**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services for 1 of 8 residents (Resident #1) reviewed for incontinence. 1. The facility failed to provide appropriate incontinent care to Resident #1 when he was observed sitting in a wheelchair in his room with visibly wet clothing on and a strong odor of ammonia was detected from his room on 9/8/25 from 11:28 a.m. until 1:58 p.m. 2. The facility failed to provide appropriate incontinent care to Resident #1 when he was observed lying on sheets visibly soiled with yellow and brown stains and a strong odor of ammonia was detected from his room and his pants were visibly wet around his left hip on 9/9/25 from 2:54 p.m. until 5:06 p.m. These failures could place residents at risk of skin break down, urinary tract infection, and diminished quality of life.Findings included:1.Review of an admission Record for Resident #1 dated 9/8/2025 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia (altered cognition), type 2 diabetes, and psychotic disorder with delusions. Review of the quarterly MDS for Resident #1 dated 8/6/2025 indicated he had severely impaired thinking with a BIMS score of 04. He required total assistance for putting on/taking off footwear; he required partial assistance with personal hygiene and showering/bathing; he required supervision with putting on/taking off footwear, lower body dressing, upper body dressing, and toileting hygiene; he required setup/cleanup assistance with oral hygiene and eating. He was occasionally incontinent of bladder, and he was always continent of bowel. Record review of the care plan for Resident #1 dated 12/2/24 indicated he had an ADL self-care performance deficit, appropriate interventions were in place including supervise as needed with bathing, walking, and bed mobility. During an observation on 9/8/25 at 11:28 a.m., Resident #1 was observed in his room. He was seated in a wheelchair watching television. His pants and shirt were visibly wet around his left hip and thigh. There was a strong odor of ammonia emanating from his person and room. During an interview on 9/8/25 at 1:30 p.m., CNA A said she was working Resident #1's hall that day. CNA A said she rounded on residents usually every 30 minutes to 1 hour, and every 2 hours at a minimum. CNA A said she rounded on residents more frequently if they were heavy wetters to ensure every resident was dry.During an observation on 9/8/25 at 1:56 p.m. Resident #1 was observed in his room sitting in a wheelchair watching television. He was visibly wet from his left knee to approximately halfway up his torso and a strong odor of ammonia was emanating from his person and room.During an observation on 9/8/25 at 2:00 p.m., CNA A entered Resident #1's room and assisted him with incontinent care.During an observation and interview on 9/9/25 at 2:54 p.m., Resident #1 was observed in his room. He was lying on his bed; his sheets were visibly wet with a brown outer ring approximately the width of half of the sheet and a smaller yellow ring approximately half the size. A strong odor of ammonia was detected from his person and room. His pants were visibly wet around the left hip area. Resident #1 said he thought he was dry. He said he was not wet all day like yesterday. He said he could not remember when a staff member last checked on him.During an observation on 9/9/25 at 5:06 p.m., Resident #1 was observed in his room. He was lying on his bed; his sheets were visibly wet with a brown outer ring approximately the width of half of the sheet and a smaller yellow ring approximately half the size. A strong odor of ammonia was detected from his person and room. His pants were visibly wet around the right hip area. Resident #1 appeared to be sleeping.During an interview on 9/9/25 at 5:08, CNA B said she worked the 2:00 p.m. to 10:00 p.m. shift and was working on Resident #1's hall that day. She said she did not round on residents until 3:30 p.m. or 4:00 p.m. because she had to assist residents with showers first. She said she checked on Resident #1 around 3:00 p.m. and checked his briefs and noted them to be dry. She said she did see something on his sheets but Resident #1 did not want her to do anything about it.During an interview on 9/10/25 at 9:00 a.m., LVN C said CNAs were expected to round on residents every 2 hours and part of that rounding should include checking for any incontinent care needs. He said CNAs should go into every room and ask the resident if they need any assistance. During an interview on 9/10/25 at 9:10 a.m., LVN D said CNAs were expected to check on every resident at least every 2 hours. She said CNAs should be checking to see if residents need peri care and providing it. She said CNAs should be checking for wet or soiled linens and changing them. She said if a resident refused care the CNA should report it to the nurse so they can assist. During an interview on 9/10/25 at 9:30 a.m., the DON said she was ultimately responsible for supervising nursing staff. The DON said CNAs were expected to round every 2 hours and should be checking for and addressing any resident needs including incontinent care and wet or soiled linens. During an interview on 9/10/25 at 9:40 a.m., the ADM said the DON was responsible for supervision of the nursing staff. The ADM said CNAs were expected to round a minimum of every 2 hours, and they should be checking for incontinent care needs and changing soiled linens as part of their regular rounding.Review of the facility's policy titled Perineal Care dated 5/11/22 revealed the following .An incontinent resident of urine and/or bowl (sic) should be identified, assessed, and provided appropriate treatment and services. Skin problems associated with moisture can range from irritation to increased risk of skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records, review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 8 residents (Resident #1) reviewed for infection control. The facility failed to maintain an infection control program on 9/8/25 at 2:00 p.m. when CNA A assisted Resident #1 with incontinent care without changing her gloves, washing/sanitizing her hands, or cleaning from clean (urethral) to dirty (rectal) areas in the correct order. These failures could place residents at risk of diminished quality of life, urinary tract infection, or hospitalization.Findings included: 1.Review of an admission Record for Resident #1 dated 9/8/2025 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia (altered cognition), type 2 diabetes, and psychotic disorder with delusions. A review of the quarterly MDS assessment for Resident #1 dated 8/6/2025 indicated he had severely impaired thinking with a BIMS score of 04. He required total assistance for putting on/taking off footwear; he required partial assistance with personal hygiene and showering/bathing; he required supervision with putting on/taking off footwear, lower body dressing, upper body dressing, and toileting hygiene; he required setup/cleanup assistance with oral hygiene and eating. He was occasionally incontinent of bladder, and he was always continent of bowel. Record review of a care plan for Resident #1 dated 12/2/24 indicated he had an ADL self-care performance deficit, appropriate interventions were in place including supervise as needed with bathing, walking, and bed mobility. During an observation on 9/8/25 at 1:58 p.m., CNA A assisted Resident #1 with incontinent care. CNA A did not wash or sanitize her hands prior to beginning incontinent care. CNA A donned gloves and cleaned Resident #1 from dirty to clean areas starting with his rectal area to clean fecal incontinence and moving to his urethral area. CNA A assisted Resident #1 with dressing including pants, shirt, shorts, and shoes. CNA A did not change her gloves or wash/sanitize her hands while providing care. During an interview on 9/8/25 at 2:15 p.m., CNA A said she had been trained in incontinent care and infection control and had recently had 1-on-1 coaching concerning resident care. CNA A said she did sanitize her hands before entering the room, but she should have changed her gloves and cleaned going from clean to dirty areas.During an interview on 9/8/25 at 5:20 p.m., the DON said CNAs were expected to follow infection control guidelines when providing resident care. The DON said CNAs were expected to wash or sanitize their hands and to change gloves when soiled. The DON said she planned to conduct in-services with direct care staff covering appropriate infection control and incontinent care technique. During an interview on 9/10/25 at 9:00 a.m., LVN C said CNAs were expected to wash/sanitize their hands when entering a room to provide resident care. He said CNAs were expected to follow infection control policies when providing incontinent care including appropriately donning/doffing PPE. LVN C said he monitored CNAs compliance with policy by rounding on residents and following behind them to ensure tasks were completed appropriately. Review of in-service dated 7/28/25 at 2:30 p.m. indicated CNA A attended an in-service which included computer-based training on customer service skills. Review of in-service dated 7/28/25 at 2:30 p.m. indicated CNA A attended an in-service which included computer-based training on bed mobility and repositioning residents. Review of coaching form dated 7/28/25 indicated CNA A received coaching on customer service skills and repositioning residents. Review of the facility's policy titled Perineal Care dated 5/11/22 revealed the following .Perform hand hygiene.Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area - CLEAN to DIRTY! .Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area.Doff gloves and PPE.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 4 residents (Resident #1 and Resident #2) reviewed for incontinence. 1. The facility failed to provide appropriate incontinent care to Resident #1 when she was observed wearing two incontinent briefs (double briefed) on 6/9/25 at 10:15 a.m. 2. The facility failed to provide appropriate incontinent care to Resident #2 when she was observed wearing two incontinent briefs on 6/9/25 at 2:30 p.m. These failures could place residents at risk of skin break down, urinary tract infection, and diminished quality of life. Findings include: 1. Record review of Resident #1's admission Record, dated 6/9/2025, indicated an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Parkinson's Disease (movement disorder), dementia (altered cognition), and functional quadriplegia (complete inability to move without physical injury). Record review of Resident #1's quarterly MDS, dated [DATE], indicated she had moderately impaired thinking with a BIMS of 12. She required total assistance for putting on/taking off footwear. She required substantial assistance with personal hygiene, lower body dressing, and toileting hygiene. She required moderate assistance with oral hygiene and upper body dressing. She required supervision eating. She was always incontinent of bladder and frequently incontinent of bowel. Record review of Resident #1's care plan, dated 12/27/24, revealed she was incontinent of bowel and bladder. Interventions were in place which included providing incontinent care frequently and notifying nurse if the resident was incontinent during activities. During an observation and interview on 6/9/25 at 9:30 a.m. revealed Resident #1 was observed in her room, lying in bed. She had pillows under her heels and left buttock which appeared to be for off-loading pressure. There was an odor of ammonia emitting from her. Resident #1 said staff at the facility left her for hours without checking to see if she was wet. She said she was wet right now and had not been changed yet today. She said CNAs usually checked on her two (2) times per shift . During an interview on 6/9/25 at 10:10 a.m., LVN A said she was a charge nurse at the facility and was assigned to hall for Resident #1 . She said it was her responsibility to supervise CNA staff at the facility to ensure resident care needs were met. She said she monitored staff compliance with resident care plans by regularly rounding, observing staff interactions with residents, and talking to the residents. She said CNA staff were expected to round on residents at least every 2 hours and assist them as needed with incontinent care . During an observation on 6/9/25 at 10:15 a.m., revealed LVN A and CNA B performed incontinent care for Resident #1. Resident #1 was observed to be wearing two incontinent briefs at the same time, and they were saturated with a yellow liquid. LVN A and CNA B provided incontinent care in accordance with Resident #1's comprehensive care plan and used only one incontinent brief. During an interview on 6/9/25 at 10:40 a.m., LVN A said she had never seen a resident double briefed before in the facility. She said double briefing was not an acceptable practice and put residents at risk for skin break down and infection. During an interview on 6/9/25 at 1:30 p.m., CNA B said she was assigned Resident #1's hall and frequently cared for Resident #1. CNA B said she checked on Resident #1 five or more times per shift because she was a heavy wetter. She said she rounded on Resident #1 around 6:00 a.m. that morning and assisted Resident #1 with incontinent care. CNA B said she did not double brief Resident #1 and had never seen any resident at the facility double briefed before. She said it was not acceptable to ever brief a resident double. 2. Record review of Resident #2's admission Record, dated 6/10/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included dementia (altered cognition), morbid obesity, and muscle weakness. Record review of Resident #2's admission MDS, dated [DATE], indicated she had moderately impaired thinking with a BIMS of 2. She required total assistance for putting on/taking off footwear and lower body dressing. She required substantial assistance with upper body dressing, showering/bathing, and toileting hygiene, and personal hygiene. She required setup or clean-up assistance with eating and oral hygiene. She was always incontinent of bowel and bladder. Record review of Resident #2's care plan, dated 2/28/25, revealed she was incontinent of bowel and bladder. Interventions were in place which included checking resident every two hours, assist with toileting as needed, and provide incontinent care after every incontinent episode. During an observation and interview on 6/9/25 at 1:40 p.m. revealed Resident #2 was observed in her room, lying in bed. She was under a blanket with only her head and face visible. There was an odor of ammonia emitting from her. Resident #2 said she had not been changed since this morning and she was wet currently. She said a CNA checked on her around 1:00 p.m., when they were picking up lunch trays, and told her she would be back to help her change. She said the CNA had not returned to help her. She could not recall the CNA's name. She said she did not think she was double briefed and could not remember if staff had ever put two incontinent briefs on her at the same time. During an interview on 6/9/25 at 2:00 p.m., CNA C said she was assigned Resident #2's hall. She said she rounded on all residents more frequently than every 2 hours to make sure their needs were met. She said she had not seen Resident #2, or any other resident double briefed. She said she had never double briefed a resident because it could cause a UTI. During an observation on 6/9/25 at 2:30 p.m., CNA D and CNA E performed incontinent care for Resident #2. Resident #2 was observed to be wearing two incontinent briefs at the same time, and they were saturated with a yellow liquid. CNA D and CNA E provided incontinent care in accordance with Resident #2's comprehensive care plan and used only one incontinent brief. During an interview on 6/9/25 at 5:22 p.m., the DON said she was responsible for overseeing supervision of all nursing staff, which included CNAs. She said CNAs were expected to round on each resident every 2 hours at a minimum and to change residents' briefs and provide incontinence care as needed. She said no staff should ever double brief a resident because it created a risk of skin break down and UTI. She said she had already begun in-servicing all direct care staff on not double briefing residents and had 1 on 1 coaching with CNA B and CNA C. She said going forward the facility planned to implement random sweeps on all shifts to identify any incidents of double briefing. During an interview on 6/10/25 at 12:10 p.m., the ADM said the DON was responsible for supervising nursing staff . She said nurses who worked on the floor were expected to supervise CNAs to ensure appropriate care was being provided to residents, which included rounding on residents every 2 hours and providing incontinent care as needed. She said she was not aware of any other incidents of a resident being double briefed in the facility. She said risks to a resident from double briefing could be skin breakdown. She said the DON had already begun training staff on double briefing and incontinent care. She said going forward the facility administration planned to begin randomly checking residents for double briefing on all shifts. During additional staff interviews on 6/9/25 and 6/10/25 at various times on multiple shifts all staff members interviewed (CNA D, CNA E, CNA F, LVN G, LVN H) said residents were rounded on every 2 hours and incontinent care was provided as needed. All staff interviewed said they had never seen a resident double briefed in the facility and risks to residents from double briefing would include skin breakdown and infections. Record review of a CNA Proficiency Audit, dated 1/28/25, revealed CNA B had successfully demonstrated all required skills competencies. Record review of a CNA Proficiency Audit, dated 2/27/2025, revealed CNA C had successfully demonstrated all required skills competencies. Record review of a Coaching Form dated 6/9/25, for CNA B revealed the following coaching instruction .Always open and check briefs on all residents. There should never be two briefs or double pads of any kind under or around residents Record review of a Coaching Form dated 6/9/25 for CNA C revealed the following coaching education .absolutely no 2 briefs, pads, or any padding agents can be used at one time Record review of an In-Service Training Record, dated 6/9/25, covering training topic Double Briefing Not Allowed indicated .Nursing staff must not apply double briefs or any type of double padding to residents that are not care planned to be Attendance sign in sheet revealed the training was attended by CNAs (10), LVNs (5), RNs (1). Record review of the facility's policy titled Perineal Care, dated 5/11/22, revealed the following .An incontinent resident of urine and/or bowl (sic) should be identified, assessed, and provided appropriate treatment and services . Skin problems associated with moisture can range from irritation to increased risk of skin breakdown

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program 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 7 residents (Resident #1) and 1 of 4 staff (CNA A) reviewed for infection control. The facility failed to ensure CNA A washed their hands upon entering rooms, donned appropriate PPE, and washed their hands upon exiting the room of Resident #1 when she was on contact precautions on 3/9/25. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings include: Record review of Resident #1's facility face sheet, dated 3/13/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a subsequent readmission on [DATE]. Resident #1 had diagnoses which included type 2 diabetes (uncontrolled blood sugar) and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS assessment, dated 2/10/25, indicated she had a BIMS score of 15, which indicated she was cognitively intact. She had a stage 3 and a stage 4 pressure ulcer. She received antibiotics. Record review of Resident #1's comprehensive care plan, initiated on 2/17/25, indicated she required contact precautions for wound and had the following interventions: .put on gown and gloves prior to entering the resident's room .wash hands or use hand sanitizer prior to entering the room Record review of Resident #1's physician's order summary report, dated 3/10/25, indicated she had the following physician's order, dated 2/7/25: .Contact Precautions every shift for Wound Healing During an observation on 3/10/25 at 11:04 AM, Resident #1's room was observed with a sign at the entrance which read: Contact Precautions and a PPE box was observed outside the doorway with PPE located inside. During an observation on 3/10/25 at 11:12 AM revealed CNA A entered Resident #1's room without donning PPE, and without washing her hands or using sanitizer. The door was left open, and CNA A was observed touching the bedsheets of Resident #1 to straighten them without gloves. She was then observed to exit the room without washing her hands or using hand sanitizer. During an interview on 3/11/25 at 8:50 AM, the DON said the facility did not have a specific policy/procedure for contact precautions. Instead, they used the contact precautions sign as a guide for staff. She said they hung the sign outside the door for residents who were under contact precautions, so staff were aware of the procedure to follow. She said she expected staff to wash their hands and don a gown and gloves before entering a room for a resident under contact precautions and expected them to remove PPE and wash hands upon exiting the room so that infections were not spread. During an interview on 3/11/25 at 11:45 AM, CNA A said she must have just been nervous and forgot Resident #1 was on contact precautions. She said she went in the room and adjusted the bedsheets without washing her hands or using PPE. She said she was trained on infection control and handwashing. She said residents could be at risk of infection or cross-contamination if proper infection control procedures were not followed. During an interview on 3/12/25 at 11:20 AM, the DON said she was responsible for infection control. She said residents could get sick if proper infection control was not followed. She said she would be doing more training and using different color signs to indicate the different types of precautions because she thought it might make it easier to distinguish contact precautions between enhanced barrier precautions. During an interview on 3/12/25 at 11:30 AM, the Administrator said residents could be at risk of getting sick if infection control procedures were not followed. She said they would be implementing more communication with staff to make sure they understood the differences between the different types of precautions. Record review of the facility's, undated, procedure sign titled Contact Precautions, read: .Don gown and gloves outside of the resident's room. Remove gown and gloves and observe [perform] hand hygiene before leaving the patient-care environment .avoid unnecessary touching of surfaces in close proximity to the patient .Perform hand hygiene: before having direct contact with patients . after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury for 1 of 4 residents (Resident #26) reviewed for abuse and neglect. The facility failed to ensure allegations of abuse were reported to the state survey agency within 2 hours after it was reported to the administrator. This failure could place residents at risk of emotional, physical and mental abuse and neglect. Findings include: 1.Record review of Resident #26's facility face sheet, dated 09/18/2023, indicated Resident #26 was an [AGE] year-old male who was admitted to the facility on [DATE] with primary diagnoses which included chronic obstructive pulmonary disease (condition involving constriction of the airways and difficulty or discomfort in breathing), psychosis (mental disorder), and anxiety. Record review of Resident #26's quarterly MDS, dated [DATE], indicated Resident #26 had a BIMS of 3, which indicated Resident #26 had severe cognitive impairment. Record review of Resident #26's care plan, dated 07/13/2023, indicated Resident #26 had a behavior problem related to unrealistic expectations and was very demanding. Resident made false allegations and demanded the administrator took care of his needs immediately. Resident #26 had impaired cognitive function and dementia, or impaired thought processes related to dementia and impaired thought process. Record review of a nurse note, dated 09/14/23 at 2:15 PM, by the DON, revealed Entry: Note Text: Resident Head to toe assessment completed with no abnormalities noted, resident denies pain or discomfort at present time; moves all extremities well, skin warm, dry, intact, with no integrity concerns noted. Record review of Texas Unified Licensure Information Portal incident reporting system, indicated intake #452028 was received on 09/19/2023 at 8:02 AM with an allegation of abuse. Record review of a progress note for Resident #26, dated 09/19/23 at 9:04 AM, revealed Text: Social Worker visited with resident concerning reports of abuse. BIMS completed with a score of 5. Resident requested to see his new doctor. SW informed nursing staff and next time his doctor comes in the facility he will be seen. Resident complains of pain especially at night. He does have pain medications. He also states he cannot sleep. He will speak to the doctor about these issues also. Resident reports that he requested money from his trust fund and that he gave the money to his 'girlfriend' which is another resident (Resident #10) within the facility. Social Services will continue to visit with resident. He was not in distress during the meeting. Social Services will continue to visit and assess for needs. During an observation on 09/19/23 at 09:30 AM of Resident #26's skin with MA C revealed a head to toe assessment was completed with no red marks, no bruising noted and no open areas on the buttocks, upper body and head as Resident #10 reported in her interview. Resident #26 testicles were pink in color with no rash or abrasions not black as Resident #10 reported in her interview. During an interview on 09/19/2023 at 10:30 AM, Resident #26 denied any incident of abuse. Resident #26 said he had never been abused or mistreated by anyone at the facility. Resident #26 said the staff was sometimes bossy but did not recall any event happening to him as reported by Resident #10. 2. Record review of Resident #10's facility face sheet, dated 09/18/2023, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included encephalopathy (disease of the brain), senile degeneration of the brain, (brain decreasing in size related to age), nontraumatic subdural hemorrhage, (bleeding on the brain), dementia (disorganized thinking related to aging), psychotic disturbance (not in touch with reality), mood disturbance and anxiety (nervousness). Record review of Resident #10's quarterly MDS, dated [DATE], indicated Resident #10 had a BIMS of 13, which indicated Resident #10 had mild cognitive impairment. Record review of the comprehensive care plan, dated 8/08/2023, indicated Resident #10 had impaired cognitive function/dementia or impaired thought processes related to brain hemorrhage and senile degeneration of the brain. During an interview on 09/19/23 at 10:10 AM, Resident #10 said Resident #26 was her man. She said Resident #26 told her a guy who looked like a football player came into Resident #26's room last Friday (9/16/23) night and beat him all around his head and back, they left bruises on his face and upper back, and he was in a lot of pain. Resident #10 said Resident #26 did not recognize the man. Resident #10 said it could have been a medication aide, because Resident #26 didn't like those girls. Resident #10 said Resident #26 reported to her that his testicles had turned black in color, and it was hurting him terribly. Resident #10 did not recall telling anyone about the incident. During an interview on 09/19/2023 at 10:00 AM, the Administrator stated she had been at the facility since September 2022 and was aware of each incident reported by Resident #10. She stated she monitored all incidents that occurred in the facility through the morning meeting and incidents reported directly to her. She stated she did not recognize the incidents needed to be reported within 2 hours if there was an allegation of abuse, because there was no evidence of any bruising on Resident #26 as reported by Resident #10. She said she investigated the allegations, and the DON assessed Resident #26 for injuries/bruises, there were none found. She thought she had 24 hours to make the report. The Administrator said Resident #26 denied any abuse during her interview with him. The Administrator said she felt Resident #26 had the right to determine if he was abused. She said at the time she did not see any risk to the residents but looking back now she could see the risk of continued abuse, if all incidents were not investigated properly and reported timely. She stated going forward she would follow the abuse program and report abuse allegations within two hours. During a phone interview on 09/20/2023 at 10:30 AM, the Ombudsman said Resident #10 had behaviors of false allegations at the assisted living she resided at before going to live at the facility. The Ombudsman said she would visit with Resident #10 and assist the facility in finding a resolution. Record review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated indicated, .Residents have the right to be free from abuse. 1. protect residents from abuse, 2. develop and implement policies and protocols to prevent and identify abuse, 3. ensure adequate staffing, 8. identify and investigate all possible incidents of abuse, 9. Investigate and report any allegations within timeframe required by federal requirements, 10. protect residents from any further harm. Record review of the facility policy titled Abuse, Neglect, Exploitation or misappropriation - Reporting and Investigating, dated March 2018 indicated Facility employees must report all allegations of abuse neglect, misappropriation of property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b. If allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure comprehensive assessments were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 1 of 4 residents (Resident #32) reviewed for care plans. The facility failed to ensure Resident #32's care plan was revised to reflected current condition after hospitalization and readmission to the facility. This failure could place residents at risk of not receiving appropriate care to meet their current needs. Findings include: Record review of Resident #32's facility face sheet, dated 9/19/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE] and subsequently readmitted on [DATE]. Resident #32 had a primary diagnosis which included urinary tract infection (Infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra). Record review of a Medicare 5-day MDS for Resident #32, dated 8/27/23, indicated he had a BIMS score of 6, which indicated he had severely impaired cognition. The assessment reference date was 8/27/23, with a lookback period of 7 days (8/20/23 to 8/27/23). He required extensive assist of one to two persons for most ADL's. He was frequently incontinent of bowel and bladder. Question I2300 indicated he had a diagnosis of urinary tract infection in the last 30 days. He was coded as receiving an antibiotic 7 out of the previous 7 days. Record review of a care plan for Resident #32 for most recent admission date of 8/21/23 indicated that it did not address his current primary diagnosis of urinary tract infection or his current antibiotic therapy. Record review of a physician order summary report for Resident #32 dated 9/19/23 indicated a phsyician order dated 8/21/23 which read .Macrobid Oral Capsule 100mg .Give 1 capsule by mouth two times a day for UTI for 10 days . During an interview on 9/19/23 at 2:39 PM, the MDS nurse said she and the ADON worked together to do the care plans and she was unsure how this was overlooked. During a joint interview with the DON and the ADON on 9/19/23 at 2:53 PM, they both said the care plan must have somehow gotten overlooked. The DON said the ADON would usually update care plans with new antibiotics when they got them or when a resident was out to the hospital. The ADON said it may had happened while he was working nights and it might had just gotten missed. The DON said she may have been out or just busy because if the ADON did not catch an update, she would usually try to catch it but said Resident #32's care plan just got missed. They both said the risk to the resident could include not receiving medications and possible sepsis if the infection got worse. During an interview on 9/19/23 at 3:19 PM, the SW said they normally did care plan reviews as a team every quarter, annually and after a significant change. She said with Resident #32, he was in the facility and went out to the hospital. Upon his return, she understood nursing should update his care plan with any new interventions. She said they did not have a care plan meeting after his hospital re-admission MDS on 8/27/23. Record review of the, undated, facility policy titled Comprehensive Care Planning, indicated .the resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions .care planning drives the type of care and services that a resident receives

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program 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 (CNA A) staff reviewed for infection control. 1. CNA A failed to perform hand hygiene after incontinent care. 2. CNA A failed to properly handle soiled linens and the brief for Resident #39 after performing incontinent care. These failures could place residents at risk of exposure to communicable diseases and infections. Findings include: Record review of Resident #39's admission Record, dated 9/20/2023, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included pneumonia (infection with inflammation in the lungs), senile degeneration of brain (a decrease in thinking ability and mental decline), and anemia (low red blood cells in the body). Record review of Resident #39's, Quarterly MDS Assessment, dated 9/4/2023, indicated he had severe impairment in thinking with a BIMS score of 3. He required extensive assistance with 1-2 person assist with bed mobility, dressing, eating, toilet use and personal hygiene. He was always incontinent of bowel and bladder. Record review of Resident #39's care plan, dated 9/1/2022 , indicated he had bladder/bowel incontinence with interventions to provide peri care after each incontinent episode and incontinent care frequently. During an observation on 9/19/2023 at 9:25 AM in Resident #39's room revealed CNA A and MA B were present to perform incontinent care. MA B entered the room and washed her hands in the bathroom. CNA A entered the room and applied gloves to both hands without washing or sanitizing her hands. CNA A removed Resident #39's pants and pulled down his brief. CNA A removed a wipe from a plastic bag and cleaned Resident #39's penis wiping in a circular motion and pulled back the foreskin and cleaned. CNA A placed the wipe on the floor and removed another wipe from the plastic bag and wiped Resident #39's inner thighs and placed it on the floor. MA B assisted and rolled Resident #39 onto his right side. CNA A removed a wipe from the plastic bag and wiped Resident #39's rectal area from front to back using multiple wipes. MA B rolled the linens up to be removed from the bed and CNA A removed a draw sheet and brief from the plastic bag and placed them underneath Resident #39's buttocks. The dirty linens and brief were rolled underneath Resident #39 and removed by CNA A and placed on the floor. MA B secured the linens on the bed and CNA A secured the brief on Resident #39 and both repositioned him in bed. MA B removed her gloves and placed them in the trash and washed her hands in the bathroom. CNA A picked up the dirty linens, wipes and brief off of the floor and placed them in a plastic bag. CNA A removed her gloves and placed them in the trash and placed the bags of linens and trash in the barrels outside in the hallway. CNA A then sanitized her hands in the hallway. During an interview on 9/19/2023 at 9:35 AM, CNA A said she had been employed at the facility on a PRN basis for two months. She said during the incontinent care provided to Resident #39 she should have changed her gloves throughout the care provided, after she changed him and before she touched anything when she was done. She said she should have changed her gloves when she went from dirty to clean. She said she should have washed her hands after the glove changes. She said she should have placed the linens in a plastic bag along with the soiled brief instead of placing them on the floor. She said she had not received any check offs with incontinent care since she started working at the facility. She said residents could be at risk for infection if staff did not change gloves or wash/sanitize their hands when providing care along with contamination of items touched with dirty gloves . During an interview on 9/19/2023 at 3:25 PM, the ADON said he had been employed at the facility since April 2023. He said he and the DON were responsible for conducting the competency check offs with the nursing staff. He said the aides in the facility had a competency check off on hire and annually along with PRN staff. He said if there was a rise in infections at the facility such was UTI's with residents who did not have a catheter, then they would begin in-servicing staff on infection control measures, proper wiping of the residents from front to back, gloving and hand hygiene. He said CNA A had been checked off on hand hygiene and incontinent care after being hired. He said staff should perform hand hygiene before providing care to the residents, between glove changes and when care was completed. He said dirty linens should be placed in a plastic bag and not on the floor and wipes in the trash. He said the risk to residents could be UTI's, sepsis and infections . During an interview on 9/20/2023 at 9:14 AM, the DON said she had been employed at the facility since April 2022. She said she and the ADON were responsible for conducting competency check offs with the nursing staff. She said the nurse aides were checked off on hire and annually. She said the check off included observing skills to determine competency. She said staff should change gloves at least 3 times during care, sanitize or wash hands between glove changes and change gloves when going from dirty to clean . She said linens and trash should be placed in a bag and not on the floor to prevent contamination. She said going forward she would in-service staff on infection control and would conduct incontinent check off with all of the nurse aides. She said the risk to the residents would be infection. Record review of a CNA Proficiency Audit, dated 7/21/2023, for CNA A indicated she was satisfactorily checked off for hand washing, perineal care of a female/male resident and handling of clean/dirty linens. Record review of the facility policy titled Fundamentals of Infection Control Precautions, dated 2019, indicated, .1. Hand Hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: When coming on duty; Before and after assisting a resident with personal care; After handing soiled or used linens .

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 1 stove in the kitchen reviewed for food service. 1. The facility failed to ensure the gas stove, in the kitchen, was in proper working order. 2. The facility failed to ensure three of six gas burners, on the stove, lit automatically, when the knob was turned (front on left, middle back, and right back). 3. The facility failed to ensure the pilot lights on the burners would stay lit and the Director of Food and Nutrition Service, had to use a striker, (a lighter with a long barrel), to light the burners. These failures could place residents at risk for injury and under cooked food. Findings include: During an observation and interview on 09/18/23 at 9:20 a.m., the front left, middle back, and right back burners of the stove would not light from the pilot when the knob was turned. The Director of Food and Nutrition Service said the pilot lights would not stay lit. She said she worked at the facility since 02/11/21 and when she came, they were using a striker to light the burners She said she thought the vent a hood was the reason the pilot lights would not stay lit. She said she told the Maintenance Supervisor the pilot light would not stay lit, but he was very new, and he was working on other things in the building. She said the pilot lights not working and having to use a striker could cause a possible fire or someone could get hurt. During an interview on 09/19/23 at 2:15 PM, the Maintenance Director said he worked at the facility since 08/07/23, and he was not aware the burners would not light from the pilot when the knob was turned until yesterday, (09/18/23). He said someone would be at the facility on Friday, (09/22/23) to work on the stove. During an interview on 09/18/23 at 9:55 AM, with the Administrator she said her expectation for the kitchen the Administrator said she expected all appliances in the kitchen to be in proper working order. She said the pilot lights and the burners not lighting when the knob was turned could cause a possible explosion and fire. Record review of a facility policy, (Dietary Services Policy & Procedure Manual), did not address maintenance of the stove.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 16 residents (Resident #25) reviewed for baseline care plans in that: Resident #25 did not have a baseline care plan completed within 48 hours of admission. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of face sheet dated 8/2/2022 for Resident #25 indicates he is [AGE] years old and was admitted on [DATE] for Dementia and recurrent falls. Other diagnosis includes emphysema (lung disease), hypertension (high blood pressure), chronic obstructive pulmonary disease (lung disease) and history of transient ischemic attack and cerebral infarction without residual effects (stroke). Record review of the admission date of 2/11/2022 indicated no baseline care plan was completed and neither resident nor his family received a written summary of care plan. Record review of Resident # 25 comprehensive care plan dated 3/10/2022 revealed it was the initial care plan in the record and was 15 days after the MDS on 2/23/2022. The care plan indicated care area/problems were resident at risk for falls, at risk for pressure injuries related to impaired mobility, risk for fluid deficit related to dementia, at risk for wondering related to dementia, has bladder incontinence, bowel incontinence, is a smoker, at risk for malnutrition, and has an ADL self are limitation due to dementia, weakness and history of stroke During an interview on 08/02/22 at 03:09 PM LVN B stated she has been a nurse for 53 years and employed at this facility for 5 years. She stated on admission, the charge nurse must complete the nursing assessments first and then the baseline care plan is started. The nurse prints the care plan and gives a copy to the resident or family and fills out the acknowledgement. We have 48 hours to complete the baseline care plan and then the MDS coordinator completes the comprehensive care plan. The process is the same on all shifts. We communicate with each other using the 24-hour report sheet. Failure to have a care plan could cause a resident not to receive appropriate care. During an interview on 08/02/22 at 03:22 PM the DON stated baseline care plans are completed by the admission nurse within 48 hours from time of admission, and resident care could suffer without it. She is not sure why it was not done because she did not work here at that time. She stated she will begin retraining and monitoring. She stated she is not sure why there was an acknowledgement of a baseline care plan in the record but has in serviced her staff on accurate documentation and consequences to falsifying medical records. During an interview on 08/02/22 at 03:28 PM RNC voiced if a baseline care plan was initiated then it would be in the system for the comprehensive care plan to be complete. In this instance, a baseline was not complete by the admission nurse and the MDS coordinator missed it and did not complete the comprehensive care plan until 3/10/22. A baseline care plan acknowledgement was created in the facility system on 2/11/2022, but the baseline care plan was not done on Resident # 25. During an interview on 08/02/22 at 03:35 PM ADMIN stated she expects care plans to be completed timely and according to regulations. The risk to the resident could vary from minor to severe depending on the issue, and staff would not know how to take care of the residents. Record review of nursing policy and procedure form number GP MC 03-19.0 regarding baseline care plans states the facility will develop and implement a baseline care plan for each resident within 48 hours of a resident's admission. The facility will provide the resident and their representative with a summary of the baseline care plan that includes initial goals, summary of medications and dietary instructions, any services, and treatments to be administered by the facility and personnel acting on behalf of the facility, and the medical record will contain evidence that the summary was given to the resident and representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop the comprehensive care plan within seven days of the completion of the comprehensive assessment (MDS) for 1 of 16 residents (Resident #25) reviewed for care plan timing, in that: Resident #25 comprehensive care plan was not complete until 15 days after the admission comprehensive assessment (MDS) dated [DATE]. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of face sheet dated 8/2/2022 for Resident #25 indicates he is [AGE] years old and was admitted on [DATE] for Dementia and recurrent falls. Other diagnosis includes emphysema (lung disease), hypertension (high blood pressure), chronic obstructive pulmonary disease (lung disease) and history of transient ischemic attack and cerebral infarction without residual effects (stroke). Record review of the admission MDS Assessment for Resident # 25 dated 2/23/2022 indicates a BIMS score of 4. This score indicates he has severely impaired cognition (memory). Record review of Comprehensive Care Plan for Resident # 25 dated 3/10/2022. This was 15 days after the comprehensive assessment (MDS) was complete on 2/23/22. Care plan indicated care area/problems were resident at risk for falls, at risk for pressure injuries related to impaired mobility, risk for fluid deficit related to dementia, at risk for wondering related to dementia, has bladder incontinence, bowel incontinence, is a smoker, at risk for malnutrition, and has an ADL self are limitation due to dementia, weakness and history of stroke During an interview on 08/01/22 at 12:29 PM Resident #25 stated he is not sure about his care plan and if he is invited to attend meetings. During an interview on 08/02/22 at 03:09 PM LVN B stated the MDS coordinator completes the comprehensive care plan. Failure to have a care plan could cause a resident not to receive appropriate care. During an interview on 08/02/22 at 03:15 PM MDS coordinator stated once the MDS is in place then the comprehensive care plan is created. I have 14 days to complete the assessment and care plan I believe but will find out. New admissions are discussed at IDT, and I make sure that the assessment and care plan has been completed. She states if a comprehensive care plan is not completed timely the staff are not aware of how to provide care to the resident. During an interview on 08/02/22 at 03:22 PM the DON stated the MDS coordinator is responsible to know when the comprehensive care plan is due. I am unsure of timeframe for completion. The IDT discusses new admissions when we meet in the mornings. We discuss what day the resident is on during these meetings. During these meetings, I would be able to see that a comprehensive care plan is not in place. I am responsible to monitoring the MDS coordinator. I was not employed as the DON at that time and unsure why it was missed. The risk to the resident not having a care plan in place would be quality of care. During an interview on 08/02/22 at 03:28 PM RNC stated the MDS coordinator did not complete the comprehensive care plan on Resident # 25 but does not know why. She states the MDS coordinator has been trained on her timeframes for completion of MDS and comprehensive care plans. During an interview on 08/02/22 at 03:35 PM ADMIN stated she expects care plans to be completed timely and according to regulations. The risk to the resident could vary from minor to severe depending on the issue, and staff would not know how to take care of the residents. Record review of Nursing policy and procedure form GP MC 03-18.0 regarding comprehensive care planning states the facility will implement a comprehensive person-centered care plan for each resident. Policy states a comprehensive care plan will be developed within 7 days after the completion of the comprehensive assessment (MDS).

Based on interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate administering, ordering and reconciliation of all drugs to meet the needs of residents reviewed for pharmacy services and to ensure medications were destroyed in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 4 of 12 months reviewed for drug destruction. (November 2021, March, April and June 2022) The facility did not have a licensed pharmacist and facility staff correctly witness and initial the pages of the drug destruction logs during each drug destruction occurrence and maintain receipt of delivery of controlled drugs for destruction at a receiving medical waste management service. These failures could put residents at risk for misappropriation and drug diversion. Findings included: Record review of Drug destruction logs dated November 2021, March, April and June 2022 did not contain the correct numbers of pages or initials on each of the logged pages of the pharmacist and staff member witnessing destruction: The listing sheets of logged drugs for destruction were not labeled correctly with a number of each sheet and total number of sheets to account for all listed drugs that were destroyed each month. The cover sheets contained a statement indicating the number of inventory pages that are attached and each of the attached pages were not initialed by the consultant pharmacist and witnesses as required by regulation. Drug destruction record for 11/2021 total of 9 pages, each page of the log of drugs for drug destruction did not include the page numbers or initials by the pharmacist and witness. Drug destruction record for 3/17/2022 had 11 total number of pages, each page of the log of drugs for drug destruction did not include the page number Drug destruction record for 4/15/2022 had 8 total number of pages, each page of the log of drugs for drug destruction did not include the page number. Drug destruction record for 4/26/2022 total of 5 pages. Destruction logs did not have the page numbers or initials of witness for all 5 pages. Drug destruction record for 6/28//2022 had a total of 10 pages with no total number of pages logged on cover sheet. Logs were not initial by the Pharmacist. The facility had no receipts for record of transfer to the waste disposal service for drug destruction until requested by this surveyor. The past 24 months were obtained by fax from Cyntox Biohazard Solutions by the Administrator on 08/02/2022. There was no method to verify if disposal receipts were for medication and dangerous drugs or routine medical waste. There was no method to verify waste disposal service or reverse distributor provided proof of destruction within 30 days of receipt of dangerous drugs or controlled substances sealed container. During an interview on 08/02/22 at 11:00 a.m., the Administrator said she has been employed at the facility since 4/27/2022. She said the facility did not have the receipts from the waste disposal management, she will be obtaining them and she is responsible for following During an interview on 08/03/22 at 08:30 a.m., DON said she started working at the facility in April of 2022. She and the Consultant Pharmacist that is responsible for drug destruction completed the drug destruction log for June of 2022. She was not aware that all pages should be initialed and numbered as required by regulation. Record Review on 8/03/22 of the facilities blank form titled: Statement for Disposal of Dangerous and Controlled substances. Form contains an area for Signature of Consultant Pharmacist and two Witnesses with areas for Signature Title and License #of each witness, and an area to log total number of pages. Destruction performed with witnesses according to TAC. Review of Facility Policy: Drug Destruction Policy dated 07/10/2013, indicated: It is the policy of this facility to destroy dangerous and controlled medications according to the State of Texas Law Record Review on 8/02/22 of the facilities blank form titled: Drug Destruction Log, Form contains an area for Signature of Consultant Pharmacist, Administrator, Director of Nursing and other, with areas for Signature Title and License #of each witness. 22 TAC §303.1 Destruction of Dispensed Drugs (a) Drugs dispensed to patients in health care facilities or institutions. (1) Destruction by the consultant pharmacist. The consultant pharmacist, if in good standing with the Texas State Board of Pharmacy, is authorized to destroy dangerous drugs dispensed to patients in health care facilities or institutions. A consultant pharmacist may destroy controlled substances as allowed to do so by federal laws or rules of the Drug Enforcement Administration. Dangerous drugs may be destroyed provided the following conditions are met. (A) A written agreement exists between the facility and the consultant pharmacist. (B) The drugs are inventoried, and such inventory is verified by the consultant pharmacist. The following information shall be included on this inventory: (i) name and address of the facility or institution. (ii) name and pharmacist license number of the consultant pharmacist. (iii) date of drug destruction. (iv) date the prescription was dispensed (v) unique identification number assigned to the prescription by the pharmacy (vi) name of dispensing pharmacy (vii) name, strength, and quantity of drug; (viii) signature of consultant pharmacist destroying drugs. (ix) signature of the witness(es); and (x) method of destruction. C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet, provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es). v) any two individuals working in the following capacities at the facility: (I) facility administrator; (II) director of nursing; (III) acting director of nursing; or (IV) licensed nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY Medication Administration 08/02/22 07:23 AM OBSERVATION OF MEDICATION ADMINISTRATION FOR 8 RESIDENTS (Resident # 45 Resident # 20 Resident # 42 Resident # 29 Resident # 39 Resident # 256 Resident # 48 Resident # 9) AND TOTAL OF 47 OPPORTUNITIES AND 2 ERRORS FOR ERROR RATE OF 4.26% - BOTH ERRORS RELATED TO MEDICATION NOT IN FACILITY - Medication Storage and Labeling 08/01/22 2:00 pm Medication storage room assessed with [NAME], LVN present. 1 opened bottled of Ready Care 2.0 Vanillla Nutritional drink in refrigerator. Undated with directions to use with in 3 days of opening. Nurse [NAME] is unsure of how long it had been there. She last worked on Friday 7/29/22. 1 opened vial of Tuberculin vaccine lot # c5841AB expiration date June 17 2023. Vial was opened and dated 6/8/22 and remained in refrigerator passed 28 days. 2 unopened vials of Influenza vaccine with lot # 308525, expiration date of 6/30/22 remained in refrigerator. 08/03/22 08:00 AM Interview with DON and states she is aware of the expiration medications, she has reviewed the pharmacy logs for finding of expired medications. Nurses are to check the carts weekly and ADON is to check behind them. The risk to residents taking expired medications could be severe. 08/03/22 11:48 AM There is no written log in facility to prove nurses are checking carts weekly for expired medications. Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing and administering of medications for 2 of 4 medication carts (Hall #1 nurse cart and Unit #2 nurse cart) and the medication storage room reviewed for pharmacy services. * The facility did not dispose of expired medications from the medication storage room (OTC, vaccines and PPD-Mantoux Testing). * The facility did not date insulin pens and vials on the Unit #1 Hall and Hall #2 nurse carts had an open date. * The facility did not dispose of expired medications from the Hall #2 cart nurse cart. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization. Findings included: During on observation and interview with LVN B on 08/01/22 beginning at 2:00 pm of the medication storage room revealed the following: 1- opened bottled of Ready Care 2.0 Vanilla Nutritional drink in refrigerator. Undated with directions to use within 3 days of opening. LVN B said she was unsure of how long it had been there and that she had last worked on Friday 7/29/22. 1- opened vial of Tuberculin PPD lot # C5841AB with manufactures expiration date 06/13/2023. Vial was opened and dated 6/8/22 and remained in refrigerator past 30 days. 2- unopened vials of Influenza vaccine with lot # 308525, expiration date of 6/30/22 remained in refrigerator. Record review of the physician orders dated August 2022 indicated Resident #41 was a [AGE] year-old female admitted [DATE]. Her diagnosis included Diabetes (high blood sugar) Hypoxia (low oxygen in the blood) and Heart Failure (heart not pumping adequately). An order revised 07/21/2022 indicated an order for Lantus SoloStar Solution Pen- Inject 50 units subcutaneously two times a day for Diabetes control. Record review of the physician orders dated August 2022 indicated Resident #50 was a [AGE] year-old female admitted [DATE]. Her diagnosis included Diabetes. An order with revision date of07/18/22 indicated an order for Humalog Kwik Pen 100 Unit per ml Inject per sliding scale. During an observation and interview on 08/02/22 beginning at 07:40 a.m. of the Hall 2 cart nurse cart with LVN A the following was found: * Resident #41 had an opened Lantus insulin vial with no open date recorded on box or vial. * An OTC bottle of Vitamin D3 125mcg 5000 IU with an expiration date of 6/2022. LVN A said insulins were to be replaced 28 days after opening. She said all insulin vials should have an open date on them since they were only good for so many days after opening. She said the number of days depended on the insulin. She said the Vitamin D should be discarded and not given to the residents, since the efficiency could be affected. During an observation and interview on 08/02/22 at 08:00 a.m. of the Hall 1 nurse cart with the ADON the following was found: * Resident #50 had a Lantus Solostar insulin pen with an open date of 7/2/2022 still in use today 8/02/2022 day 31 and administered to resident #50 on 08/02/2022. ADON said multi use vials, usually are good for 28 days. She said all insulin vials should be dated when opened and discarded in 28 days. She said the charge nurses were expected to check their carts at least weekly and usually on night shift. The ADON said nurses were to put an open date on the insulins because they were only good for so many days after opening depending on the manufacturer and use of expired insulin could effect the efficiency. During an interview on 8/3/22 at 08:00 a.m. the DON said that she was aware of the expired medications, insulin and vaccines found in the medication storage room and on the carts. She said the night nurses were responsible for ensuring the carts were checked and all expired medications were removed. The DON said she also reviewed the pharmacy consultant's report to see if they report any expired medications on the carts. The DON said not discarding the insulin after 28 days as required by manufacturers could affect the efficacy of the insulin and the risk to residents taking expired medications and vaccines could be severe. She said it is her expectation staff would date multi use vials when opened and discard after 28 days or whenever the manufacturer suggests it should be thrown away. All OTC vitamins and medication should be discarded before expiration date. The DON said an in-service will be conducted for all nursing staff. Requested documentation from the DON supporting medication cart and medication room checks but none was provided at time of exit. Record review of the package insert for Lantus (insulin pen) accessed at https://www.Lantus.com on 08/02/22 indicated unopened and stored at room temperature was good for 28 days, unopened and refrigerated was good until the expiration date, and opened was good for 28 days. Record review of the package insert for Lantus Solostar pen accessed at https://www.Lantus.com on 08/02/22 indicated unopened and stored at room temperature was good for 28 days, unopened and refrigerated was good until the expiration date, and opened was good for 28 days. Record review of the package insert for Levemir insulin accessed at https://www.humolog.com on 08/02/22 indicated unopened and stored at room temperature was good for 28 days, unopened and refrigerated was good until the expiration date, and opened was good for 42 days. Record review of the package insert for Novolin Care, insulin pen accessed at www.Novolin.com on 08/02/22 indicated after first use of the pen, the pen can be stored for (28 days) at controlled room temperature (59°F to 86°F; 15°C to 30°C) or in a refrigerator (36°F to 46°F; 2°C to 8°C). Review of policy revised 07/2012 Medication Storage Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that is clear when the medication was opened. Insulins expire 28 days after initial use, (PPD Mantoux) Multiuse vials expire 30 Days after initial use.

**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 by 5 of 8 staff reviewed for infection control, (CNA D, CNA F, CNA G, CNA C and NA E), in that: CNA D, CNA F, CNA G, and NA E did not wash or sanitize their hands when changing gloves before, during or after performing incontinent care for Resident #9. Facility staff failed to change soiled linens for Resident #19. CMA C failed to clean reusable equipment to prevent the spread of infection. This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of a Face Sheet for Resident #9 dated 8/3/2022 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of malignant neoplasm of ascending colon (colon cancer), cerebral infarction due to unspecified occlusion or stenosis (stroke), Diabetes Mellitus, gastrostomy tube (feeding tube placed into stomach), dysphagia (difficulty swallowing). Record review of an Annual MDS Assessment for Resident # 9 dated 7/18/2022 indicated a BIMS score of 10. This score indicated he had moderately impaired cognition (memory). Record review of a Care Plan for Resident # 9 dated 5/26/2022 indicated care area/problems of bowel incontinence, bladder incontinence, and ADL selfcare performance deficit related to stroke, weakness, and limited mobility. He required assistance times 1 person in bathing, bed mobility, dressing, and toileting, and assistance times 2 persons for transfers. He was at risk for pressure injuries related to decreased mobility and incontinence. During observation on 08/01/2022 at 3:03 pm Resident # 9 pushed his call light for incontinent care. CNA D and NA E entered the room and neither performed hand hygiene. Resident # 9 was transferred x 2 persons using a gait belt from the wheelchair to his bed. Observation made to the back of left pant leg revealed the area was wet. CNA D donned (applied) gloves without hand hygiene (handwashing or ABHR). Resident #9 pants were removed, brief pulled down and observation made of a wet brief with dark urine. CNA D cleansed front of peri-area and penis using one wipe at a time. CNA D removed gloves and placed new gloves without performing hand washing. Resident #9 then turned to left side and buttocks cleaned using one wipe at a time. CNA D then placed clean brief with same gloves and Resident #9 was dressed in clean pants. Gloves were removed and CNA D left resident room with dirty linen bag. CNA D did not wash her hands before leaving room. During an interview on 08/01/2022 at 3:54 pm CNA D voiced she should have washed her hands between her glove changes and before leaving the room. She stated she had been trained and had been checked off on incontinent care in the last few months. She stated by not washing her hands she could cause infections to her residents. She stated she had been a CNA for 8 years and had worked in the facility on and off the last 7 years. During observations on 08/02/22 at 10:41 AM CNA F and CNA G were in the hallway with supplies to provide incontinent care to Resident #9. CNA F stated she has been a CNA for 2 years and worked at the facility through an agency. CNA G stated she had been a CNA for 2 years and worked through an agency. Both CNA's entered the room and donned (applied) gloves without providing handwashing or using ABHR. Observed both CNA's transfer Resident #9 using gait belt from his wheelchair to his bed. The back side of Resident #9 pants and wheelchair are visually wet and had a urine odor. Resident #9 was placed on top of his clean linen. Soiled pants removed and placed in trash liner that was placed on bed by CNA G. Brief removed and was wet with urine and stool. CNA G cleansed Resident #9 with one wipe at a time and with the same gloves is rolled to the left side. CNA G cleansed his buttocks and stool from peri-area using wipes. A clean brief is placed without glove change or hand hygiene and CNA F placed barrier cream. Using the same soiled gloves new pants applied by CNA F and CNA G. Resident #9 was left in bed on top of wet linen and CNA F left room without washing hands or using ABHR. CNA F returned with clean linen and the bed was then changed. Both CNA F and CNA G wore their soiled gloves into the hallway carrying trash liner before removing their gloves. Neither were observed washing their hands or using ABHR. Both were asked regarding what they would do differently. Both stated they did not understand, but after asking the question again regarding incontinent care and hand hygiene they voiced they would have been more prepared and washed their hands. They both stated they have received training many times but got nervous. During an interview on 08/02/22 at 10:56 AM RNC stated nurse aides are trained with a fellow nurse aide upon hire and overseen by the ADON and DON. The DON/ADON was responsible for ensuring the nurse aides competency. Each CNA was reevaluated annually and as needed. The risk of CNA's not providing proper incontinent care and hand washing/hygiene could cause infections to all residents in the facility. They will immediately begin retraining the CNAs on incontinent care and hand hygiene. During a record review on 08/02/22 at 12:20 PM CNA proficiency audit was reviewed for CNA D AND NA E. CNA D received retraining on 6/23/22 and skills for handwashing, perineal care, handling of clean and dirty linen are marked as satisfactory. NA E per phase 2 competencies for nurse aides, she has completed satisfactorily including perineal care/incontinent care. The DON voiced during an interview on 08/02/2022 at 1:00 pm that she does not have the competencies for the agency nurse aides, but she would reach out to the agency and obtain their training. These documents were not supplied to surveyor. Record review of a Face Sheet for Resident #19 dated 8/4/2022 indicated she was admitted to the facility on [DATE]. She was [AGE] years old with diagnoses of mental disorder due to known physiological condition, acidosis (increased acid in the blood), hyponatremia (low sodium), hypertension (high blood pressure), heart disease, depression, and muscular wasting (breakdown of muscles). Record review of an annual MDS Assessment for Resident # 19 dated 10/1/2021 indicated a BIMS score of 3. This score indicates he has severely impaired cognition (memory). Record review of a Care Plan for Resident # 19 dated 7/29/2022 indicated a care area/problem of bowel incontinence, bladder incontinence, ADL selfcare performance deficit, history of urinary tract infection, and risk for impaired skin integrity related to bowel and bladder incontinence. She required limited assistance in bed mobility and transfer, and extensive assistance in toileting, dressing, and personal hygiene. During an observation on 08/01/22 at 10:26 AM Resident #19's bed linen was observed with smears of a brown substance on the bottom fitted sheet. During an observation on 08/01/22 at 3:58 PM Resident # 19 bed was unmade, and a clean draw sheet was over the fitted sheet, however the smears of brown substance remained under the clean linen visible on the side of the bed sheet. Observation on 08/02/2022 at 07:30 AM Resident # 19 had brown smeared substance remaining on fitted bed sheet. Observation on 08/03/22 at 07:30 AM Resident # 19 was sitting up in the common area with her hair damp and in clean clothes. Observation made on 08/03/22 at 12:45 PM revealed Resident # 19 bed and fitted bed linen remained soiled with brown smeared substance and covered with a clean linen. During an interview on 08/03/22 at 12:50 PM CNA H stated it was the responsibility of the nurse aides to change the linen with shower days, when dirty or as needed. CNA H stated Resident #19 had her shower this morning, but they were not sure when her shower days are. CNA H was the assigned aide to the hall for this day but did not know who worked the days before. During an interview on 08/03/22 at 12:53 PM LVN A stated the charge nurse was responsible for overseeing that the resident was showered, and linens are changed. Resident #19 shower days recorded for Monday, Wednesday, and Friday on ADL sheet. During an interview on 08/03/22 at 01:16 PM the DON stated the charge nurse was responsible for overseeing showers and that linen are changed. The risk of not changing linens that are soiled would be infection control. Residents that are left to lay in soiled bed linens could develop infections. Her expectation was to provide the staff with education and will monitor to see this task is being done. During observation on 08/02/22 at 07:50 AM CMA C was observed using cleansing wipes for incontinent care while cleaning a reusable blood pressure cuff before resident use. During observation and interview on 08/02/22 at 11:43 AM CMA C was observed on another cart, and she was using alcohol wipes while cleaning a reusable blood pressure cuff. During interview she said she had changed to alcohol wipes after she switched carts. She stated she had been taught how to clean the equipment but got nervous and forgot. During an interview on 08/03/2022 at 08:00 AM the DON stated she was made aware of CMA C not cleansing a reusable blood pressure cuff appropriately and has provided training. She stated the staff were unaware of the wet time (time that equipment must be wet to kill microorganisms) for the cleaning products they use, but she has in-serviced them. She stated that there is an infection control risk to each resident that the blood pressure cuff is used on, and she expects for the staff to follow the cleaning protocols using the correct wet times for the products they use. Record review of facility policy titled infection control dated 2019 indicated, .1. Hand hygiene continues to be the primary means of preventing the transmission of infections and list situations that require hand hygiene. These include before and after assisting resident with personal care, before and after assisting a resident with toileting, after removing gloves 2. gloving, wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use and hands can become contaminated during removal of gloves. Also, nursing personal care procedure for perineal care dated 5/11/2022 states, 1-9 preparation, 10. perform hand hygiene before starting perineal care, 11. don gloves .,24. Doff gloves and PPE, 25. Perform hand hygiene Record review of a facility handout titled Hand Hygiene indicates, that hand hygiene with alcohol based cleaner or soap and water is indicated after handling soiled or used linens, dressings, bedpans, and urinals, and after removing gloves.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in the kitchen. The facility failed to store, prepare, and distribute foods according to facility policy. The dish machine tested at 25 ppm, and the DA didn't know the reading was too low to sanitize the dishes per manufactures recommendations. There was unlabeled and undated food in the refrigerator and freezer. This failure could place the residents who eat meals prepared in the kitchen at risk for food borne illness. Findings included: During an observation on 08/01/22 at 9:46 A.M., the DA, ran the dish machine to get water temperature to required 120 degrees F, then took a chemical sanitizing test strip, and dipped it into the water in the bottom of the dish machine. The test strip read 25 ppm; the DA was unaware the test strip should read between 50-100 ppm per the manufacturer's recommendations. During an observation on 08/01/22 at 9:55A.M., there was a cookie sheet with toasted marshmallows in the refrigerator uncovered, and not labeled or dated. During an observation on 08/01/22 at 10:05 AM, there was a bag of frozen chicken strips, and a bag of frozen biscuits, in the walk-in freezer with no label or dates. The CDM said those are supposed to be labeled and dated. The CDM said everyone in the kitchen is responsible for dating and labeling the food. During an interview on 08/01/22 at 10:10 AM, the DA said she had been working at the facility two and a half or three months. She didn't remember who trained her to test the dish machine, but they didn't work here anymore. During an interview on 08/01/22 at 12:25PM, the CDM said she was unsure who trained the DA, to test the dish machine, but whoever it was they didn't work here anymore. She said she would inservice the staff on testing the dish machine, correct temperature of 120F and required sanitizer lever of 50-100 parts per minute. During an interview on 08/01/22 at 12:52 PM, the CDM said the AD, had an activity on Friday, and the BOM placed the marshmallows in the refrigerator. During an interview on 08/03/22 at 12:51 PM, the Administrator said her expectations for the kitchen was for all foods in the kitchen to be labeled and dated for the resident's safety. She said she expects the sanitation level on the dish machine to be the correct level per the manufacture recommendation. She said she would just have to keep training and inservicing the staff and the CDM. During an interview on 08/03/22 at 12:51 PM with the CDM she said her expectations for the kitchen was for it to be clean and to serve good, appetizing food. Review of the facility's Sanitation and Infection Control Dietary Services Policy & Procedure Manual dated 2012: c. The wash period shall be at least 40 seconds with a temperature of 120 degrees F in dish machine. The sanitizing rinse period shall be at least 20 seconds with minimum temperature of 120 degrees. h. Facilities shall use an approved test kit to measure the parts per million (ppm) of the chemical solutions in the low temperature dish machine daily. Any abnormal test results shall be reported to the Dietary Service Manager. A ppm of 50 will be attained prior to dishes being washed. During exit on 08/03/22 at 2:30 PM, the Administrator was asked for additional information at exit, no additional information was provided.