was asked if there were any other group activities other than bingo, and she stated that there were no other activities done for the residents, only bingo. CNA B also stated the Activities Director was supposed to come to the unit and do more, but they did not. She explained there was usually a calendar posted but that was not followed. An interview was conducted with LVN A on 3/4/2025 at 1:38 PM. LVN A was asked what was being implemented to reduce aggression within MSU, and she stated behaviors were reduced when the residents were kept busy and occupied. LVN A reported that organized activities were rarely hosted within the unit, and the residents sometimes have bingo but that it was inconsistent. She also explained the residents expected bingo on Monday/Wednesday/Friday per the usual routine and would prepare the bingo supplies in anticipation of the event and express disappointment when the event did not occur. LVN A was asked if individual, one-on-one activities ever occur within the residents' rooms, and she said no. LVN A was asked if the residents were ever taken out of the unit to participate in facility-wide group activities, and she responded that the residents would leave MSU when occupational therapy or physical therapy come to get the resident for individual therapy sessions but that nobody ever came to get them for activities. LVN A stated she had voiced her concerns to AD C and ADON D but there were no changes after those conversations. During a subsequent interview with LVN A on 3/5/2025 at 09:50 AM, she was asked why she felt like the residents become aggressive with each other and had physical altercations, and she answered that it was because the residents were bored and under stimulated. She continued that they have nothing to do most of the time so they fight with each other. ADON D was interviewed on 3/6/2025 at 09:50 AM. ADON D was asked about activities and engagement on MSU. ADON D reported that AD C participates in care plan meetings all day on Tuesday and all day on Wednesday, so his schedule limited the number of activities that he could do on those days. ADON D stated she had absolutely been made aware of staff concerns regarding lack of activities and attributed it to AD C's schedule because he can't be in two places at one time. ADON D was then asked how the activities were performed when AD C was unable to attend, and she stated some of the staff would find things for the residents to do, but not all the staff members would do this. ADON D was asked if the residents on MSU ever participated in facility group activities, and she explained many of the residents could not tolerate the stimulation of large-scale activities, but a few would be picked to participate and integrate with mixed success. AD C was interviewed on 3/6/2025 at 1:05 PM. AD C explained he attended just about all of the care plan meetings because the other activities director was new. AD C stated group participation during activities in MSU was pretty decent and the residents required a lot of encouragement for participation. In response to question regarding notification to residents about activities, AD C stated the monthly calendar was often posted on the main activities board around the 5th or 6th of the month because the printing company took several days to print the large print calendar. AD C stated that something was planned every day. AD C was asked how the residents were made aware of activities in that time frame, before the calendar was available. AD C answered that he would go door to door or leave notes. He also said the residents knew that bingo occurred on Monday/Wednesday/Friday and did not usually need reminders for that event. AD C was asked if he did any in-room activities and what types of activities he hosted in an individual environment, for residents who were unable or unwilling to attend group activities. AD C answered that he typically did and that he had session where we talk about current events. He also reported that he would engage in conversations when he was inviting residents to group activities. In response to a question about hosting activities when he was unavailable, AD C explained he would ask the other activities director if she could bring some of the MSU residents to participate in her scheduled events. He also stated he had asked a few of the CNAs to host events in MSU but that it was hard to get them onboard to help you out . I could use a little more support from them . it's not an issue on the women's unit, they'll usually jump in and call bingo or whatever, but not there. AD C said he had brought up his concerns with leadership at the facility and was told that they would see what they could do. AD C indicated residents who did not receive activities could experience sadness, depression, and isolation. Record review of group activity attendance and individual activities for 90 day period were requested for review from AD C on 3/6/2025 at 07:48 AM. AD C stated he did not maintain records detailing attendance for group activities or records for individual activities performed. AD C explained his documentation consists of quarterly progress notes written in the EMR during care planning, with no other routine documentation. Record review of activity progress notes from February 2024 through March 2025 for Residents #1-6 revealed documentation consistent with AD C's description except that all 6 residents progress notes contained one additional note detailing daily activity for a single date concurrent with on-site investigation time frame. Calendars of activities for January-March 2025 were reviewed on 3/7/2025 to confirm that daily activities were planned for MSU residents. Facility policy titled Activity Programs revised 2021, states at least two group activities per day are offered on Saturday, Sunday, and holidays and at least four group activities are offered per day Monday through Friday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when CNA-A provided peri and catheter care for Resident #1. This deficient practice could place residents at-risk for spread of infection. Findings include: Record review of Resident #1's face sheet dated 01/30/2025 revealed she was a [AGE] year-old woman, with an initial admission date of 04/04/2024, with re-admission on [DATE] and with diagnoses which included: Non-traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain); Gastrostomy status (presence of surgically created opening in stomach through which a feeding tube can be placed); Pressure ulcer of right hip, stage 4 (a severe wound that extends deep into tissue potentially with bone or muscle exposure on hip); Pressure ulcer of left buttock stage 4; and Neuromuscular dysfunction of bladder (condition where bladder muscles and nerves do not function properly). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Further review revealed Resident #1 was assessed as having an indwelling catheter. Record review of Resident #1's Active Orders dated 01/30/2025 revealed a orders which included: - Enhanced Barrier Precautions start date 06/25/2024. - Foley Catheter: Provide catheter care every shift start date 01/26/2025. - Wound treatment Order: Location: Right Hip Clean with Normal Saline/Wound Cleanser Apply .QD/PRN start date 01/29/2025. Record review of Resident #1's Care Plan dated 12/18/2024 revealed a Problem of General which included I require enhanced barrier precautions due to the following: I am at increased risk of a MDRO acquisition due to having a wound, edited 07/22/2024. This problem area included the following interventions: - A sign will be posted on my door that says, 'contact nurse before entering room'.; and - PPE will be available (including gowns/gloves/face shield or goggles) will be available right outside my room, in the shower room. Observation on 01/30/2025 at 10:30a.m. revealed there was no sign of any type on or outside the door to Resident #1's room, and there was no supply of PPE available outside the door/room. Further observation revealed CNA-A put on gloves, but did not put on or wear a gown while performing peri-care and foley care for Resident #1. During an interview with CNA-A on 01/30/2025 at 10:43 a.m., CNA-A stated that she did not know what Enhanced Barrier Precautions (EBP) were and had not heard that term before. When Surveyor described what the Enhanced Barrier Precautions were, CNA-A stated that they did that during COVID, but not now. CNA-A stated she had received training in infection control and they get annual training, but did not recall ever having received training on EBP. During an interview with the DON on 01/30/2025 at 10:50 a.m., the DON stated that there should have been an EBP sign on or just outside Resident #1's door, as well as a supply of PPE available outside her door. The DON further stated that the CNA should have worn both a gown and gloves while providing peri-care and foley-care to Resident #1, but also confirmed that EBP were not included in the training provided to staff. The DON stated she viewed this as an opportunity for improvement and was taking immediate action to in-service all the staff on EBP and providing needed signage and PPE supply. The DON stated that not using Enhanced Barrier Precautions could cause the spread of infection. Record review of facility policy titled Enhanced Barrier Precautions revised 4/1/2024 revealed It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistance organisms. Further review revealed An order for enhanced barrier precautions will be obtained for residents with any of the following: 1. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. Central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. Review of the section titled Implementation of Enhanced Barrier Precautions revealed Make gown and gloves available immediately near or outside of the resident's room . and PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .which include: Providing hygiene .changing briefs or assisting with toileting .Device care or use: central lines, urinary catheters, feeding tubes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assured accurate administering of all drugs to meet the needs of residents for 1 of 11 residents (Resident #3) reviewed for pharmaceutical services, in that: 1. MA A administered Resident #9's Gabapentin to Resident #3 when Resident #3 did not have the medication available on 12/14/2024. 2. The facility did not reorder Resident #3's Lyrica, Gabapentin and Clonazepam timely, resulting in Resident #3 missing 3 doses of Lyrica, 5 doses of Gabapentin and 2 doses of Clonazepam. 3. LVN A received an Ativan prn order from NP A on 12/14/2024 for Resident #3 and did not add the medication to Resident #3's physician orders or order the medication from the pharmacy. 4. LVN C documented LVN C administered an Ativan prn to Resident #3 on 12/15/2024 that had not been administered. These failures could place residents who receive medications administered by the facility at risk of not receiving the intended therapeutic benefit of their medication. The findings included: Record review of Resident #3's undated face sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 12/15/2024 with diagnoses that included Vascular Dementia (a general term for impaired ability to remember, think, or make decisions), Type 2 Diabetes (a chronic condition that happens when your body can't use insulin properly), Schizoaffective Disorder, Bipolar Type (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), Anxiety Disorder (a feeling of worry, nervousness, or unease) and Depression (a mood disorder that causes persistent feelings of sadness and loss of interest). Record review of Resident #3's quarterly MDS assessment, dated 10/09/2024, revealed Resident #3 had a BIMS score of 14, indicating no cognitive impairment. Record review of Resident #3's comprehensive care plan revealed the following care plans: 1) [Resident #3] has behaviors in the dining area, during meals, that agitates other residents' r/t he uses vulgar language, racial slurs and talks loudly, start date 11/11/2023. 2) [Resident #3 wants to express himself sexually and is cognitively intact to choose to have a sexual relationship(s), start date 11/13/2023. 3) [Resident #3] has behaviors while outside smoking that agitates other residents' r/t he uses vulgar language, racial slurs, and talks loudly, start date 11/13/2023. 4) Resident has physically abusive behavioral symptoms of physical aggression directed toward another resident, start date 11/11/2023, end date 02/11/2024. 5) Resident has been heard calling his roommate 'my lover', which upsets the roommate. He stated he calls him that because he believes it to be funny, but he does not consider his roommate to be his lover, start date 11/07/2023. 6) Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by [Resident #3] talks in a loud voice and says inappropriate things to staff and other residents. [Resident #3] tells untrue stories such as the Administrator will buy him gifts. [Resident #3] stated his cigarettes were marijuana. [Resident #3] makes false allegations against staff, start date 11/05/2024. 7) Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by recent behaviors reported by nursing staff: argumentative, refusing to come inside late at night, yelling and cursing at staff, singing and talking loudly in the dining area during meal services, start date 10/17/2023. 8) [Resident #3] was observed engaging in a sexual act with another male resident, start date 10/12/2023. 9) Resident has potential for socially inappropriate/disruptive behavioral symptoms r/t bipolar disorder and anxiety, start date 10/12/2023. Record review of Resident #3's December MAR revealed Resident #3 had the following orders: 1. Clonazepam 1mg, 1 tablet, scheduled for 8:00 a.m. and 8:00 p.m. daily for bipolar disorder with a start date of 05/13/2024. The MAR reflected the medication was not administered on 12/13/2024 at 8:00 a.m., the reason documented was unavailable. 12/13/2024 at 8:00 p.m. the medication was not administered; the reason documented was pending delivery. 12/14/2024 at 8:00 a.m. the medication was not administered; the reason documented was unavailable. 2. Benztropine 1mg, 1 tablet, scheduled for 8:00 a.m. daily for schizoaffective disorder with a start date of 12/15/2024. The MAR reflected the medication was administered on 12/15/2024 at 8:00 a.m. 3. Cymbalta delayed release 60mg, 1 capsule, scheduled for 7 a.m.-10 a.m. daily for major depression disorder with a start date of 05/06/2024. The MAR reflected the medication was administered daily as ordered. 4. Gabapentin 400mg, 2 tablets to equal 800 mg scheduled for 8:00 a.m., 2:00 p.m., and 8:00 p.m. for neuropathy pain with a start date of 10/12/2023. The MAR reflected the medication was not administered 12/10/2024 2:00 p.m., the reason documented was pending delivery. 12/12/2024 at 8:00 a.m. and 2:00 p.m. the medication was not administered, and the reason documented was the medication was on order. 12/13/2024 at 8:00 a.m. the medication was not administered, and the reason documented was not available. 12/13/2024 at 8:00pm the medication as not administered, and the reason documented was pending delivery. 12/14/2024 the medication was not administered, and the reason documented was unavailable. 5. Lyrica 50mg, 1 capsule scheduled for 8:00 a.m.-10:00 a.m. and 8:00 p.m.- 10:00 p.m. for pain with a start date of 05/06/2024. The MAR reflected the medication was not administered 12/13/2024 8:00 a.m.-10:00 a.m., the reason documented was unavailable. 12/13/2024 8:00 p.m. -10:00 p.m. the medication was not administered, and the reason documented was pending delivery. 12/14/2024 8:00 a.m. -10:00 a.m. the medication was not administered, and the reason documented was unavailable. 6) Trazadone 150mg, ½ tab scheduled for 8:00 p.m. for insomnia. The MAR reflected the medication was not administered on 12/10/2024 at 8:00 p.m. and the reason documented was pending delivery. Record review of Resident #3's progress note by LVN C, recorded as late entry on 12/15/2024 at 2:03 p.m. and dated 12/12/2024 at 9:55 a.m. stated, Call placed to [pharmacy name] requesting the status of Clonazepam, Lyrica, Gabapentin and Trazodone due to not being filled, [pharmacy] states it's an issue with his insurance since he came off hospice services. Medicaid is listed as his secondary and not primary, Pharmacy is unable to bill for medications. BOM aware. Will continue to follow up. Record review of Resident #3's progress note by LVN A, 12/13/2024 at 2:49 p.m., stated asked BOM to update insurance information so that pharmacy may send medications. done and verified with [pharmacy name] that they received form. Meds should be delivered this evening. Record review of Resident #3's progress note by LVN A, recorded as late entry on 12/14/2024 at 11:50 a.m. and dated 12/13/2024 at 4:40 p.m., stated, Pharmacy called and stated would not send meds because Medicaid is calling themselves secondary payor. Medicaid needs to be called on Monday to get to change. Passed on in report for nurse to call the DON to get approval for meds for the weekend to be sent until situation resolved. Record review of Resident #3's progress note, 12/14/2024 at 11:50 a.m. by LVN A, stated, told in report that DON was not reached. Pt has been very argumentative with staff and other patients all day. Pharmacy called and dose of Clonazepam removed from the ER kit [Emergency Kit]. Pharmacist aware there are only 3 doses left in ER kit and pt takes BID. Lyrica dose is 50 mg and ER kit only has 150 mg capsules. DON contacted and explained situation. She then in turn contacted the pharmacy and meds to be delivered this evening. Difficult to get pt to take the Clonazepam due to being resistant to care and being argumentative. After 15 minutes, pt final took the meds. NP called and informed and gave N.O. for Ativan 0.5mg Q6 PRN. Record review of Resident #3's progress note by Agency LVN B, 12/15/2024 at 1:38 a.m., 14-day supply of Lyrica and Clonazepam delivered. Gabapentin/Benztropine still pending delivery. Record review of Resident #3's progress note by LVN C, 12/15/2024 at 11:21 a.m., stated, Enter this shift this morning and observed resident very talkative, speaking with other residents and staff loudly, sometimes 15 minutes with kisses and hugs. Administered all medications including PRN Ativan 0.5mg. STAT labs CBC. CMP, UA with C&S. Record review of Resident #3's prescription order revealed an ordered received by LVN C on 12/15/2024 for Ativan .5mg, 1 tablet, PRN. Record review of Resident #3's progress note by the DON, 12/16/2024 at 11:55 a.m., stated Identified in a progress note dated 12/14/2024 at 11:50 a.m. that am floor nurse informed to PRN floor nurse to contact DON regarding delivery of a medication from pharmacy. No contact attempted from pm floor nurse. No missed calls, no missed emails, and no missed text messages identified. Floor nurse for am shift instructed to not endorse the need to DON. When needed, please contact DON immediately. Record review of Resident #3's progress note by the ADON, 12/16/2024 at 4:11 p.m., stated notification received from med aide that she attempted to pull Clonazepam 1mg, Lyrica 50 mg and Gabapentin 400 mg, but was unsuccessful due to a billing issue. Floor nurse notified; NP notified via floor nurse. During an interview with the DON, 12/17/2024 at 9:37 a.m., the DON stated she was notified by LVN A on 12/14/2024 that Resident #3 was out of Clonazepam, Lyrica and Gabapentin and the pharmacy was not sending the medication due to a billing issue. The DON said when she was notified, she immediately called the pharmacy and approved for the medications to be billed to the facility and the medications were delivered the same day. The DON said medications should be reordered at least 24-48 hours prior to a resident reaching the last available dose of their medication and the DON stated she should have been notified by staff immediately, when the facility staff became aware that the pharmacy was not approving the medication so the DON could approve the medication so there would be no disruption in the availability for Resident #3's medications. The DON stated Resident #3 did miss 2 doses of his Clonazepam on 12/13/2024 but received his 8:00 a.m. dose from the E-kit on 12/14/2024 and the 8:00 p.m. dose arrived from the pharmacy. The DON stated the medication aides and charge nurses are responsible for reordering resident medications and the expectation for billing concerns or undelivered medications was for the ADON or DON to have been notified immediately. The DON stated the importance of administering medications per the physician orders and reordering medications timely was to potentially avoid adverse outcomes. The DON stated medication doses should not be missed in order to ensure therapeutic blood levels of the medications. During an interview with MA A, 12/17/2024 at 10:49 a.m., MA A stated she was the medication aide for Resident #3 and stated she notified a hospice representative around 11/25/2024 that Resident #3 needed a refill on Clonazepam and Lyrica. MA A stated Resident #3 was still on hospice at that time and Resident #3 still had a 14-day supply of the medication when she made the notification. MA A stated, on 12/04/2024 MA A noticed Resident #3 was running low on the medications and called the pharmacy and asked them if they got the reorder prescriptions. MA A stated the pharmacy said Resident #3 was no longer on hospice and needed new billing information and could not send the medication until the billing information was updated. MA A stated she reported this information to LVN A and to the ADON. MA A stated Resident #3's behavior was changing so MA A took a Gabapentin from Resident #9 and administered it to Resident #3 on 12/13/2024 at 2 p.m. MA A stated Resident #9 had enough so I pulled from one of her extra blister packs. Even if she were to run out, I would have enough time to order more for her. She gets 4 or 5 blister packets at a time. MA A said she did not document anything on Resident #9's chart regarding MA A taking one of Resident #9's Gabapentin pills from Resident #9's blister pack. MA A stated she had been educated on not taking administering or borrowing medications from other residents and MA A said, I know we are not supposed to do that. MA A stated staff know when to reorder medications based on the medication blister packet. MA A stated the blister packet has four columns with medications and the 4th column is blue. MA A stated staff are trained to reorder medication when staff reach the blue column and stated staff reorder 7-10 days prior getting to the end of the blister packet. MA A stated the medication aides or nurses can order the medications and if the medication aides have an issue when ordering a medication, the medication aide is required to notify the charge nurse and ADON. The MA A stated, if a medication is not available for a resident, MA would pull it from the E-kit and if it is not available in the E-kit, MA A stated, I will borrow from other residents if they need it. I know we are not supposed to do that, and I don't want to get in trouble, but I would do that. Now, if it was a narcotic, I would not do that, but other meds I would borrow. During an interview with LVN A, 12/17/2024 at 12:30 p.m., LVN A stated MA A reported to her on Monday or Tuesday that Resident #3 was low on some medications, and she was trying to reorder his medications. LVN A stated LVM A printed Resident #3's physician orders and faxed them to the pharmacy. LVN A stated when she returned to work on Friday, 12/13/2024, MA A told her Resident #3 was out of Clonazepam, Gabapentin and Lyrica. LVN A stated, I asked her what she did while I was off, and she said she told the ADON. LVN A said she called the pharmacy and was told the face sheet needed to be updated. LVN A went to the BOM and got the face sheet updated and then faxed it to the pharmacy. LVN A stated around 4:40 p.m. the pharmacy called and said they could not send the medication because Medicaid was not aware they were the primary payor source. LVN A stated she called the Medicaid office and sat on hold but by that time it was after 5 p.m. on a Friday so LVN A called NP A and told NP A there was a billing issue with Resident #3's medications and the facility would have to follow up on Monday. LVN A stated NP A was notified that LVN A would pull the medications from the E-kit or would see if the facility could pay for the medication for a few days. LVN A stated she notified Agency LVN B at shift change of the medication concern and LVN A stated she asked Agency LVN B to call the DON and ask her to call the pharmacy to send at least a 3 day supply of the meds since we can't call Medicaid until Monday LVN A stated Agency LVN B asked if Agency LVN B should call the DON that night and LVN A said yes, it's 6 p.m. and still early. LVN A stated when LVN A returned to the facility on [DATE] at 6 a.m. for her shift, Agency LVN B gave report and Agency LVN B stated the DON was not called and notified about the medication and stated Agency LVN B stated she called the pharmacy instead and was told the facility needed to contact Medicaid on Monday. LVN A said LVN A called the DON immediately and notified her Resident #3 did not have his medications and the DON called the pharmacy, covered the cost of the medications and the medications were delivered later that day. LVN A stated LVN A notified NP A on 12/14/2024 that Resident #3's Lyrica dose was different than what was available in the E-kit and NP A gave an order for Ativan prn but LVN A did not administer the medication because Resident #3 said he did not want to take it. LVN A stated Resident #3 was alert and oriented and able to verbal pain and did not verbalize any pain or exhibit pain symptoms related to the missing doses of Gabapentin and Lyrica. LVN A stated the medication aides and charge nurses are responsible for reordering medications and reorder based on the blister pack. LVN A stated medication are usually reordered when a resident has less that a 5-day supply and if a resident does not have a medication available, staff can pull the medication from the e-kit. LVN A stated the charge nurses are responsible for following up on medications that have not arrived from pharmacy and nurses are trained to notify the ADON or DON if a medication was not available. LVN A stated the DON will approve medications to be billed to the facility until funding concerns can be resolved so residents do not miss doses of medications. During an interview with LVN C, 12/17/2024 at 1:09 p.m., LVN C stated the pharmacy informed LVN C on 12/12/2024 Resident #3's Clonazepam, Lyrica and Gabapentin were not covered due to a billing issue. LVN C notified the ADON and the ADON told LVN C to notify the BOM. LVN C stated she then notified the BOM and she said she would look into it. LVN C said she did not work on 12/13/2024 or 12/14/2024. LVN C stated she was notified by the medication aide on 12/15/2024 that Resident #3's Clonazepam and Lyrica had arrived, but the Gabapentin had not and said, we gave him a prn Ativan since we knew he did not have all of his medications in his system. LVN C if there was an issue with reordering resident medication, LVN C usually gets approval to have the facility pay for the medication. LVN C stated she thought the billing issue was being addressed since the BOM said she was taking care of it. I thought it was being taken care of and then I was not here. During an interview with the Pharmacist, 12/17/2024 at 2:02 p.m., the Pharmacist stated Resident #3 missing a few doses of Clonazepam would not send a resident into a psychotic situation, especially if they are taking other medications as well because the Clonazepam stays in the system for a while. During an interview with Resident #3's Psychiatrist, 12/17/2024 at 2:33 p.m., the Psychiatrist stated when Resident #3 admitted to the facility, Resident #3 exhibited sexually inappropriate, agitated, and disruptive behaviors including delusions related to his diagnoses of Schizoaffective of bipolar types, depression and anxiety. The Psychiatrist stated Resident #3 settled down and was doing well and then had a health decline and was admitted to hospice in April 2024. The Psychiatrist stated, approximately 2 months ago, Resident #3 began showing significant improvement in health and was discharged from hospice services and had been less anxious and agitated and there were no reports of sexual behaviors until this weekend. The Psychiatrist stated Resident #3 was seen weekly and stated Resident #3's behaviors were not the result of Resident #3 missing some doses of his Clonazepam and Lyrica. The Psychiatrist stated Resident #3 was on other psychotropic medications to control mood and behavior and stated Resident #3 is Bipolar and has a history of behaviors and anything could have triggered his bipolar behaviors. During an interview with Agency LVN B, 12/18/2024 at 10:34 a.m., Agency LVN B stated LVN A never told me to call the DON. She edited to say she passed it on to me, but she did not pass it on to me. No one has called to question me or ask me a question about it. Agency LVN B stated she called the pharmacy on the night of 12/13/2024 and they said Medicaid was closed over the weekend and there was nothing that could be done. I notified the ADON the following morning. Agency LVN B stated Resident #3's medications were available on her shift on 12/14/2024. Agency LVN B stated she had been educated to notify the ADON if a medication was not available or not delivered by the pharmacy. During an interview with ADON A, 12/18/2024 at 12:06 p.m., ADON A stated she was notified by LVN A on 12/13/2024 that the pharmacy needed updated billing information from the BOM. ADON A stated she was not aware Resident #3 was completely out of the medication and thought the BOM was addressing it. ADON A stated a medication aide informed her 3 days earlier that Resident #3 only had 3 pills left of his Clonazepam, gabapentin and Lyrica and ADON A said she spoke to the pharmacy and was told the medications would be delivered. ADON A stated, Friday 12/13/2024, all of a sudden, the pharmacy would not send due to an insurance issue. The BOM updated it and sent it over and then the pharmacy called late in the day and said Medicaid says they are a secondary insurance and would not approve so LVN A was trying to call Medicaid. LVN C called me on the morning of 12/14/2024 and I told her to pull the medications from the E-kit and then the DON was contacted and approved for the facility to pay for the medications, and they were delivered the same day. During an interview with NP A, 12/18/2024 12:21 p.m., NP A stated he observed Resident #3 on 12/13/2024 walking around in the hall and he seemed ok. NP A stated Resident #3 had been really great over the last several months. NP A stated he was notified by LVN A on 12/14/2024 that Resident #3 was being verbally aggressive toward people and cursing at other residents. LVN A stated Resident #3's Clonazepam was out of stock and LVN A was getting the medication out of the E-kit and NP A stated he gave her an order for prn Ativan. NP A stated the on-call NP was notified on Sunday that Resident #3 was having disruptive behaviors and ordered a UA, C&S, CBC and CMP. NP A stated he did not think the missing doses of Clonazepam would have contributed to his behavior stating he was also on Cymbalta and Trazadone that are both mood stabilizers as well and Clonazepam stays in the body awhile. If you missed it for a week or more, you could see changes in behavior. During an interview with the BOM, 12/18/2024 at 12:16 p.m., the BOM stated she was notified by LVN C on 12/12/2024 that nursing was having a hard time reordering Resident #3's medication from the pharmacy. I looked into it and realized his payor source had not been updated by hospice in TMHP when he was discharged from hospice services on 12/01/2024. The BOM stated she corrected his face sheet and faxed the information over to the pharmacy as requested on 12/13/2024. During an interview with the DON, 12/18/2024 at 2:12 p.m., the DON stated nursing staff have received education on not administering medications that have been borrowed from other residents or are not prescribed to the resident. The DON stated administering medications to a resident that had been borrowed from another resident could increase the chance for a medication error stating, a med can look similar but not be the same, the doses could be different. They are not trained enough in pharmacology, and we are not pharmacists The DON stated a resident who has medication removed from their blister pack and administered to another resident had the potential to miss doses of their medications if they ran out of the medication before the medication could be reordered. During an interview with LVN A, 12/19/2024 at 7:03 p.m., LVN A stated LVN A received an order from NP A for Resident #3 on 12/14/2024 around noon for Ativan prn. LVN A stated she never administered the medication to Resident #3 and LVN A did not enter the PRN Ativan into Resident #3's consolidated orders or send the order to the pharmacy. LVN A stated well, I guess I missed it and did not put the order in the system. During an interview with LVN C, 12/20/2024 at 1:33 p.m., LVN C stated she did not administered Ativan to Resident #3 on 12/15/2024. LVN C stated she received the order from the on-call NP and entered the order on the order summary but did not pull the medication from the E-kit because Resident #3 was already wired up at that point and was not going to take anything. LVN C said, I must have pre-documented that I gave it thinking I was going to give it but I did not give it. LVN C stated medications should not be documented as administered until after administration, had received training on accurate documentation and stated medication administration should be documented on the MAR. During an interview with the DON, 12/20/2024 at 1:43 p.m., the DON stated medication administration should not be documented until a resident takes the medication because a resident could decline the medication or spit the medication out and should ideally be documented in the resident MAR. The DON stated it was important to document medication administration after the medication is administered to ensure the medication was consumed. During a telephone interview, 12/21/2024 at 10:38 a.m., Agency MA D stated she could not remember if she did or did not administered Resident #3 his 8 AM doses of Gabapentin and Lyrica on 12/14/2024. Agency MA D said if a medication was not available, she would inform the nurse so the nurse could obtain the medication from the E-kit. MA D stated she could not remember who the nurse was that worked on 12/14/2024 and did not remember if she told the nurse if the medications were not available. During a telephone interview, 12/21/2024 at 11:27 a.m., the Medical Director, who was Resident #3's primary physician, stated he thought his NP A was notified that Resident #3 did not receive Gabapentin medication on 12/10/2024, 12/12/2024, 12/13/2024, and 12/14/2024, did not receive Lyrica mediation on 12/13/2024 and 12/14/2024. The Medical Director said the facility's protocol was to notify the physician/primary care provider when a resident did not receive a medication. The Medical Director stated he did not think there would be any harm from not receiving a couple of doses of Gabapentin or Lyrica. The Medical Director stated it was unpredictable if Resident #3 had received the prn dose of Ativan if it would have affected the resident's decomposition or not, and the physician did not think the prn Ativan would have curbed his aggression. The Medical Director said Ativan was to treat anxiety, it was effective with low levels of anxiety, but the effectiveness of the medication was unpredictable in individuals with bipolar [disorder] or schizophrenia diagnoses. During a telephone interview, 12/21/2024 at 11:54 a.m., Resident #3's NP A stated he was not notified that Resident #3 did not receive the Gabapentin medication on 12/10/2024, 12/12/2024, 12/13/24 and 12/14/2024; and he was not notified Resident #3 did not receive the Lyrica medication on 12/13/2024 and 12/14/2024. NP A said there would not have been any harm to Resident #3 when he missed his medication Gabapentin, he could have had .some peripheral [extremities] pain in his feet and legs . and the resident would have to miss a weeks' worth of the medication before it would affect the resident. NP A stated the harm of not receiving the medication Lyrica could result in some pain since it was used to treat Resident #3's neuropathy. NP A stated he gave a verbal order to a nurse over the phone for prn Ativan every 6 hours, he was not informed the resident refused the medication or did not receive the medication. NP A stated had he known Resident #3 refused the Ativan, he would have asked for a more detailed assessment from the nurse such as what medications the resident took that day, what medications the resident had refused, and might have asked for a psychiatric consult sooner or had the resident placed on 1:1 sooner if the resident was agitated. The NP A stated he did not think the missed doses of PRN Ativan could have caused his outburst and had Resident #3 received the Ativan, the resident probably would have mellowed out and not reached the level of aggression that he did, but unfortunately we can't force our patients [residents] to take the medications. During a telephone interview, 12/21/2024 at 12:09 p.m., MA A stated she did not administer Resident #3 his 8 AM doses of Gabapentin and Lyrica on 12/13/2024 because the medications were not available. MA A stated she informed the nurse the medications were not available and thought the nurse she told was LVN A. MA A stated the week before Resident #3 ran out of the medications Gabapentin and Lyrica she had informed the nurses he would be out of the medications in the following week. During an interview, 12/22/2024 at 11:35 a.m., ADON A stated nobody communicated to me that Resident #3 did not receive his Gabapentin medication . on 12/10/2024, 12/12/2024, 12/13/2024 and 12/14/2024. ADON A said if she had been informed Resident #3 had not received his Gabapentin medication, she would have contacted his physician or nurse practitioner, would have contacted the pharmacy to see if the resident needed a new order or if there was a problem with his insurance. ADON A stated the harm of Resident #3 not receiving his Gabapentin medication could cause him to have increased pain, but he did not exhibit or express that he was in pain when she spoke to him, and she spoke to him daily, and he did not communicate that he was in pain. ADON A stated LVN A informed her on 12/13/2024 that Resident #3 had a billing issue for his medication Lyrica because he just came off hospice, the pharmacy was showing the resident was still under hospice and his Medicaid was pending. ADON A stated when she left for the day on 12/13/2024, LVN A was working on this issue. ADON A said she informed LVN A to write a note that there was a billing issue in Resident #3's chart, to contact his physician, and the ADON was not certain if she had communicated this to the DON or not. During an interview on 12/22/2024 at 1:27 p.m., ADON A stated she contacted their pharmacy to find out when Resident #3's prn Ativan was delivered to the facility, and the pharmacy had never received the order, so it was not delivered to the facility. ADON A stated she had checked the medications carts and verified Resident #3 did not have any Ativan in the medication carts. During an interview on 12/22/2024 at 1:30 p.m., the DON stated the procedure for ordering medications was for the nurse to enter the order into the resident's clinical record immediately after it was received. Once the order was entered into the computer and saved, the order would be transmitted to the pharmacy to be filled. The DON stated the pharmacy would not fill a medication order if the order was not in the computer and the nurse cannot pull a medication from the E-kit if the order for the medication was not in the resident's electronic clinical record. The DON said she was not informed Resident #3 had not received his Gabapentin medication on 12/10/2024, 12/12/2024, 12/13/2024 and on 12/14/2024, and Lyrica medication 12/13/2024 and 12/14/2024. The DON stated she was only informed via text message from LVN A on 12/14/2024at 10:55 AM that Resident #3's medications Gabapentin, Clonazepam, and Lyrica needed her approval so they could be refilled, which she did immediately. The DON said had she known Resident #3 had missed doses of his medications Gabapentin, Clonazepam, and Lyrica, she would have contacted the resident's physician or nurse practitioner. Record review of a facility policy titled, PREPARATION AND GENERAL GUIDELINES. IIA2: Medication Administration-General Guidelines (Pharmacy: NPS Care LLC, a [pharmacy name] Pharmacy Services, LLC company, Effective 06/01/2022) stated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procureme[TRUNCATED]

**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, in that: Resident #276's baseline care plan did not include her prescribed diet, food allergies, or code status. This deficient practice could result in newly admitted residents receiving improper care. The findings were: Record review of Resident #276's face sheet, dated 06/28/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Type 2 diabetes mellitus without complications, Gastro-esophageal reflux disease without esophagitis, and Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding. Record review of Resident #276's clinical record as of 06/28/2024 revealed her initial MDS had not yet been completed. Record review of Resident #276's care plan, dated 06/27/2024, revealed her prescribed diet, food allergies, and code status were not included. Record review of Resident #276's physician orders, dated 06/24/2024, revealed, Diet: Regular diet. Texture: regular Fluid Consistency: thin allergic to eggs Special Instructions: allergic to eggs lactose intolerant, can not eat food with seeds. Further review revealed, Code status: Full Code. During an interview with MDS/LVN A on 06/26/2024 at 12:50 p.m., MDS/LVN A stated the baseline care plan includes showering, diet, and shows staff what needs to happen until we get comprehensive [care plan] in. MDS/LVN A further stated that no specific staff member was responsible for creating baseline care plans, and that the task was a team effort of floor nurses, ADONs, the DON, and MDS nurses. During an interview with LVN/ADON J on 06/28/2024 at 10:21 a.m., LVN/ADON J confirmed Resident #276's baseline care plan did not include her prescribed diet, food allergies, or code status. LVN/ADON J stated these elements of the baseline care plan included information necessary to meet the resident's basic needs. LVN/ADON J confirmed she had created Resident #276's baseline care plan, stated the missing information should have been included, and the deficient practice was an oversight. During an interview with the DON on 06/28/2024 at 1:15 p.m., the DON stated the facility had been using a template to create the baseline care plans that did not include prescribed diet, food allergies, or code status. The DON stated she would change the baseline care plan template to include prescribed diet, food allergies, or code status and would expect staff to include the missing information in the future. Record review of the facility policy, Care Plans - Baseline, revised December 2016, revealed, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #385), reviewed for infection control. LVN B failed to sanitize or wash her hands between glove changes during wound care for Resident #385. This failure could place residents at risk of cross contamination, infection, delayed wound healing, and illness. The findings were: Record review of Resident #385's face sheet dated 6/28/24 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included osteomyelitis (inflammation of the bone caused by an infection, which may spread to the bone marrow, and tissues near the bone), surgical amputation of toes to right foot (surgical removal of toes), and type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene (reduced circulation of blood to a body part other than the brain or heart caused by damaged cells in the blood vessels due to high levels of glucose resulting in tissue death). Record review of Resident #385's admission MDS dated [DATE] revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. (The MDS was in process and no diagnoses, skin conditions, or special treatments were marked). Record review of Resident #385's care plan dated 6/27/24 revealed a problem for surgical amputation of all digits to right foot with a goal and target date of 9/27/24 the surgical wound will heal without complications (infection, ., and interventions included to change dressing per physician order daily. During a wound care observation on 6/28/24 at 11:50 a.m. LVN B provided ordered wound care for Resident #385. During this observation LVN B cleansed the surgical wound, changed her gloves, and continued with the wound care without sanitizing or washing her hands between the glove change. In an interview on 6/28/24 at 12:05 p.m. LVN B stated she did not sanitize or wash her hands for that one glove change only but she should have sanitized or washed her hands after removing her gloves and prior to putting on another pair. In an interview on 6/28/24 at 12:10 p.m. the DON stated not sanitizing or washing hands between glove changes could create a potential for infection, and or contamination. Review of the facility's policy on handwashing/hand hygiene revised 1/20/23 indicated This facility considers hand hygiene the primary means to prevent the spread of infections . 3. Wash hands with soap and water . 4. Use an alcohol-based hand rub .5. Hand hygiene must be performed prior to donning and after doffing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' physical, mental, and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 4 of 30 residents (Residents #24, #59, #88 and #97) reviewed for care plans. 1. The facility failed to implement a comprehensive person-centered care plan to address Resident #24's diagnosis of depression. 2. The facility failed to implement a comprehensive person-centered care plan to address Resident #59's diagnosis of depression. 3. The facility failed to implement a comprehensive person-centered care plan to address Resident #88's ability to leave the facility independently. 4. The facility failed to implement a comprehensive person-centered care plan to address Resident #97's admission to hospice. These failures could affect residents who have care areas not addressed by the care plan by not having their needs met and putting them at risk of not receiving appropriate care. The findings were: 1. Record review of Resident #24's face sheet, accessed 07/25/2024, revealed an admission date of 04/02/2020 with diagnoses that included: Dementia (the loss of cognitive functioning, such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), Depression (loss of pleasure or interest in activities for long periods of time), and cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition, such as attention, memory, organization, problem solving/reasoning, and executive functions). Record review of Resident #24's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 01, which indicated the resident had severe cognitive impairment. Further review revealed in Section I, Active Diagnoses, under the category Psychiatric/Mood Disorder that 15800. Depression (other than bipolar) was checked. Record review of Resident #24's active orders revealed a physician's order, with the following order: Fluoxetine, 40 mg capsule once a day, indicated for depression. Primary Physician Diagnoses: Major depressive disorder, recurrent, moderate. Start date: 11/04/2023. Last administered: 06/26/2024 at 8:06 AM. Record review of Resident #24's Care Plan, last revision date 05/21/2024, revealed no focus area related to depression, monitoring for signs or symptoms of depression, goals or interventions related to the management of depression. 2. Record review of Resident #59's face sheet, accessed 07/25/2024, revealed an admission date of 02/08/2023 with diagnoses that included: Severe intellectual disabilities (a level of functioning severely below age expectations), major depressive disorder (a form of depression with symptoms affecting an individual's ability to eat, sleep, work, and function) and anxiety disorder (feeling of intense, excessive and persistent worry and fear about everyday situations). Record review of Resident #59's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 00, which indicated the resident had severe cognitive impairment. Further review revealed in Section I, Active Diagnoses, under the category Psychiatric/Mood Disorder that 15800. Depression (other than bipolar) was checked.` Record review of Resident #59's active orders revealed a physician's order, revealed the following order: Prozac (fluoxetine) 20 mg capsule once a day, indicated for depression. Primary Physician Diagnoses: Depression, unspecified. Start date: 01/23/2024. Last administered: 06/26/2024 at 8:23 AM. Record review of Resident #59's Care Plan, last revision date 04/10/2024, revealed no focus area related to depression, monitoring for signs or symptoms of depression, goals or interventions related to the management of depression. During an interview on 06/28/24 at 10:15 AM with the LVN A she stated the diagnosis of depression was not listed as a focus area in both Resident #24's or Resident #59's comprehensive care plans and it should have been. During an interview on 06/28/24 at 01:34 PM with the DON she stated she looked through Resident #24 and #59's comprehensive care plans, the diagnosis of depression should have been listed as a focus area in both care plans, and it was not listed. The DON further stated it was LVN A's responsibility to include this diagnosis in the resident's care plan. 3. Record review of Resident #88's face sheet, dated 6/26/24, revealed an admission date of 10/14/21 with diagnoseis that included: type 2 diabetes mellitus ( a condition in which the body has trouble controlling blood sugar), absence of the right leg below the knee, and essential hypertension ( a condition in which there was an abnormally high blood pressure). Record review of Resident #88's Quarterly MDS assessment, dated 6/2/24, revealed a BIMS score of 13 which indicated cognitive intact function. Record review of Resident #88's ongoing care plan initiated on 10/4/21 revealed that the Resident's ability to leave the nursing facility independently was not care planned. During an interview with the MDS LVN A on 6/26/24 at 12:45p.m., she stated that Resident # 88's ability to leave the facility independently was not care planned. She stated that the resident's ability to leave the facility independently should have been care planned for treatment purposes. During an interview with Resident #88 on 06/27/24 at 8:25 a.m., stated that he felt he had the ability to leave the facility independently and recently went to a local grocery store by himself. 4. Record review of Resident # 97'S face sheet dated 6/26/24 revealed an admission date of 1/11/23 with diagnosis of vascular dementia (a condition in which there is brain damage due to lack of blood flow to the brain), type 2 diabetes mellitus (a condition in which the body has trouble controlling blood sugar), and history of drug induced dyskinesia (a condition that involves a movement disorder). Record review of Resident #97s Quarterly MDS assessment, dated 6/7/24, revealed a BIMS score of 12 which indicated moderate cognitive impairment. Record review of Resident #97's physician orders dated 6/26/24 revealed an order to admit to hospice with a start date of 4/5/24. Record review of Resident #97's ongoing care plan initiated on 10/11/23 revealed that the resident's admission to hospice was not addressed in the care plan. During an interview with the MDS LVN A and the DON on 6/28/24 at 9:00a.m., they stated that Resident # 97's hospice status should have been care planned for treatment purposes. Record review of the facility's policy titled Comprehensive Care Plans dated 01/24 revealed, It is the policy of the facility is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychological needs that are identified in the resident's comprehensive assessment.

Based on interviews and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required. The Dietary Manager (DM) did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: Record review of the employee personnel file provided by the facility revealed the hire date for the DM was 03/22/2023. Further review of this personnel file, which included the DM's resume, did not reveal the DM was: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Had similar national certification for food service management and safety from a national certifying body; or (D) Had an associate's or higher degree in food service management or in hospitality; or (E) Had 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and had completed a course of study in food safety management that included topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. Record review of the DM's certification documentation provided by the facility revealed the DM successfully completed the Texas Food Safety Manager Certification Examination, effective 07/26/2023, expiration date 5 years from the effective date. Record review of the facility employee files revealed the facility's RD was contracted and not a full-time employee of the facility. During an interview on 06/28/2024 at 11:45 AM, the DM stated he was hired by the facility in early 2023, completed a Texas Food Manager's Certification program, received a certificate, and believed this certification met the requirements for the position. During an interview on 06/28/2024 at 11:05 AM with the Administrator he stated he understood the Texas Food Manager's Certification was not a national certification and was not the appropriate certification for the position of the DM, and the DM did not meet any of the other qualifying criteria for the position. The Administrator further stated the DM was hired three months prior to his arrival at the facility. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with §2-102.12.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The DM wore a facial hair restraint that did not cover all his facial hair. 2. The facility failed to store, label and date food items properly in the walk-in cooler and dry storage room. 3. In the dish room there were multiple trays of plastic cups stored on trays without air-drying nets separating them from the trays. 4. One of the two reach-in freezers in the dining room (Freezer #1) failed to maintain temperatures at a level to keep frozen food solid. 5. DAs G and H were not wearing hair restraints during food preparation in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 06/25/2024 at 11:00 AM in the kitchen revealed the DM walked through the food preparation area of the kitchen during the preparation of the lunch meal. The DM wore a cloth face covering that covered the facial hair on his chin and the sides of his face. There was facial hair approximately ¼ in length on the DM's upper lip that was not covered by the face covering. During an interview on 06/25/2024 at 11:01 AM with the DM, he did not have a response as to why the facial hair above his lip was not restrained with a facial hair restraint. The DM moved the cloth covering his chin hair to restrain the hair above his lip. Observation on 06/28/2024 at 11:45 AM in the kitchen revealed the DM was present in the kitchen during the lunch meal preparation. The DM wore the same cloth face covering observed on 06/25/2024. The cloth covered the hair on his upper lip and chin. There was visible hair on the side of the DM's face and neck that was not properly restrained. During an interview on 06/28/2024 at 11:46 AM, the DM stated the cloth covering was a beard guard and was adequate to cover his facial hair. He removed the cloth covering and replaced it with a hair net that restrained all of his facial hair. 2. a. Observation on 06/25/2024 at 11:06 AM in the walk-in cooler revealed: (1) An opened 10-lb. package of ready-to-eat ham, unsliced, loosely covered with a piece of plastic wrap. The ham was not sealed in a container or zipper-lock type bag, and there was no date on the ham indicating when it was opened and the use-by date. During an interview on 06/25/2024 at 11:06 AM with [NAME] D, she stated the package of ham had been opened, was not properly sealed in a container or bag, and was not labeled with a use by date. She did not know when it was opened. During an interview on 06/25/2024 at 11:07 AM with the DM, he stated the ham should have been properly sealed, labeled, and dated. He stated it was the responsibility of the cooks to store and label opened food products in the cooler, and he needs to check on it more. (2) An opened gallon of 2% milk, approximately 1/8th full, without a marking or label indicating the date the milk was opened and a use-by date. During an interview on 06/25/2024 at 11:09 AM with the DM, he stated the milk should have been labeled with the date it was opened and a use-by date. (3) A clear, plastic 2-qt. container of cooked vegetables loosely covered with a piece of plastic wrap and without a label or date indicating the preparation or use-by date. During an interview on 06/25/2024 at 11:11 AM with [NAME] D, she stated the vegetables were probably cooked the day before with the intended use for soup to be prepared that day. During an interview on 06/25/2024 at 11:12 AM with the DM, he stated the facility made soup daily, the vegetables were prepared for the soup, and the container should have been labeled and dated with the preparation and use-by date. b. Observation on 06/25/2024 at 11:17 AM in the dry storage room there was an opened bag of cornbread mix not sealed in an enclosed container or bag and without a use-by date. During an interview on 06/25/2024 at 11:18 AM with the DM, he stated the bag of cornbread mix was not stored properly adn should have been in a sealed bag or covered container to prevent spoilage and also the potential for infestation from pests. 3. Observation on 06/25/2024 at 11:24 AM in the dish room revealed three trays of clear plastic drinking cups on the clean side of the dish machine. Each tray had 24 cups, and the cups were stacked with the open side touching the trays without air-drying nets separating the cups from the trays. The trays were wet to the touch. During an interview on 06/25/2024 at 11:26 AM. with the DM, he stated the cups should have been separated from the trays with air-drying nets to allow for proper air-drying and prevent the potential growth of microorganisms. The DM further stated he would ensure the facility procured the nets as soon as possible. 4. Observation on 06/25/2024 at 11:28 AM of the analogue thermometer inside Freezer #1 outside the kitchen revealed the reading fluctuated between 40 and 42 degrees Fahrenheit. Further observation of several food items in Freezer #1 (a 6.5-lb. container of sliced strawberries, biscuit dough from a closed case, and a sealed, uncooked pork butt of unknown weight) were all in a completely thawed state. Record review of the temperature log attached to Freezer #1 revealed the temperature of Freezer #1 was 1.4 in the AM on 06/25/2024, 1.5 the PM on 06/24/2024, 1.4 the AM on 06/24/2024, and -1 the PM on 06/24/2024. During an interview on 06/25/2024 at 11:29 AM with the DM, he stated the food items in Freezer #1 were completely thawed. The DM further stated the seal of the door to Freezer #1 was not working properly, he was aware of this situation and had put in a work order three weeks prior. He last checked on the contents of Freezer #1 on 06/21/2024 and there were no issues. During an interview on 06/25/2024 at 11:37 AM with the Corporate RN, she stated all the food in Freezer #1 was thawed and would be discarded. Observation on 06/25/2024 at 1:00 PM with the Corporate RN revealed the analogue thermometer inside Freezer #1 displayed a temperature of approximately 40 degrees Fahrenheit and the digital display outside the freezer read 32 degrees Fahrenheit. During an interview on 06/25/2024 at 1:30 PM with the Maintenance Director, he stated he was told the middle door gasket on Freezer #1 was not sealing properly 1.5 weeks prior. He ordered the part and it came in on 06/23/2024. He had not opened Freezer #1 and checked the status of the food items inside the freezer because he did not have the key to the freezer. He further stated it was possible the external digital display on Freezer #1 had inadvertently changed from displaying the temperature in Fahrenheit measurements to Celsius measurements, which could occur with machines that had temperature displays. Therefore, the recorded temperature of 1.4 on the temperature log would convert to between 34 - 35 degrees Fahrenheit. While this was a safe storage temperature for foods that needed to be kept cold, it still indicated Freezer #1 did not work properly and was not freezing food items. During an interview on 06/25/2024 at 1:40 PM with the Administrator, he stated Freezer #1 should not have been used once it was noted the door was not sealing properly. Record review of the work order provided by the facility revealed it was placed on 05/23/2024 by the Maintenance Director and stated: 3-Door Freezer the middle door gasket is coming off and one of the doors is not closing right and it's locked all the time and when someone is trying to open with locks on one of the doors stays propped open and temp drops so need a better locking method so door stays closed. Further review of the work order revealed the part was expected on 5/29/2024, it was delayed, and delivered on 06/10/2024. The Maintenance Director changed the status to completed on 06/10/2024 at 12:40 PM. 5. Observation on 06/27/2024 at 11:47 AM revealed DA'S G and H were in the kitchen in the food preparation area. DA G stood several inches away from the stove, where several food items were being prepared for the lunch meal. DA G had long hair secured in a bun at the nape of her neck. She was not wearing a hair restraint. Observation on 06/28/2024 at 11:50 AM revealed DA H stood next to a steel preparation table where food for modified diets were prepared. DA H had a full head of hair approximately 3-4 in length around his head, and he was not wearing a hair restraint. Attempts to interview DAs G and H on 06/28/2024 at 11:49 and 11:51 were unsuccessful, as both employees spoke little to no English. During an interview on 06/27/2024 at 11:53 AM with the DM, he stated he ensures all employees passed the food handlers course, which covered employee hygiene, and he also trained employees on the importance of wearing hair restraints prior to entering the kitchen. Record review of facility policy 04.001 dated 10/01/2018, revealed: Policy: The Nutrition & Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Employee Sanitation: 3. Employee Cleanliness Requirements. b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. Review of facility policy 03.003 revised 06/01/2019 revealed: Food Storage: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Code and HACCP guidelines. 1. Dry Storage. d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators. d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are 72 hours old. 3. Freezers: a. Store all frozen meats, poultry, seafood, fruits and vegetables, and some dairy products, such as ice cream, in the freezer at a temperature that maintains the frozen state of food. h. Place a thermometer inside freezers near the door where the temperature is warmest. Check the temperature of all freezers using the internal thermometer to make sure the temperature stays at 0°F or below. Temperatures should be checked each morning and again on the PM shift. Record the temperatures on a log that is kept near the freezer. i. Once frozen food has been thawed, it must be maintained at 41°F or less prior to cooking. Record review of facility policy 04.006, approved 10/01/2018, revealed: Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment. Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 9.Store all cleaned and sanitized utensils and equipment and all single-service articles at least 6 inches above the floor in a clean, dry location in a way that protects them from contamination by splash, dust and other means. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed, 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 4-901.11 Equipment and Utensils, Air-Drying Required. Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-302.11 Packaged and Unpackaged Food - Protection Separation, Packaging, and Segregation. The freezer equipment should be designed and maintained to keep foods in the frozen state. Corrective action should be taken if the storage or display unit loses power or otherwise fails.

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 reach-in freezers (Freezer #1) reviewed for essential equipment. The facility did not ensure Freezer #1 was in safe operating condition. This failure could place the residents at risk of foodborne illness for consuming food not stored at a safe temperature. Findings included: Observation on 06/25/2024 at 11:28 AM of the analogue thermometer inside Freezer #1 revealed the reading fluctuated between 40 and 42 degrees Fahrenheit. Further observation of several food items in Freezer #1 (two 6.5-lb. containers of sliced strawberries, a sample of biscuit dough from a closed case, and a sealed, uncooked pork loin of unknown weight) were all in a completely thawed state. Record review of the temperature log attached to Freezer #1 revealed the temperature of Freezer #1 was 1.4 in the AM on 06/25/2024, 1.5 the PM on 06/24/2024, 1.4 the AM on 06/24/2024, and -1 the PM on 06/24/2024. During an interview on 06/25/2024 at 11:29 AM with the DM, who was present during the observation of the analog thermometer's reading, he stated the food items in Freezer #1 were completely thawed. The DM further stated the seal of the door to Freezer #1 was not working properly, he was aware of this situation, and had put in a work order three weeks prior. He last checked on the contents of Freezer #1 on 06/21/2024 and there were no issues. During an interview on 06/25/2024 at 11:37 AM with the Corporate RN, she stated all the food in Freezer #1 was thawed and would be discarded. Observation on 06/25/2024 at 1:00 PM with the Corporate RN revealed the analogue thermometer inside Freezer #1 displayed a temperature of approximately 40 degrees Fahrenheit and the digital display outside the freezer read 32 degrees Fahrenheit. During an interview on 06/25/2024 at 1:30 PM with the Maintenance Director, he stated he was told the middle door gasket on Freezer #1 was not sealing properly 1.5 weeks prior. He ordered the part and it arrived on 06/23/2024. He had not opened Freezer #1 and check the status of the food items inside the freezer because he did not have the key to the freezer. He further stated it was possible the external digital display on Freezer #1 had inadvertently changed from displaying the temperature in Fahrenheit measurements to Celsius measurements, which could occur with machines that had temperature displays. Therefore, recorded temperature of 1.4 on the temperature log would convert to between 34 - 35 degrees Fahrenheit. While this was a safe storage temperature for foods that needed to be kept cold, it still indicated Freezer #1 did not work properly and was not freezing food items. During an interview on 06/25/2024 at 1:40 PM with the Administrator, he stated Freezer #1 should not have been used once it was noted the door was not sealing properly. Record review of the word order provided by the facility revealed it was placed by on 05/23/2024 by the Maintenance Director and stated: 3-Door Freezer the middle door gasket is coming off and of the doors is not closing right and it's locked all the time and when someone is trying to open with locks on one of the doors stays propped open and temp drops so need a better locking method so door stays closed. Further review of the work order revealed the part was expected on 5/29/2024, it was delayed, and delivered on 06/10/2024. The Maintenance Director changed the status to completed on 06/10/2024 at 12:40 PM. During an interview on 06/26/2024 at 2:40 PM with [NAME] E, he stated he reported the problem with the freezer door on Freezer #1 not sealing properly several times to the DM and the Maintenance Director over the past month and was told they were working on it and waiting on parts. He worked the AM shift and [NAME] F worked the night shift. Neither he nor [NAME] F had used any food for residents from Freezer #1 over the past 2 weeks. This freezer is used to store items such as biscuits and ice-cream. The pork loin was excess from a recently served meal and not needed. Record review of facility policy 03.003 Food Storage, 2018, revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 3. Freezers. a.Store all frozen meats, poultry, seafood, fruits and vegetables, and some dairy products, such as ice cream, in the freezer at a temperature that maintains the frozen state of the foods. h. Place a thermometer inside freezers near the door where the temperature is warmest. Check the temperature of all freezers using the internal thermometer to make sure the temperature stays at 0°F or below. Temperatures should be checked each morning and again on the PM shift. Record the temperatures on a log that is kept near the freezer. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-302.11 Packaged and Unpackaged Food - Protection Separation, Packaging, and Segregation. The freezer equipment should be designed and maintained to keep foods in the frozen state. Corrective action should be taken if the storage or display unit loses power or otherwise fails.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns. The facility failed to repair a gap surface on a wall in a resident's room, repair a penetration in a resident's bathroom wall, replace light bulbs in a shower stall in a hallway shower room, repair a cracked corner surface of a shower stall in a hallway shower room, clean the dirt/dust particles a bathroom ceiling vent in two residents' rooms, and remove mold from the floor surface of a shower stall in a hallway shower room. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment. The findings included: During an observation on hallway A from 10:20 a.m., to 11:30 a.m., revealed the following: 1. Resident room # 51 on the B-side had a 4 foot gap in the wall surface behind the resident's headboard. 2. Resident room# 51 had a 6- inch round wall penetration in the bathroom. 3. The shower room in the hallway corridor had two of three lights above the sink vanity that were not working. 4. The shower stall in the shower room on the hallway corridor had a cracked surface measuring approximately 2x4 inches on the lower right section of the shower stall. During an observation on the men's secure unit from 11:30 a.m., to 1:15p.m., revealed the following: 5-Resident rooms'#85 and #87 had dust and dirt particles on the bathroom ceiling vents. 6-The shower stall in the shower room which had a 4 foot perimeter had mold around all sections of the floor surface. During an interview with the Maintenance Director at 1:15 p.m., he stated that all of the areas noted that needed replacement or repair in the resident's room on resident hallway A, in the shower room of resident hallway A, in the residents' rooms of the men's secure unit, and in the shower room of the men's secure unit were the responsibility of the Maintenance Director. The Maintenance Director stated that he had not received any work order requests for the repairs. He stated that all of the repairs would be important for resident comfort and safety. During an interview with the Administrator on 6/27/24 at 3:45p.m., he stated that all of the areas that needed repair in the resident room and shower room on A-hallway and the resident rooms and shower room on the men's secure unit would be addressed for repair. The Administrator stated that having the repairs completed would be important for resident safety and comfort. During a record review of the facility policy on Homelike Environment dated 2/2021 revealed residents are to be provided with a safe, clean, comfortable, and homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 9 residents (Resident #9) reviewed for misappropriation and exploitation, in that: The facility did not prevent Resident #9's personal belongings from being lost when he discharged to the hospital. This failure could affect residents and their responsible party by preventing them from having access to their personal effects and belongings. The findings included: Record review of Resident #9's face sheet, dated [DATE], revealed the resident was admitted on [DATE] with diagnoses that included: dementia, anxiety, and mood disorder. The resident was a male age [AGE]. The RP was listed as a family member. Record review of Resident #9's quarterly MDS, dated [DATE], revealed the resident had BIMS score of 01 (severe cognitive impairment). Record review of facility's discharge list, dated [DATE], revealed Resident #9 expired in the facility on [DATE] under hospice care. Record review of Resident #9's Nurse Note dated [DATE] authored by LVN M reflected: Progress Note: Resident was pronounced dead at: [DATE] 10:46 PM. Further review revealed Resident #9's RP was notified of the resident's death. The resident's personal effects were documented as, none, and not sent to the RP or the Mortuary. Also, the said note reflected, No, Personal effects secured for release at a later time . During a telephone interview on [DATE] at 1:50 p.m., Resident #9's RP stated the facility, never returned [to her the resident's] property after his death . Resident #9's RP stated she remembered the resident's belongings included six different blankets and all the resident's clothes. During a telephone interview with LVN M on [DATE] at 2:28 p.m., LVN M stated no inventory was done on Resident #9's belongings at admissions or at discharge. LVN M stated, no personal effects, belonging to Resident #9 were returned to the family or the RP. LVN M stated the admitting nurse and the discharge nurse were responsible for inventorying the resident's personal belongings. During an interview with the DON on [DATE] at 3:15 p.m., the DON stated at admission a nursing staff member inventoried what personal items the resident brought into the facility. The DON stated the procedure for Resident #9 was to do a paper inventory; but as of [DATE] the inventory was not done or located in the EMR. The DON stated when new items were brought into the facility, the inventory sheet was supposed to be updated and signed by nursing staff. The DON stated at discharge the personal items were supposed to be inventoried by a nursing staff and the items are to be given to the resident or the RP. Regarding Resident #9, the DON stated, signatures are not captured and noted in the progress notes; in other words, no inventory of Resident #9's personal belongings was done by nursing staff either at admission or discharge. The DON repeated the facility could not find an inventory sheet involving Resident #9 done at admissions or discharge. Record review of facility's Transfer or Discharge Documentation dated revised [DATE] reflected, .When a resident is transferred or discharged from the facility, the following information will be documented in the medical record .Disposition of personal effects. Record review of the facility's Admitting the Resident: Role of the Nursing Assistant policy dated revised February 2022 read, .Assist with Inventory of the Resident's Personal Effects . Record review of facility's Resident Rights policy dated revised February 2021 reflected, .be free from abuse, neglect, misappropriation of property . Record review of the facility's Abuse, Neglect, and Exploitation dated revised [DATE] read, The facility will provide protection for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Review of the facility's electronic forms did not reveal the presence of any electronic form addressing inventory of personal belongings at admissions or discharge of a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review the facility failed to immediately inform the resident's responsible party and physician when there was a significant change in the resident's physical, mental or psychological status for one resident (Resident #1) reviewed for notification of change of condition, in that: The facility failed to notify Resident #1's responsible party and physician when Resident #1 sustained a burn injury after spilling hot coffee on himself. The non-compliance was identified as past non-compliance. The non-compliance began on 08/28/2023 and ended on 09/01/2023. The facility had corrected the non-compliance before the survey began. This failure placed residents' caregivers at risk of not being aware of any changes in their conditions and could result in a delay in treatment and decline in residents' health and well-being. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE]. His diagnoses included Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), viral pneumonia (an infection caused by a virus that causes inflammation in one or both of the lungs), chronic kidney disease, vascular dementia (dementia caused by problems in the blood supply to the brain, resulting from a cerebrovascular disease), and diabetes mellitus type II (an endocrine diseases characterized by sustained high blood sugar levels). Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1's BIMS could not be conducted as the resident was rarely/never understood and could not answer questions. Further review of this MDS revealed Resident #1 total assistance for eating with one person assistance. Record review of Resident #1's Care Plan, dated 05/21/2021, revealed, Eating amount of assistance: One person assist. Further review revealed the resident's care plan did not state whether it was total or extensive assistance. Record review of LVN A's progress note in Resident #1's EMR dated 08/28/2023 at 5:43 a.m. revealed: Resident was in dining room being assisted with coffee but dropped the cup when taking a drink. Redness to right side of abdomen and mid right arm. Record review of Resident #1's EMR revealed the next note referring to the accident was on 08/31/2023. LVN A documented: Post coffee burn to right flank now with two open areas. Large open area measures 4 cm x 3 cm and smaller one measures 1.5 cm diameter. Dry dressing applied and secured with tape. Will make wound care aware of changes. There was no documentation Resident #1's RP, physician or NP were notified of the accident anywhere in Resident #1's EMR. Interview on 11/09/2023 at 9:11 a.m. with CNA C stated she brought Resident #1 a cup of coffee in the dining room before the breakfast meal, as was the resident's routine. He picked it up, went to take a sip, and spilled it on himself. As soon as it happened, CNA C put her hand under his shirt to keep the liquid from causing any additional injury, wheeled the resident to his room, changed him, brought him back to the dining room, and reported the incident to LVN A. CNA C stated the resident had never demonstrated difficulty holding a cup prior to this incident. Telephone interview on 11/08/2023 at 1:08 PM with LVN A stated she was informed of the incident by CNA C the morning of 08/28/2023, who was standing next to Resident #1 and saw the incident occur. LVN A said she did a skin assessment on Resident #1 and reported the incident to LVN B, the incoming day nurse. LVN A was off the next two days. Upon returning to work on 08/31/2023, LVN A called the resident's physician and spoke with the on-call service, who stated they would have the physician call the facility. Interview on 11/09/2023 at 12:29 PM with Resident #1's NP stated she was told about the incident days after it happened. Interview with the DON on 11/08/23 at 3:45 PM, the DON stated LVN A did not contact her, the ADON, the administrator, Resident #1's RP or Resident #1's physician/NP about the incident when it occurred and she was not made aware of the incident until 08/31/2023. All the notifications were made on that date. The DON stated LVN A believed notifying the incoming nurse was all she had to do. The DON stated LVN A had been a CNA at the facility for several years and received her nursing license within the last year, and LVN A had been trained multiple times on notification procedures when there was a significant change in a resident's condition prior to the incident. Record review of training records provided by the facility revealed LVN A received training on Notification to NPs on 7/25/2023. The flyer attached to the sign-in sheet stated: Notify Nurse Practitioner of vital signs out of parameters or changes in condition every time. Record review of LVN A's Clinical Skills evaluation dated 05/09/2023 revealed LVN A demonstrated competency in: 7. Resident Care Procedures f) Recognizes abnormalities; documentation; reporting. Record review of the Job Description for Licensed Vocational Nurse, revised 05/20/2021, provided by the facility, revealed: Essential Functions/Primary Duties: .communicate with residents, family members, other interdisciplinary team members and management regarding resident status. Record review of facility policy Accidents and Incidents - Investigating and Reporting, revised July 2017, revealed, 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom. The facility completely corrected the deficient practice and provided as evidence the following: - Record review of a copy of the self-report made to HHSC with investigation of the incident dated 08/31/2023. - Record review of Quality Assessment Performance Improvement Committee documents related to the incident dated 08/31/2023 and attended by Administrator, DON and Medical Director. - Record review of the facility's new policy regarding communication of documentation (attached to sign-in rosters dated 09/01/2023). Further review of the pokicy revealed: - During the morning clinical meeting when reviewing documentation from the previous 24 hours, the ADON and DON will text regarding important information that needs to be added to a nurse note such as provider or responsible party notification. - We ask that throughout the day you add the information to the resident chart. - During the 3:30 stand down meeting, the ADON and I will review to be sure the missing information has been added. **Everyone does a great (job) documenting (in) the progress notes. The missing piece is usually the notification.** - Notify and document provider of blood glucose >70 seems silly but it is what the physician asked us to do - Notify and document for any blood sugar out of parameter - Document and notify provider of all changes in condition including skin especially burns - DOCUMENTATION PROTECTS YOU - LVN A was suspended the day she received the counseling, on 08/31/2023 - Record review of sign in rosters for inservices on: Accidents/Incidents, Investigation and Reporting Burn/Skin Issues/Change of Condition, Safety & Supervision of Residents with evidence that all staff received the training dated 9/1/2023. Training conducted by DON and ADON. - Record review of employee memorandum for LVN A detailing her failure to report change of condition to supervisor, physician and to notify responsible party; LVN A's suspension and education on failure to report dated 08/31/2023. Memorandum signed by DON and LVN A.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 7 residents (Reident #1), reviewed for care plan revisions, in that: Resident #1's care plan was not revised a total of four times changes were made to the MDS specific to eating assistance. This deficient practice could place residents at risk for lack of coordination of services and confusion as to eating assistance. The finding included: Record review of Resident #1's face sheet, dated 11/30/23, and EMR revealed the resident was admitted on [DATE] with diagnoses that included: Alzheimer's disease (primary) (progressive mental deterioration), abnormal gait and mobility, lack of coordination, stroke affecting right side of face; and hospice. Further review revealed the resident was a male; age [AGE], Advanced Directive was DNR, and the resident's Responsible Party was listed as a family member. Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1's BIMS could not be conducted as the resident was rarely/never understood and could not answer questions. Further review of this MDS revealed Resident #1 total assistance for eating with one person assistance. Record Review R#1's MDS for four time periods reflected: MDS-07/26/23: Eating was total one person. MDS-4/26/23: Eating was limited one person assistance. (staff does about 25%) MDS-1/30/23: Eating was limited one person assistance. (staff does about 25%) MDS-12/20/22: Eating was extensive one person assistance. (staff does about 50%-75%) [changes to the MDS were not captured in the CP dated 5/31/23] Record review of Resident #1's care plan, dated 5/31/21, Resident #1's ADL reflected Eating amount of assist: One Person Assist [CP did not state whether it was total or extensive assistance] During an interview on 11/30/23 at 11:10 AM, the Administrator stated the timeline was as follows: - 5/31/21 Resident #1's care plan for ADL reflected, Eating amount of assist: One Person Assist. - 7/06/23 Resident #1's MDS (quarterly) reflected, one person total assistance for eating. - 8/28/23 in the morning Resident #1 spilled coffee on self not being assisted by CNA C. - 8/30/23 Resident #1's MDS (significant change) reflected extensive assistance X1 (one person) - 8/31/23 Resident #1 discovered with blisters: MD, RP, and Hospice notified. HHS report submitted. - 9/06/23 Resident #1's care plan was revised to read, Eating assist with meals as needed. During an interview on 11/30/23 at 12:23 PM, RN K (ADON) stated total assistance was defined as the person doing the feeding assistance, they provided 100 % of weight bearing, meaning the resident was not involved in the weight bearing. RN K (ADON) stated prior to the incident on 08/28/23, Resident #1 was total assistance in eating. RN K stated that extensive assistance meant that the staff provided the assistance in 50-75% of the weight bearing. Resident #1 was changed to extensive after the incident on 8/28/23. RN K stated Resident #1's care plan prior to the incident reflected Resident #1 was helped with eating/drinking. RN K further stated after the incident Resident #1's care plan was revised for eating was assist with meals as needed versus the MDS, dated [DATE], which documented for Resident #1 as extensive. RN K stated Resident #1's record contained no evidence or information which indicated the resident was independent in eating at the time of the incident.; nor was the CP revised. During an interview on 11/30/23 at 1:00 PM, the Rehab Director stated a review of the Rehab notes for Resident #1 for the past year revealed there were no referrals to rehab involving feeding assistance; nor a referral for PT, OT, or SP; nor was a change to the care plan made by the Rehab department. During an interview on 11/30/23 at 2:16 PM, LVN G (MDS) stated Resident #1's MDS dated [DATE] was coded that Resident #1 was total dependence one person for eating. LVN G added that there was a coding error in the MDS and the code for Resident #1 should have been extensive assistance with one person assistance. LVN G stated the CP dated 5/31/21 was not revised. During an interview on 11/30/23 at 4:24 PM, CNA C stated Resident #1 feed himself and she had worked with the resident for over one year. CNA C stated the resident's eating requirement was extensive which meant that he was able to do some eating tasks with staff assistance. CNA C did not respond to the question as to whether she knew Resident #1's eating code by checking the resident's MDS, care plane, or checking with the charge nurse; nor was she aware of any revisions to the resident's care plan. Record review of facility's Care Area Assessments policy, revised November 2019, read: . Document interventions on the care plan. Record review of facility's Care Plans policy, dated December 2020, read: . care plans are revised as information about the residents and the residents' conditions change .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that licensed nurses had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety for 2 of 29 licensed staff (LVN A and LVN B) reviewed for competent staff, in that: 1. The facility failed to ensure LVN A completed an incident report and notified Resident #1's RP and physician after he sustained a burn incident. 2. The facility failed to ensure LVN B documented care provided to Resident #1 in his EMR. The non-compliance was identified as past non-compliance. The non-compliance began on 08/28/2023 and ended on 09/01/2023. The facility had corrected the non-compliance before the survey began. These failures could place residents at risk for not receiving the appropriate care and services to maintain their health and safety. The findings included: 1. Record review of Resident #1's face sheet, dated 11/08/2023, and EMR revealed a revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), viral pneumonia (an infection caused by a virus that causes inflammation in one or both of the lungs), chronic kidney disease, vascular dementia (dementia caused by problems in the blood supply to the brain, resulting from a cerebrovascular disease), and diabetes mellitus type II (an endocrine diseases characterized by sustained high blood sugar levels). Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1's BIMS could not be conducted as the resident was rarely/never understood and could not answer questions. Further review of this MDS revealed Resident #1 total assistance for eating with one person assistance. Record review of Resident #1's Care Plan, dated 05/21/2021, revealed, Eating amount of assistance: One person assist. Further review revealed the resident's care plan did not state whether it was total or extensive assistance. Record review of LVN A's progress note in Resident #1's EMR dated 08/28/2023 at 5:43 a.m. revealed: Resident was in dining room being assisted with coffee but dropped the cup when taking a drink. Redness to right side of abdomen and mid right arm. Further review of the resident's EMR revealed there was no record of an incident report related to this incident and no documentation that the DON, Resident #1's RP or physician had been notified of the incident. Telephone interview on 11/08/2023 at 1:08 PM with LVN A revealed she was informed of the incident the morning of 08/28/2023 by CNA C, who was standing next to Resident #1 and saw the incident occur. LVN A stated she did a skin assessment on Resident #1 and reported the incident to LVN B, the incoming day nurse. LVN A stated she was off the next two days and upon returning to work on 08/31/2023, LVN A stated she called the resident's physician and spoke with the on-call service, who stated they would have the physician call the facility. LVN A stated she completed the incident report on 08/31/2023. Interview on 11/08/2023 at 3:45 PM with the DON revealed LVN A should have reported the incident to her supervisor, either an ADON or the DON and completed the incident report before leaving the facility on 08/28/2023 and failed to make the notifications and complete the report. The DON stated the incoming nurse would have expected her to do the incident report. The DON stated LVN A did it on 8/31/2023 when she reported the incident to LVN B. The DON further stated LVN A was put on a performance improvement plan for failure to report the incident to the appropriate individuals and she was counseled. The DON stated LVN A was upset and tearful she did not do the right thing for the resident. The DON stated when LVN A reported the incident to the incoming nurse, LVN A thought that was all she had to do. The DON stated LVN A has had training on the responsibilities of a nurse that specified documentation and reporting prior to the incident. Interview on 11/09/2023 at 10:38 a.m. with ADON D stated LVN A told her about the incident on 08/31/2023, days after it had happened, and she (ADON D) told the DON. ADON D stated she knew LVN A pretty well, both as a CNA and a nurse and LVN A was a new nurse and was learning. ADON D stated when questioned LVN A cried and said over and over, I told LVN B. ASNO D stated the severity of the incident was made very clear to LVN A, that she needed to report this incident to us, the resident's RP and physician. ADON D staed tt was a hard lesson LVN A would not forget. Interview on 11/09/2023 at 12:29 PM with Resident #1's NP revealed she was told about the incident days after it happened. 2. Record review of Resident #1's EMR revealed the note referring to Resident #1's burn incident after the initial note was dated 08/31/2023 at 5:32 a.m. LVN A documented: Post coffee burn to right flank now with two open areas. Large open area measures 4 cm x 3 cm and smaller one measures 1.5 cm diameter. Dry dressing applied and secured with tape. Will make wound care aware of changes. Further review revealed there was no other documentation in the resident's progress notes about this incident. Telephone interview with LVN B on 11/08/2023 at 5:03 p.m., LVN B stated she was informed of the incident by LVN A. LVN B stated she used a hydrophilic wound dressing on Resident #1's burned area, and then placed a bandage with soft tape on the area. LVN B stated she did not document the care she provided to Resident #1 because, That side of the building had a million blood sugars I had to check before breakfast, so I did not document the treatment. I know I should have. LVN B stated she did not return to work at the facility until 08/31/2023. Interview with NP E on 11/09/2023 at 12:29 p.m., NP E stated she was informed about Resident #1's burn after it happened. NP E stated when she saw Resident #1, the wound was healing well and the staff had been treating it before they told her. NP E further stated, Whatever they did, they did a good job. There was no infection, it was healing well. Interview with wound NP F on 11/09/2023 at 12:23 p.m., wound NP F stated nurses could use triad hydrophilic cream without a prescription if they had it on hand for burns, though they preferred if the nursing staff contacted the wound care team. Interview with the DON on 11/10/2023 at 10:55 a.m., the DON stated there was no documentation of the care Resident #1 received on his burn wound from the time of the injury on 08/28/2023 until 08/31/2023 and there should have been. The DON stated LVN A also did not complete an incident report at the time of the injury, and this should have been done before she ended her shift. The DON further stated ADON D was responsible for ensuring nurses completed all mandatory training. The DON stated in-person training was provided monthly and was also available online. Record review of LVN A's Clinical Skills evaluation dated 05/09/2023 revealed LVN A demonstrated competency in: 7. Resident Care Procedures f) Recognizes abnormalities; documentation; reporting. Record review of the Job Description for Licensed Vocational Nurse, revised 05/20/2021, provided by the facility, revealed: Essential Functions/Primary Duties: .communicate with residents, family members, other interdisciplinary team members and management regarding resident status. Record review of facility policy Accidents and Incidents - Investigating and Reporting, revised July 2017, revealed, 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom. Record review of facility policy Guidelines for Charting and Documentation revised April 2012 revealed: Personnel authorized to record data. 4. Nurses/Nursing Assistants. Purpose. The purpose of charting and documentation is to provide: 1. A complete account of the resident's care, treatment, response to care, signs, symptoms, etc., and the progress of the resident's care; 2. Guidance to the physician in prescribing appropriate medications and treatments; 3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident; 4. Nursing service personnel with a record of the physical and mental status of the resident; 5. Assistance in the development of a Plan of Care for each resident; 6. A legal record that protects the resident, care providers, and the facility. General Rules for Charting and Documentation. 1. Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc. as well as routine observations. 5. Chart as often as the need arises. 6. Document assessments, interventions, treatments, outcomes, etc. The facility completely corrected the deficient practice and provided as evidence the following: - Record review of a copy of the self-report made to HHSC with investigation of the incident dated 08/31/2023. - Record review of Quality Assessment Performance Improvement Committee documents related to the incident dated 08/31/2023 and attended by Administrator, DON and Medical Director. - Record review of the facility's new policy regarding communication of documentation (attached to sign-in rosters dated 09/01/2023). Further review of the policy revealed: - During the morning clinical meeting when reviewing documentation from the previous 24 hours, the ADON and DON will text regarding important information that needs to be added to a nurse note such as provider or responsible party notification. - We ask that throughout the day you add the information to the resident chart. - During the 3:30 stand down meeting, the ADON and I will review to be sure the missing information has been added. **Everyone does a great (job) documenting (in) the progress notes. The missing piece is usually the notification. ** - Notify and document provider of blood glucose >70 seems silly but it is what the physician asked us to do - Notify and document for any blood sugar out of parameter - Document and notify provider of all changes in condition including skin especially burns - DOCUMENTATION PROTECTS YOU - LVN A was suspended the day she received the counseling, on 08/31/2023 - Record review of sign in rosters for inservices on: Accidents/Incidents, Investigation and Reporting Burn/Skin Issues/Change of Condition, Safety & Supervision of Residents with evidence that all staff received the training dated 9/1/2023. Training conducted by DON and ADON. - Record review of employee memorandum for LVN A detailing her failure to report change of condition to supervisor, physician and to notify responsible party; LVN A's suspension and education on failure to report dated 08/31/2023. Memorandum signed by DON and LVN A.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which were complete and accurate for one resident (Resident #1) reviewed for accuracy of records, in that: The facility did not document in Resident #1's electronic medical record (EMR) an incident report or care that was provided after the resident sustained a burn injury. The non-compliance was identified as past non-compliance. The non-compliance began on 08/28/2023 and ended on 09/01/2023. The facility had corrected the non-compliance before the survey began. These failures could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided. The findings included: Record review of Resident #1's face sheet, dated 11/08/2023, and EMR revealed a revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), viral pneumonia (an infection caused by a virus that causes inflammation in one or both of the lungs), chronic kidney disease, vascular dementia (dementia caused by problems in the blood supply to the brain, resulting from a cerebrovascular disease), and diabetes mellitus type II (an endocrine diseases characterized by sustained high blood sugar levels). Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1's BIMS could not be conducted as the resident was rarely/never understood and could not answer questions. Further review of this MDS revealed Resident #1 total assistance for eating with one person assistance. Record review of Resident #1's Care Plan, dated 05/21/2021, revealed, Eating amount of assistance: One person assist. Further review revealed the resident's care plan did not state whether it was total or extensive assistance. Record review of LVN A's progress note in Resident #1's EMR dated 08/28/2023 at 5:43 a.m. revealed: Resident was in dining room being assisted with coffee but dropped the cup when taking a drink. Redness to right side of abdomen and mid right arm. Further review of Resident #1's EMR revealed the next note referring to the incident was dated 08/31/2023 at 5:32 a.m. LVN A documented: Post coffee burn to right flank now with two open areas. Large open area measures 4 cm x 3 cm and smaller one measures 1.5 cm diameter. Dry dressing applied and secured with tape. Will make wound care aware of changes. There was no evidence of an incident report completed on the date of the incident. Telephone interview on 11/08/2023 at 1:08 PM with LVN A revealed she was informed of the incident the morning of 08/28/2023 by CNA C, who was standing next to Resident #1 and saw the incident occur. LVN A stated she did a skin assessment on Resident #1 and reported the incident to LVN B, the incoming day nurse. LVN A stated she was off the next two days and upon returning to work on 08/31/2023, LVN A stated she called the resident's physician and spoke with the on-call service, who stated they would have the physician call the facility. Telephone interview with LVN B on 11/08/2023 at 5:03 p.m., LVN B stated she was informed of the incident by LVN A. LVN B stated she used a hydrophilic wound dressing on Resident #1's burned area, and then placed a bandage with soft tape on the area. LVN B stated she did not document the care she provided to Resident #1 because, That side of the building had a million blood sugars I had to check before breakfast, so I did not document the treatment. I know I should have. LVN B stated she did not return to work at the facility until 08/31/2023. Interview with wound NP F on 11/09/2023 at 12:39 p.m., wound NP F stated nurses could use triad hydrophilic cream without a prescription if they had it on hand for burns, though they preferred if the nursing staff contacted the wound care team. Interview with the DON on 11/10/2023 at 10:55 a.m., the DON stated there was no documentation of the care Resident #1 received on his burn wound from the time of the injury on 08/28/2023 until 08/31/2023 and there should have been. The DON stated LVN A also did not complete an incident report at the time of the injury, and this should have been done before she ended her shift. The DON further stated ADON D was responsible for ensuring nurses completed all mandatory training. The DON stated in-person training was provided monthly and was also available online. Record review of facility policy Guidelines for Charting and Documentation revised April 2012 revealed: Personnel authorized to record data. 4. Nurses/Nursing Assistants. Purpose. The purpose of charting and documentation is to provide: 1. A complete account of the resident's care, treatment, response to care, signs, symptoms, etc., ad the progress of the resident's care; 2. Guidance to the physician in prescribing appropriate medications and treatments; 3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident; 4. Nursing service personnel with a record of the physical and mental status of the resident; 5. Assistance in the development of a Plan of Care for each resident; 6. A legal record that protects the resident, care providers, and the facility. General Rules for Charting and Documentation. 1. Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc. as well as routine observations. 5. Chart as often as the need arises. 6. Document assessments, interventions, treatments, outcomes, etc. The facility completely corrected the deficient practice and provided as evidence the following: - Record review of a copy of the self-report made to HHSC with investigation of the incident dated 08/31/2023. - Record review of Quality Assessment Performance Improvement Committee documents related to the incident dated 08/31/2023 and attended by Administrator, DON and Medical Director. - Record review of the facility's new policy regarding communication of documentation (attached to sign-in rosters dated 09/01/2023). Further review of the policy revealed: - During the morning clinical meeting when reviewing documentation from the previous 24 hours, the ADON and DON will text regarding important information that needs to be added to a nurse note such as provider or responsible party notification. - We ask that throughout the day you add the information to the resident chart. - During the 3:30 stand down meeting, the ADON and I will review to be sure the missing information has been added. **Everyone does a great (job) documenting (in) the progress notes. The missing piece is usually the notification.** - Notify and document provider of blood glucose >70 seems silly but it is what the physician asked us to do - Notify and document for any blood sugar out of parameter - Document and notify provider of all changes in condition including skin especially burns - DOCUMENTATION PROTECTS YOU - LVN A was suspended the day she received the counseling, on 08/31/2023 - Record review of sign in rosters for inservices on: Accidents/Incidents, Investigation and Reporting Burn/Skin Issues/Change of Condition, Safety & Supervision of Residents with evidence that all staff received the training dated 9/1/2023. Training conducted by DON and ADON. - Record review of employee memorandum for LVN A detailing her failure to report change of condition to supervisor, physician and to notify responsible party; LVN A's suspension and education on failure to report dated 08/31/2023. Memorandum signed by DON and LVN A.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 2 of 6 resident (Residents #44 and, #114) reviewed for privacy, in that: 1. LVN X did not completely close Resident #44's privacy curtain while providing wound care for the resident. 2. LVN A did not completely close Resident #114's privacy curtain while providing colostomy care for the resident. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: 1. Record review of Resident 44's face sheet, dated 04/13/2023, revealed an admission date of 10/03/2022, with diagnoses which included: Cerebral aneurysm (weak spot in an artery of the brain that bulges out), Hypertension (High blood pressure), Depression (feeling of severe despondency), Hyperlipidemia (too much lipids (fat) in the blood), Anxiety (a feeling of worry, nervousness or unease) Record review of Resident #44's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 9, indicating moderate impairment. Resident #44 required extensive assistance and was always incontinent of bladder, frequently incontinent of bowel and was coded at risk for pressure ulcer. Observation on 04/13/23 at 09:56 a.m. revealed LVN X provided wound care for Resident #44, LVN X did not pull the curtains completely around Resident #44's bed to offer privacy to the resident during care. The privacy curtain was too short to completely surround the bed and an area was left open during care Resident #44's wound was on the knee and the resident's pants had to be pulled down. The opened area was large enough the resident could be seen through it. During an interview with LVN X on 04/13/2023 at 10:18 a.m., LVN X confirmed the staff was supposed to provide complete privacy during care and completely close the privacy curtain. She confirmed the bed and resident were partially uncovered. She confirmed receiving training about privacy during care. During an interview with the Housekeeping Supervisor on 04/13/2023 at 11:05 a.m., the Housekeeping Supervisor revealed housekeeping changed the curtain every month or when they were soiled or broken. But she could not know if they needed replacement unless the nursing staff would tell her. 2. Record review of Resident 114's face sheet, dated 04/14/2023, revealed an admission date of 12/08/2022 and, a readmission date of 12/21/2022, with diagnoses which included: Type 2 diabetes mellitus (blood glucose, also called blood sugar, is too high), Legal blindness (poor visual perception), Colostomy status (opening in the belly (abdominal wall) that's made during surgery. It's usually needed because a problem is causing the colon to not work properly), Hypertension (High blood pressure), Cirrhosis of liver (late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions). Record review of Resident #114's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 8, indicating moderate impairment. Resident #114 required limited assistance, was always continent of bladder and. had a ostomy (a surgical procedure that creates an opening in the abdominal wall)- Observation on 04/13/23 at 12:13 p.m. revealed LVN A provided colostomy care for Resident #114, LVN A did not pull the curtains completely around Resident #114's bed to offer privacy to the resident during care. The end of the bed was left open during care Resident #114's ostomy site and abdomen were exposed and could have been seem by someone opening the room's door. During an interview with LVN A on 04/13/2023 at 12:25 p.m., LVN A confirmed the staff was supposed to provide complete privacy during care and close completely the privacy curtain. She confirmed the bed and resident were partially uncovered. She confirmed receiving training about privacy during care. During an interview with the Administrator and Regional Nurse on 04/14/2023 at 3:00 p.m., the Administrator confirmed the curtain should have been closed during care to provide privacy. The Administrator confirmed the staff received training on resident rights. The facility did annual skill checklists with the staff. The ADON did spot checks on different staff to check their knowledge and skills. Review of the facility's policy titled Residents rights guidelines for all nursing procedures, dated 10/2010, revealed, For any procedure that involves direct resident care, follow this steps: [ .] f. Close the room entrance door and provide for the resident's privacy.

Based on interview and record review, the facility failed conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 days calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition for 1 of 7 resident (Resident #423) reviewed for Comprehensive Assessments and timing. The facility failed to ensure an MDS Assessment for Resident #423 was completed within 14 days after admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings include: Record review of Resident #423's face sheet dated 04/13/2023, revealed an admission date of 03/15/2023, Record review of Resident #423's medical record revealed as of 04/14/2023 no admission assessment MDS had been completed. Interview with the MDS Coordinator on 04/14/23 at 2:52 p.m. revealed the time frame for an initial MDS to be completed was 14 days from admission and the Comprehensive Assessment within 21 days of admission. She stated she was the only MDS for the facility and had fallen behind with her assessment. She revealed she used the RAI manual as reference and she had electronic access to the manual. Interview with the Administrator on 04/14/2023 at 3:00 p.m. revealed the Administrator was aware the MDS coordinator needed help with the assessments for the facility and the facility was trying to hire another MDS nurse. Record review of the mds-3.0-rai-manual-v1.17.1_October_2019 revealed The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if: -this is the resident' s first time in this facility, OR -the resident has been admitted to this facility and was discharged return not anticipated, OR -the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's 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 for 1 of 47 residents (Resident #2) whose care plan was reviewed, in that: The facility failed to ensure Resident #2's care plan included insulin This deficient practice could place residents at risk of receiving the incorrect care and cause health complications with subsequent illness. The findings were: Record review of Resident #2's face sheet, dated 04/14/2023, revealed the resident was re-admitted on [DATE] with diagnoses that included: vascular dementia, type 2 diabetes, anxiety and psychotic disturbance. Record review of Resident #2's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 08, which indicated moderate cognitive impairment. Further review for Active Diagnoses revealed I2900. Diabetes Mellitus (DM) . checked as a current diagnoses. Record review of Resident #2's continuity of care document, dated 04/14/2023, revealed a medication with a start date of 01/30/2023 and a last administered date of 04/12/2023 at 08:21 pm and specifically read Levemir U-100Insulin (insulin detemir u-100)100 unit/mL solution; Once An Evening; 10 units, subcutaneous, Once An Evening, Administer 10 units subcutaneously in the evening for DM 2 HOLD IF BSIS < 100; E11.9 : Type 2 diabetes mellitus without complications. Record review of Resident #2's care plan, undated, revealed insulin nor diabetes was not listed as a problem area. During an interview and record review on 05/13/2021 at 2:30 p.m., the Regional DON stated insulin was supposed to be on Resident #2's care plan. He stated it was supposed to be care planned when resident was diagnosed (with diabetes), which possibly since this resident was admitted . The Regional DON stated care plans began with the MDS or CCN and then the DON overseas that position. He stated it must have been overlooked. The Regional DON stated the potential harm to resident was a new nurse would not know this resident needed insulin or was diabetic, by just looking at the care plan. He further stated that if the order is in the system, the resident was supposed to be receiving the insulin regardless. During an interview on 05/13/2023 at 4:38 p.m., the Administrator stated insulin was supposed to be added to the care plan at on-site of the problem. She further stated anyone in the nursing department has the authority to add items from the orders to the care plans. The Administrator stated that care plans are reviewed during their review date. The Ato the care plan. She then stated the IDT during the team conference ensured that everything was in place starting Administrator did not believe there was a potential harm to resident, being there was an order for the insulin and Resident #2 was receiving the service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to follow menus for 1 of 1 resident meals (lunch meal on 04/11/2023) reviewed for menus in that: 1. Residents on a regular diet were served lunch items on 04/11/2023 that did not reflect what was on the menu. 2. Residents on modified diets were served lunch items on 04/11/2023 that did not reflect what was on the menu. These failures could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss. The findings included: 1. Observation on 04/11/2023 at 10:15 a.m. in the dining room revealed the lunch meal posted for that day was: Cheeseburger, French Fries, Tomato/Lettuce/Pickles/Onion, Hot Spiced Apples, Iced Tea or Punch and Water. There was no weekly menu posted. Record review of the current week's menu provided by facility labeled, Week 5 revealed the lunch meal scheduled for Tuesday, 04/11/2023, for residents on a regular diet was: Pot Roast, Roasted New Potatoes, Sliced Carrots, Herb butter Roll, Banana Pudding. The consultant dietitian signed the menu. During the Resident Council Meeting on 04/12/2023 from 9:30 a.m. to 10:30 a.m., all twelve residents in attendance denied requesting a cheeseburger meal every Tuesday. The residents claimed they received cheeseburgers every Tuesday and also every Saturday and they were not happy about the lack of variety. Interview on 04/11/2023 at 10:30 a.m. with the facility's Ombudsman revealed the Ombudsman was at every Resident Council meeting and this request was never mentioned by any resident at any meeting. During an interview on 04/11/2023 at 10:30 a.m. with the DM and [NAME] W, both the DM and [NAME] W stated that the Resident Council had decided that they wanted cheeseburgers for lunch every Tuesday. Review of the minutes from the Resident Council Meetings for the months of January, February and March 2023 revealed there was no mention of requesting hamburgers or cheeseburgers for lunch every Tuesday. 2. Record review of the current week's menu provided by the facility labeled, Week 5 revealed the lunch menu scheduled for Tuesday, 04/11/2023, for residents on a pureed diet, was: Pureed Pot Roast, Pureed Roasted New Potatoes, Pureed Herb Butter Roll, Pureed Banana Pudding Dessert. The consultant dietitian signed the menu. During an interview on 04/11/2023 at 10:40 a.m. with the DM, when asked what the residents who had a physician's order for a pureed diet would receive for lunch that day, the DM stated residents on a pureed diet would receive pureed cheeseburgers for the lunch meal. Record review of the Diet Order Report 3/11/2023 - 4/11/2023 revealed that Residents #48, #57 and #63 had diet orders from their physicians that read: Regular with Puree Texture. Observation of lunch service on 04/11/2023 from 12:25 - 12:35 p.m. revealed Resident #57 was served a plate with pureed food. On Resident #57's plate was a scoop of food that was brown in color, a scoop that was off-white in color, and a scoop that was bright red in color. Residents #48 and #63 were served similar looking plates with pureed food. Review of the meal tickets for Residents #48, #57 and #63 revealed they read: Regular/Puree and listed the following: Entrée - ½ C PUR Pot Roast; Starch - ½ C PUR New Potatoes; Vegetable - 1/3 C PUR Carrots; Bread - ¼ C PUR Herb Butter Roll; Dessert - ½ C PUR Banana Pudding [NAME]. During an interview on 04/11/2023 at 1:30 p.m. with CNA I, CNA I stated that the scoop of pureed red food on Residents #48, #57 and #63's plates was not carrots, and that it was pureed stewed tomatoes. Sitting at the same table were residents served stewed tomatoes in their unpureed form, and the color of the tomatoes on those plates matched the color of the pureed stewed tomatoes. During an interview on 04/11/2023 at 12:40 with the DM, he stated he believed the residents on pureed diets would be served pureed cheeseburgers for the lunch meal and he did not know they would be served pureed pot roast, pureed potatoes, and a pureed vegetable. The DM further stated that he did not speak with the consultant RD about the change in menu. Record review of facility policy 01.0007 Menu Substitutions, revised 06/01/2019, revealed, 1. The menu will be served as written unless an emergency situation arises. 2. If a specific item is not available, the cook will consult with the Nutrition & Foodservice Manager or consultant RD regarding an appropriate substitution. If the Nutrition & Foodservice Manager or dietitian is not available, the cook will refer to the Menu Substitution Guide included in this section and their approved diet manual. 3. All substitutions will be made in accordance with the Menu Substitution Guide to ensure that the meal is well-balanced and adequate. 4. All changes to the menu will be recorded on the Menu Substitution Approval Form. 5. The consultant RD will review the Menu Substitution Approval Form on each visit to determine trends in substitutions and accuracy of substitutions so that appropriate training can be provided if needed. 6. The dietitian will initial off the Menu Substitution Form after review. The Menu Substitution Form will be retained with dated menus for a 12-month period.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. There was a zip-locked bag in the reach in cooler with diced ham that was past its use-by date. 2. There was an open bag of flour in the dry storage room that was not stored in a closed or tightly covered container. 3. The tabletop can opener blade, bar, and base were covered in sticky black and brown grime. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 04/11/2023 at 10:20 a.m. in the reach-in cooler revealed there was a zip-locked bag on a shelf with the words, Diced ham. Also written on the bag was the date 3/23 and OP 3/28. Interview on 04/11/2023 at 10:30 a.m. with the DM revealed the dates meant the ham was received by the facility on 3/23/2023 and opened on 3/28/2023. The DM stated that the ham had been in the cooler for 14 days by 04/11/2023 and should have been discarded in accordance with the facility's food storage policy. The DM further stated that any dietary staff member that stores food in the cooler is responsible for ensuring food is properly labeled, dated, and discarded according to the policy, and that failing to discard food in a timely manner could result in foodborne illness. Training on foodservice sanitation and safety was provided on a regular basis by the consultant dietitian. 2. Observation on 04/11/2023 at 10:35 a.m. in the dry storage room revealed a 25 lb. bag of flour on a shelf. The bag was approximately ¼ full, and the top of the bag was rolled down. The bag was not closed with any type of fastener, and the bag was not enclosed in a sealed container. Interview on 04/11/2023 at 10:41 a.m. with the DM revealed the bag of flour was not sealed, and the bag should have been stored either in a larger bag with a zip lock or a sealed container. The DM further stated that all kitchen staff store food in the dry storage room, and that failing to ensure food was properly sealed could result in deterioration in food quality and potential contamination from pests. 3. Observation on 04/11/2023 at 10:45 a.m. in the kitchen revealed the tabletop can opener was covered with sticky grime that was black and brown in color. The grime covered the blade portion of the can opener, the adjustable bar, and also surrounded the base that was affixed to the table with screws. During an interview on 04/11/2023 at 10:46 a.m. with the DM, the DM stated that the can opener blade, bar and base were covered in sticky grime and should not have been. The DM stated the cooks were responsible for ensuring the can opener and area surrounding the base remained clean and free of debris, and that failing to do so could result in contamination of food from bacteria lingering on the blade and potential foodborne illness. Review of facility policy 03.003 revised 06/01/2019 revealed: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Code and HACCP guidelines. 1. Dry Storage. d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. 2. Refrigerators. e. Use all leftovers within 72 hours. Discard items that are 72 hours old. Review of facility policy 04.009 Can Opener dated 10/01/2018 revealed, The facility will maintain can openers free of food particles and dirt to minimize the risk of food hazards. Can openers be cleaned after each use. 1. Hand held or table top. a. Remove can opener shank from base. b. Wash shank in sink with warm water and detergent or in the dishwasher. c. Give close attention to the blade and moving parts. d. Rinse in clean, hot water. e. Sanitize with approved sanitizer. Follow manufacturer's instructions for immersion times. f. Air dry. g. Wash base of can opener with clean cloth soaked in warm water and detergent, removing all food particles and dirt. h. Rinse with clean cloth soaked in clear hot water. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, , ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed, 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 6 residents (Residents #44, #94 and, #114) reviewed for infection control, in that: 1. LVN X did not wash or sanitize her hands or change her gloves after touching Resident #44's environment and before starting wound care for Resident #44. 2. CNA Y and CNA D did not wash or sanitize their hands or change their gloves after touching Resident #94's environment and before starting incontinent care for Resident #94. 3. LVN A did not wash or sanitize her hands between change of gloves during colostomy care for Resident #114. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1 .Record review of Resident 44's face sheet, dated 04/13/2023, revealed an admission date of 10/03/2022, with diagnoses which included: Cerebral aneurysm (weak spot in an artery of the brain that bulges out), Hypertension (High blood pressure), Depression (feeling of severe despondency), Hyperlipidemia (too much lipids (fat) in the blood), Anxiety (a feeling of worry, nervousness or unease) Record review of Resident #44's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 9, indicating moderate impairment. Resident #44 required extensive assistance and was always incontinent of bladder, frequently incontinent of bowel and was coded at risk for pressure ulcer. Observation on 04/13/23 at 09:56 a.m. revealed, after washing her hands, LVN X touched the handle of the door to close the door and the light cord to turn the bed light on. Then, without sanitizing or washing her hands she donned (put on)her gloves. The nurse touched the privacy curtain with her gloved hands and without changing gloves and washing or sanitizing her hands started to provide care including cleaning Resident #44's wound. During an interview with LVN X on 04/13/2023 at 10:18 a.m., LVN X confirmed the environment around the resident was considered dirty and she should have washed or sanitized her hands and changed her gloves prior to start the care. She confirmed the staff received infection control training. During an interview with the Administrator and Regional Nurse on 04/14/2023 at 3:00 p.m., the Administrator confirmed the staff should have washed or sanitized her hands and changed her gloves. The Administrator confirmed the staff received training on infection control. The facility did annual skill checklists with the staff. The ADON did spot checks on different staff to check their knowledge and skills. 2. Record review of Resident 94's face sheet, dated 04/14/2023, revealed an admission date of 08/06/2021, with diagnoses which included: Quadriplegia (paralysis of all 4 limbs), Chronic viral hepatitis (chronic liver infection), Anxiety disorder (a feeling of worry, nervousness or unease), Urinary tract infection (infection of any part of the urinary system) Record review of Resident #94's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 15, indicating no impairment. Resident #94 required extensive assistance and was always incontinent of bowel and, had a urinary catheter Observation on 04/13/23 at 11:45 a.m. revealed, after washing her hands and donning their gloves, CNA Y and CNA D, both touched the privacy curtain with their gloved hands to close it. Then without changing their gloves or washing their hands, they started to provide incontinent care for the resident. During an interview with CNA Y and CNA D on 04/13/2023 at 11:55 a.m., CNA Y and CNA D confirmed the environment around the resident was considered dirty and they should have washed or sanitized their hands and changed their gloves prior to start the care. They confirmed the staff received infection control training. During an interview with the Administrator and Regional Nurse on 04/14/2023 at 3:00 p.m., the Administrator confirmed the staff should have washed or sanitized her hands and changed her gloves. The Administrator confirmed the staff received training on infection control. The facility did annual skill checklists with the staff. The ADON did spot checks on different staff to check their knowledge and skills. 3. Record review of Resident 114's face sheet, dated 04/14/2023, revealed an admission date of 12/08/2022 and, a readmission date of 12/21/2022, with diagnoses which included: Type 2 diabetes mellitus (blood glucose, also called blood sugar, is too high), Legal blindness (poor visual perception), Colostomy status (opening in the belly (abdominal wall) that's made during surgery. It's usually needed because a problem is causing the colon to not work properly), Hypertension (High blood pressure), Cirrhosis of liver (late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions). Record review of Resident #114's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 8, indicating moderate impairment. Resident #114 required limited assistance, was always continent of bladder and. had a ostomy.(stoma is an opening on the abdomen that can be connected to either the digestive or urinary system) Observation on 04/13/23 at 12:13 p.m. revealed LVN A provided colostomy care for Resident #114, LVN A did not wash or sanitize her hands after changing her gloves after cleaning the stoma and before applying the new collection bag. During an interview with LVN A on 04/13/2023 at 12:25 p.m., LVN A confirmed she had not wash or sanitize her hands between change of gloves and shoe should have at least sanitize to prevent cross contamination. She confirmed receiving infection control training. During an interview with the Administrator and Regional Nurse on 04/14/2023 at 3:00 p.m., the Administrator confirmed the staff should have sanitize her hands between change of gloves. The Administrator confirmed the staff received training on infection control and hand washing. The facility did annual skill checklists with the staff. The ADON did spot checks on different staff to check their knowledge and skills. Review of the facility policy titled, Standard precautions, dated October 2019, revealed Hand hygiene is performed with ABHR or soap and water: [ .] (3) after contact with items in the resident's room, and (4) after removing PPE.

Based on interview, and record review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) Training that outlines and informs staff of the elements and goals of the facility's QAPI program for 13 of 23 staff (CNAs E, F, G, H, I, J, K, L, and LVNs N, Q, and ST, PT, and OT, reviewed for training, in that: The facility failed to ensure that 13 of 23 staff (CNAs E, F, G, H, I, J, K and LVN's N, Q, and ST, PT, OT staff had completed their mandatory QAPI annual training. This failure could place residents at risk for care by CNA, LVN, and therapy staff who have been insufficiently trained while working in the facilit The findings included: Record review of the annual CNA, LVN, and therapy staff training information revealed that: CNA E (hired-11/1/18), CNA F (hired-5/5/20), CNA G (hired-8/2/20), CNA H (hired-11/1/18), CNA I (hired-11/1/18), CNA J (hired-11/1/18),CNA-K((hired- 11/1/18),CNA-L(hired-3/3/20), LVN N (hired-5/28/19), LVN-Q (hired-2/20/19), and ST (hired-9/1/20), and PT (hired-9/21/20) and OT (hired-3/15/22) had not completed their mandatory QAPI annual training During an interview with the HR Coordinator on 4/14/23 at 11:00am the HR Coordinator stated that there was not a record of a annual QAPI training for CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA-K, CNA-L, LVN-N, LVN-Q, ST,,PT,, and OT The HR Coordinator stated that she was not aware of any facility policy that addressed the QAPI training requirement for staff. During an interview with the Administrator on 4/14/23 at 12:55p.m., the Administrator stated that she was not aware of a record of a annual QAPI training for CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA-K, CNA-L, LVN-N, LVN-Q, ST,,PT,, and OT The Administrator stated that she was not aware of a QAPI training program held by the facility for the identified staff. Record review of the facility policy titled In-service Training Program Nurse Aide revised in May 2019 stated that all personnel are required to attend regularly scheduled in-service training classed.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 2 of 4 shower rooms observed for environment, in that: The facility failed to ensure potential hazards were locked up in two communal shower rooms. This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment. The findings were: During an observation, on a side table against the wall in a communal shower room near station 1, and interview on 03/09/2023 at 5:55 a.m., LVN A confirmed observing razors (located in a rolling plastic cart), cleaning solution and shaving cream in an unlocked communal shower room. Further observation revealed LVN B put cleaning solution and shaving cream in the shower room closet and locked it up. LVN A and LVN B rolled the plastic cart, with razors in it, to the other communal shower room, where the door locked. During an observation, in an unlocked closet in the communal shower room located in the women's memory care unit, and interview on 03/09/2023 at 6:01 a.m., LVN C confirmed observing razors and shaving cream in the unlocked closet of the shower room. LVN C stated the potential harm to resident was death. During an interview on 03/09/2023 at 6:57 a.m., the Administrator stated yes, razors and shaving cream was supposed to be locked up away where residents do not have access to it. The Administrator stated the potential harm to residents was harming themselves. The Administrator stated nursing assistants were responsible for making sure those items were locked up. During an interview on 03/09/2023 at 10:15 a.m., the Administrator stated the facility did not have a policy for hazards in unlocked shower rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed the ensure physician visits were conducted once every 60 days and did not occur within the 10 days after the date the visit was required for 8 of 53 residents (Resident # 106, Resident # 35, Resident #17, Resident 76, Resident #105, Resident #51, Resident # 116, and Resident #95) whose care was reviewed in that: The facility failed to have Resident # 106 seen by physician at least once every 30 days for the first 90 days after admission since 09/09/2021. The facility failed to have Resident # 95 seen by physician at least once every 30 days for the first 90 days after admission on [DATE]. Resident #95 was last seen 10/14/2021. The facility failed to have Resident # 17 seen by physician at least every 60 days after the first 90 days after admission on [DATE]. Resident #17 was last seen 10/14/2021. The facility failed to have Resident # 35 seen by physician at least every 60 days after the first 90 days after admission on [DATE] since 10/14/2021. The facility failed to have Resident # 51 seen by physician at least every 60 days after the first 90 days after admission on [DATE]. Resident #51 was last seen 09/09/2021. The facility failed to have Resident # 116 seen by physician at least every 60 days after the first 90 days after admission on .01/28/2019. Resident #116 was last seen on 09/09/2021 The facility failed to have Resident #76 seen by physician at least every 60 days after the first 90 days after admission on [DATE]. Resident #76 was last seen 09/09/2021. The facility failed to have Resident #105 seen by physician at least every 60 days after the first 90 days after admission on [DATE]. Resident #76 was last seen since 08/09/2021. This deficient practice could lead to a decline in health status or untreated conditions. The findings include: Per record review of Resident #106's Face Sheet, resident was admitted [DATE]. Diagnosis includes: Uncontrolled Electrical Brain Activity, Memory Loss, Depression, Acute Pain, Impaired Muscle Coordination. Per review of Minimum Data Set (MDS) Section C dated 1/5/2022, Brief Interview for Mental Status (BMS) score is 09 (Mildly Impaired). Per review of Physician Progress Notes resident #106 was last seen by primary physician on 09/09/2021. Per record review of Resident # 95's Face Sheet, resident was admitted on [DATE]. Diagnosis includes: Disease that affects the brain, Mental Illness, Low Blood Count, Depression, Nutritional Disorder. Per review of MDS section C dated 12/2/2021, BIMS score of 15 (Cognitively intact). Per review of Physician Progress notes resident#95 was last seen by primary physician on 10/14/2021. Per record review of Resident # 17's Face Sheet, resident was admitted on [DATE]. Diagnosis includes: Genetic Condition of extra chromosome, Difficulty swallowing, Unspecified Mental Disorder. Per review of MDS resident Section C dated 10/26/2021 BIMS Score of 99 (severely impaired). Per review of Physician Progress notes resident #17 was last seen by Primary Physician on 10/14/2021. Per record review of Resident #51's Face Sheet: resident was admitted on [DATE]. Diagnosis includes Progressive Mental Deterioration, Blood Sugar Disorder, Heart Failure, Paralysis on one side of the body. Per review of MDS section C dated 12/01/2021 BIMS score 03 (moderately impaired. Per review of Physician Progress notes Resident #51 was last seen by Primary Physician on 09/09/2021. Per record review of Resident #35's Face Sheet resident was admitted on [DATE] Diagnosis includes Acute neurological Condition, Depression, Anxiety, High Blood Pressure. Per review of MDS section C dated 11/13/2021, BIMS score 14 (Cognitively intact). Per review of Physician Progress notes, Resident #35 was last seen by Primary Physician on 10/14/2021. Per record review of Resident #116's Face Sheet, resident was admitted on [DATE] . Diagnosis includes Irregular Heart Rate, Poor blood Circulation. Per review of MDS section C dated 1/10/2022 BIMS score 99 (Severely impaired). Per review of Physician Progress notes, Resident #116 was last seen by Primary Physician on 6/10/2021. Per record review of Resident # 76's Face Sheet, resident was admitted on [DATE]. Diagnosis includes, Memory Loss, Lung Disease, Depressive Episode, Unspecified Mood Disorder. Per review of MDS section C dated 12/16/2021 BIMS score 99 (Severely impaired). Per review of Physician Progress notes, Resident #76 was last seen by Primary Physician on 9/9/2021. Per record review of Resident #105's Sheet, resident was admitted on [DATE]. Diagnosis includes, Difficulty Breathing, Difficulty Swallowing, Blood sugar Disorder Nicotine Dependence, High Blood Pressure. Per review of MDS section C dated 1/5/2022 BIMS score 15 (Cognitively intact). Per review of Physician Progress notes, Resident #105 was last seen by Primary Physician on 8/9/2021. During an interview on 01/21/2022 at 09:35 AM DON stated, Expectation of residents being seen by physician is Medicare residents seen monthly and Medicaid residents every 60 days. Medical Records should be tracking. I have great confidence that the residents are being seen. Their doctors are in the building all the time. DON did not state why the failure occurred. During an interview on 01/21/2022 at 09:40 AM ADON stated, I am unsure why the residents were missing their physician visits. The MD is coming today at noon and get all residents all caught up. During an interview on 01/21/2022 at 12:30 PM with Medical Director. My office keeps a spreadsheet of who needs to be seen each visit. I just feel bad that we are not caught up on our visits. I have been doing this for over 20 years, so I know when I am required to see my residents. I am here today to make rounds and get caught up. Per review of facility's policy statement Policy Title: Physician Services 3. Supervising the medical care of the residents includes (but is not limited to): f. conducting routine required visits. 6. Physician orders and progress notes are maintained in accordance with current OBRA regulations and Center policy. 7. Physicians visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA regulations and Center policy. Revised October 2021

Based on observations, interviews, and record review the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen's reviewed for kitchen sanitation. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and freezers. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: Observation on 01/18/22 at 10:03 AM of the kitchen revealed: Refrigerator #2 of 2 1. 1 opened package of diced ham dated 12/28/2021, that being more days allowed for opened refrigerated packages 2. 4 packages of Polish sausage in steel container, no receiving date. 3. 4 unopened packages of Frozen vegetables not dated. 4. 2 heads of lettuce in box, open to elements, not dated. 5. 1 container of peanut butter, not in original container, not labeled or dated. 6. 1 box of whole apples not dated. 7. 1 box containing four 5-pound packages of cut and peeled carrots, not dated. 8. 1 clear bag of grapes open to elements, with no date or label. 9. 8 individual blocks of golden sweet margarine not dated. 10. 1 box of bacon not dated. 11. 30 small, clear containers of Jello, with no labels or dates. 12. 2 separate bags containing cilantro, wilted and black, not dated. 13. 1 box of 12 individually wrapped molded cucumbers, not dated. 14. 1 clear bag containing 10 boiled eggs not labeled or dated. 15. 1 container labeled lemon pudding, dated 01/04, use by 01/07. Freezer #2 of 2 1. 4 boxes of strawberry ice cream not dated. 2. 1 box of 6 individually wrapped ice cream sandwiches, not dated. 3. 1 opened clear bag of frozen sliced potatoes, not labeled or dated. 4. 1 frozen pork loin in original packaging, date received was unreadable. 5. 1 opened bag of French bread, not labeled or dated. In an interview on 01/19/2022 at 12:01 PM with DM, she stated her expectations for storage and labeling are for the dietary staff including herself, should date and label products as they are being received into the kitchen as well as when they are being used. She also stated the failure is due to herself not following up on the storage and labeling to make sure it is being done properly. During interview 01/21/2022 at 09:13 AM with ADMIN, she stated her expectations are when items are received in the kitchen from the vendor, items are to be labeled and dated accordingly. She also stated the failure occurred when the items were received, they were not dated by dietary staff as well as the failure of daily monitoring. Record review of policy from Next level Hospitality Services titled, Food Receiving and Storage, not date, revealed: #7 All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to three of seven (Medication Cart for Hall A/B, Medication Cart for co-ed secure Unit, Medication Cart for Hall C ) medication carts. The facility failed to ensure the medication cart for Hall A/B and the co-ed unit were secured at all times when left unattended. The facility failed to ensure opened medications were labeled with open dated and or expiration dates in medication carts for Hall C and Hall A/B. The facility failed to ensure that medications were not lose in the Hall A/B medication cart #1 drawers. These failures could place residents at risk of harm or decline in health due to lack of potency of supplies, medications/biologicals or misappropriation of medications, or drug diversions. The findings include: Per observation on 01/18/2022 at 10:57 AM medication cart for Hall A/B was unlocked and unattended at the nurse's station by the lobby of the facility for 10 minutes. There were 2 residents in the lobby at this time approximately 8 feet from the unattended medication cart. The closest nurse was approximately 6 feet away from the medication cart and not in proximity to intervene if a resident attempted to get into the medication cart. Medication Cart contained: Insulin, syringes, lancets, alcohol prep pads, tizanidine, ondansetron, baclofen, gabapentin, oxcarbazepine, benztropine, prednisolone, quetiapine, risperidone, atorvastatin, metformin, divalproex, trazadone, amlodipine, mirtazapine, benazepril, clonidine, buspirone, Eliquis, cephalexin, pantoprazole, potassium ER, metoprolol tartrate, furosemide, fluoxetine, omeprazole, sevelamer, hydralazine, Montelukast, cyclobenzaprine, levetiracetam, folic acid, citalopram, carvedilol, APAP, hyoscyamine, glipizide, levothyroxine, famotidine, sucralfate, haloperidol, primidone, lisinopril, amitriptyline, spironolactone, losartan potassium, vitamin D2, stimulant plus, isosorbide, Levemir, Novolog, Lantus, Victoza, EC ASA, APAP, probiotic, naproxen, B complex, Thera M, melatonin, Vit B 12, Vit C, stool softener, zinc, Vit D, Thiamin B-1, allergy relief, stomach relief, loratadine, senna plus, calcium carbonate, mucous relief, gas relief, ipratropium bromide, Haldol concentrate, Maalox, Milk of Magnesium, Flonase nasal spray, albuterol inhaler, budesonide, diclofenac gel, Duo-neb, oxybutynin, donepezil, Zoloft, KCL ER. Per observation on 01/18/2022 at 3:57 PM medication cart for Hall A/B was observed unlocked and unattended at the nurse's station by the lobby for 5 minutes. The closest nurse to this medication cart was six feet away and not in proximity to intervene if a resident attempted to get into the medication cart. There were 2 residents sitting in chairs in the lobby, approximately 8 feet from the unattended medication cart. Medication Cart contained: Insulin, syringes, lancets, alcohol prep pads, tizanidine, ondansetron, baclofen, gabapentin, oxcarbazepine, benztropine, prednisolone, quetiapine, risperidone, atorvastatin, metformin, divalproex, trazadone, amlodipine, mirtazapine, benazepril, clonidine, buspirone, Eliquis, cephalexin, pantoprazole, potassium ER, metoprolol tartrate, furosemide, fluoxetine, omeprazole, sevelamer, hydralazine, Montelukast, cyclobenzaprine, levetiracetam, folic acid, citalopram, carvedilol, APAP, hyoscyamine, glipizide, levothyroxine, famotidine, sucralfate, haloperidol, primidone, lisinopril, amitriptyline, spironolactone, losartan potassium, vitamin D2, stimulant plus, isosorbide, Levemir, Novolog, Lantus, Victoza, EC ASA, APAP, probiotic, naproxen, B complex, Thera M, melatonin, Vit B 12, Vit C, stool softener, zinc, Vit D, Thiamin B-1, allergy relief, stomach relief, loratadine, senna plus, calcium carbonate, mucous relief, gas relief, ipratropium bromide, Haldol concentrate, Maalox, Milk of Magnesium, Flonase nasal spray, albuterol inhaler, budesonide, diclofenac gel, Duo-neb, oxybutynin, donepezil, Zoloft, KCL ER. Per observation on 01/19/22 at 03:47 PM the medication cart on Co-ed secure unit unlocked and unattended in hallway outside of rooms [ROOM NUMBERS] for 5 minutes. There were several residents in the dining area at the time. The dining area is approximately 8 feet from where the medication cart was located. The nurse was approximately 4 feet from the medication cart and not in proximity to intervene if a resident attempted to get into the medication cart. Medication Cart contained: Insulin, syringes, eye drops, Methotrexate, Zofran, scissors, Albuterol inhalers, Nebulizers, Hyoscyamine, Lidocaine patches, Nicoderm Patches, Glucose Gel, Hydrocortisone Suppository's, Promethazine, Metocaprynal, Enulose Solution, Tylenol 500, Milk of Mag, Melatonin, Benadryl, nystatin powder, saline, odor spray Hemorrhoid's cream, Muscle rub cream, Clotrimazole, Disinfectant Ativan, Hydrocodone with Tylenol 3, Tylenol 3 and 4, Temazepam, Clonazepam, Clorazepate, Methadone, Tramadol, Vimpat, Phenobarbital, Fycompa, Lyrica, Morphine soleplate tab, Temazepam, Morphine sulfate liquid, Per observation on 01/20/2022 2:05 PM of medication cart #2 for Hall C Third drawer revealed: 1 bottle Valproic acid SLN with no open date or expiration date 1 bottle of Lactulose solution with no open date or expiration date 1 bottle of Levetiracetam with no open date or expiration date 1 bottle Fluticasone spray no open date or expiration date 1 open tube Muscle Rub with no open date or expiration date Per observation of medication cart #1 for Hall A/B on 01/20/2022 at 3:32 PM Top drawer contained: One Lispro Insulin bottle with no open date or expiration date One Victoza bottle with no open date or expiration date One Lantus Solostar insulin pen with no open date or expiration date One Novolog bottle with no open date or expiration date One Levemir bottle with no open date or expiration date Second drawer contained: One loose square pill with markings 54 on one side and X on other side. One loose round white pill scored on one side and starburst on other side. Third drawer contained: Two bottles of Lactulose with no open date or expiration date Two bottles of Haloperidol oral solution with not open date or expiration dates Per interview on 01/18/2022 at 10:57 AM ADON stated, The nurse for medication cart for Hall A/B went down the hall to see who was screaming and what they needed and forgot to lock the cart. She should have locked it before she left it. I don't know why she didn't lock it. Per interview on 01/18/2022 at 3:57 PM LVN D nurse for medication cart Hall A/B stated, I had just gone back to the nurses' station to double check a new order for a resident, my cart was where I could see it and no resident was around my cart. I just wanted to make sure that I gave the right medication, and I had the screen up at nurse's station and not on my computer on my medication cart. I know that I am supposed to have the cart locked unless I am pulling out meds. Per interview on 01/19/2022 at 09:21 AM RN B stated, Medication cart should be locked anytime I am not with it or right in front of it. Per interview on 01/19/2022 at 10:02 AM DON stated, I expect my nurses to keep the medication carts locked when not getting something out of them. I know yesterday the nurse left it unlocked because she heard a resident call out and she went to help the resident. Per interview on 01/19/2022 10:10 AM RN B stated, I thought it (medication cart) was locked, I'm so nervous. I just sat down at the nurses' station to use the computer. I don't know why this happened. Per interview on 01/19/2022 at 3:45 PM LVN D stated, Opened bottles of insulin should have date opened and expiration date. Opened insulin expires in 28-30 days after opened. I don't know why these are not dated. Per interview on 01/19/22 at 03:47 PM LVN A stated, That it (medication cart) should be locked. I just forgot to do it. Important to keep medication cart locked because medications are stored in it. If residents got medications, there could be adverse effect of residents taking medicines that are not theirs. Per interview on 01/19/2022 at 03:55 PM ADON stated No idea what those pills are, I will put them in the sharps container. There should not be any loose pills in the medication cart. Not sure how this happened. The medication carts should be locked when not in use. Per interview on 01/20/2022 at 03:25 PM DON stated, I expect the nurses to clean the medication carts weekly and as needed. All medications should have an open date when it is opened, and Insulins should have an expiration date as per manufacturer's policy. Per review of facility's policy titled Security of Medication Cart policy statement: 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 4. Medication carts must be securely locked at all times when out of the nurse's sight. 5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room. Revised April 2007