**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs and describes the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 2 of 12 residents (Residents #16 and Resident #34) reviewed for care plans in that: The facility failed to develop a comprehensive care plan for the use of side rails for Resident #16 that were in use on 2/4/2025. The facility failed to develop a comprehensive care plan for the use of side rails for Resident #34 that were in use on 2/3/25. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings included: 1. Record review of an admission Record dated 2/4/2025 for Resident #16 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of diastolic congestive heart failure (heart not being able to pump blood effectively throughout the body), dementia, malignant neoplasm of right breast (breast cancer), and type 2 diabetes. Record review of active physician orders dated 2/4/2025 for Resident #16 indicated there were not any orders for the use of bed rails. Record review of an Annual MDS assessment dated [DATE] for Resident #16 indicated she had severe impairment in thinking with a BIMS score of 3. She required substantial/maximal assistance with rolling left and right. The use of physical restraints for bed rails was not coded. Record review of a care plan for Resident #16 dated 8/3/2022 revealed she was not care planned for the use of bed rails. She was at risk for falls related to history of frequent falls with interventions to maintain safe environment. Record review of assessments for Resident #16 indicated she did not have any assessments completed for bed rails. During an observation on 2/4/2025 at 8:28 AM, Resident #16 was in her bed resting with eyes closed. There were side rails up on both sides of the bed with two at the at the head and two at the foot of the bed. During an observation on 2/4/2025 at 9:07 AM, Resident #16 was still in bed asleep with all four rails up on both sides of the bed. During an observation on 2/4/2025 at 9:20 AM, Resident #16 was still in bed asleep with all four rails up on both sides of the bed. During an observation on 2/4/2025 at 9:32 AM, Resident #16 was in bed asleep, CNA A was in the room to provide incontinent care and when care was provided, she lowered the bed rails on both sides of the bed. Once care was completed she raised the top two rails and kept the two rails at the foot of the bed lowered. 2. Record review of an admission Record dated 2/4/25 for Resident #34 indicated that he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of multiple sclerosis (a chronic autoimmune disease that affects the central nervous system, which includes the brain, spinal cord, and optic nerves). Record review of active physician orders dated 2/4/25 for Resident #34 indicated that there were not any orders for the use of bed/assist rails. Record review of a Quarterly MDS assessment dated [DATE] for Resident #34 indicated that he had a BIMS score of 14 which indicated no cognitive impairment. He required partial/moderate assistance for most ADLs. He was always continent of bowel and bladder. The use of physical restraints for bedrails was not coded in the assessment. Record review of a care plan for Resident #34 dated 7/10/22 revealed he was not care planned for the use of bed/assist rails. He was at risk for falls related to a history of falls and physical limitations with interventions to maintain a safe environment. Record review of assessments for Resident #34 indicated he did not have any assessments completed for bed rails. During an observation on 2/3/25 at 9:21 am Resident #34's bed was observed with ½ rail noted on left side of bed. During an interview on 2/5/25 at 10:41 am Resident #34 said he used the rail to assist himself when turning in bed. He said it helped him roll over when he needed to. During an interview on 2/4/2025 at 9:47 AM, CNA A said she had been employed at the facility for a month. She said when she started her shift that morning, Resident #16 was in the bed and all four of the rails on her bed were up and that could be a form of restraint. She said she kept all four rails up because she thought therapy would be getting Resident #16 up but was told she was sick and when she was not alert, they keep her in bed. She said most mornings when she arrived for her shift, Resident #16 would only have the top two rails up. She said they used the top rails all the time for Resident #16. She said the staff were to report to the charge nurse when they saw that all four of the rails were up and it had happened in the past. During an observation on 2/4/2025 at 1:15 PM, Resident #16 was still asleep in bed with two rails up on both sides of the bed at the head of bed. During an interview on 2/4/2025 at 2:10 PM, the DON said RN H was responsible for completing the care plans for the residents and completed the initial and quarterly assessments. The DON said if something needed immediate attention, then she would update them. She said if care plans were not being updated then staff would not be able to provide adequate care for their needs. She said bed rails should be care planned to reflect the use of bed mobility. During an interview on 02/5/2025 at 12:14 PM, RN H said she primarily helped with care plans. She said bed rails should be on care plans, especially if they were being used. During an interview on 2/5/2025 at 1:39 PM, the Administrator said care plans were the responsibility of the IDT, but RN H completed a lot of the care planning along with the DON and ADON. She said bed rails should be care planned and that was the facility's plan on how they cared for the residents. She said if things were not put in correctly then staff would not know how to effectively perform patient care for those residents. Record review of a facility policy titled Care plan, comprehensive dated March 2022 indicated, .A comprehensive, person-centered plan that included measurable objectives and timetables to meet the residents' physical, psychosocial and functional needs is developed and implemented for each resident. 2. The comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive person-centered care plan: a. includes measurable objectives and timeframes; c. includes the resident's stated goals upon admission and desired outcomes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation for 2 of 5 residents (Resident #16 and Resident #34) reviewed for bed rails. The facility failed to obtain an order or complete an assessment for the use of bedrails for Resident #16 who had full bed rails on both sides of her bed on 2/4/2025. The facility failed to obtain an order or complete an assessment for the use of assist rail for Resident #34 who had a ½ rail in place to the left side of his bed on 2/3/25. These failures could place residents at risk of entrapment or injury. Findings included: 1. Record review of an admission Record dated 2/4/2025 for Resident #16 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of diastolic congestive heart failure (heart not being able to pump blood effectively throughout the body), dementia, malignant neoplasm of right breast (breast cancer), and type 2 diabetes. Record review of active physician orders dated 2/4/2025 for Resident #16 indicated there were not any orders for the use of bed rails. Record review of an Annual MDS assessment dated [DATE] for Resident #16 indicated she had severe impairment in thinking with a BIMS score of 3. She required substantial/maximal assistance with rolling left and right. She was always incontinent of urine and bowel. The use of physical restraints for bed rails was not coded in the assessment. Record review of a care plan for Resident #16 dated 8/3/2022 revealed she was not care planned for the use of bed rails. She was at risk for falls related to history of frequent falls with interventions to maintain safe environment. Record review of assessments for Resident #16 indicated she did not have any assessments completed for bed rails. During an observation on 2/4/2025 at 8:28 AM, Resident #16 was in her bed resting with eyes closed. There were side rails up on both sides of the bed with two at the at the head and two at the foot of the bed. During an observation on 2/4/2025 at 9:07 AM, Resident #16 was still in bed asleep with all four rails up on both sides of the bed. During an observation on 2/4/2025 at 9:20 AM, Resident #16 was still in bed asleep with all four rails up on both sides of the bed. During an observation on 2/4/2025 at 9:32 AM, Resident #16 was in bed asleep, CNA A was in the room to provide incontinent care and when care was provided, she lowered the bed rails on both sides of the bed. Once care was completed she raised the top two rails and kept the two rails at the foot of the bed lowered. 2. Record review of an admission Record dated 2/4/25 for Resident #34 indicated that he admitted to the facility on [DATE]and was [AGE] years old with diagnosis of multiple sclerosis (a chronic autoimmune disease that affects the central nervous system, which includes the brain, spinal cord, and optic nerves). Record review of active physician orders dated 2/4/25 for Resident #34 indicated that there were not any orders for the use of bed/assist rails. Record review of a Quarterly MDS assessment dated [DATE] for Resident #34 indicated that he had a BIMS score of 14 which indicated no cognitive impairment. He required partial/moderate assistance for most ADLs. He was always continent of bowel and bladder. The use of bed rails was not coded in the assessment. Record review of a care plan for Resident #34 dated 7/10/22 revealed he was not care planned for the use of bed/assist rails. He was at risk for falls related to a history of falls and physical limitations with interventions to maintain a safe environment. Record review of assessments for Resident #34 indicated he did not have any assessments completed for bed rails. During an observation on 2/3/25 at 9:21 am Resident #34's bed was observed with ½ rail noted on left side of bed. During an interview on 2/5/25 at 10:41 am Resident #34 said he used the rail to assist himself when turning in bed. He said it helped him roll over when he needed to. During an interview on 2/4/2025 at 9:47 AM, CNA A said she had been employed at the facility for a month. She said when she started her shift that morning, Resident #16 was in the bed and all four of the rails on her bed were up and that could be a form of restraint. She said she kept all four rails up because she thought therapy would be getting Resident #16 up but was told she was sick and when she was not alert, they keep her in bed. She said most mornings when she arrived for her shift, Resident #16 would only have the top two rails up. She said they used the top rails all the time for Resident #16. She said the staff were to report to the charge nurse when they saw that all four of the rails were up and it had happened in the past. During an observation on 2/4/2025 at 1:15 PM, Resident #16 was still asleep in bed with two rails up on both sides of the bed at the head of bed. During an interview on 2/4/2025 at 1:57 PM, LVN B said she had been employed since March 2024 and worked 6 am-6 pm. She said she made rounds on Resident #16 that morning and she was resting in the bed with the side rails up on both sides of the bed at the head of bed. She said she was not aware that Resident #16 had all four rails up that morning and said having all four up was a form of restraint. She said she had talked to the nurse aides in the past about not putting up all four rails up on Resident #16's bed. She said she had never completed a bed rail assessment for any residents in the facility and was not told to do so. She said there was an option in the charting system for bed rail assessments. She said if all four rails were up on the bed, it was a form of restraint, and the resident could hurt herself if she tried to get up. She said the staff used the rails to assist the resident with positioning and bed mobility. During an interview on 2/4/2025 at 2:10 PM, the DON said Resident #16 had the bed that she was in for over a year. She said she was not aware that staff were putting up all four bed rails on her bed. She said bed rail assessments were done for residents but not documented and it was in her head. She said she was not aware they needed an order for bed rails. She said the Maintenance Supervisor checked the bed rails and mattresses quarterly. She said the bed rails were used for the resident's safety to promote independence. During an interview on 2/4/2025 at 2:31 PM, the Maintenance Supervisor said he had been employed at the facility since June 2024. He said he checked the bed rails and mattresses quarterly. He said he checked the placements and measurements of the bed rails from the mattress to the rail and headboard. He said the purpose of checking the bed rails was to ensure safety while using them as restraint and so the residents will not be able to get body parts stuck in them. Record review of Bed/Bed rail safety audit from April 2024-January 2025 was conducted by the Maintenance Supervisor quarterly. During an interview on 2/5/2025 at 10:56 AM, the ADON said she was told about the use of bed rails for Resident #16 on yesterday 2/4/2025 when all four of her rails were up and was only supposed to have 1/2 rails at the top up. She said residents could be at risk for restraints, psychosocial well-being, entrapments, injury or falls if all four rails were used. During a follow-up interview on 2/5/2025 at 11:30 AM, the DON said residents could be at risk for injury if all four bed rails were up on the beds and if the resident tried to get out. She said she conducted an in-service with staff on yesterday 2/4/2025 about the use of bed rails. She said they removed the bottom two rails from Resident #16's bed. She said Resident #34 used his rails. She said bed rail assessments should be done quarterly and prn. She said the facility tried to use assist bars (bars on the side of the bed to assist with bed mobility) with Resident #16 before and she could not use them effectively. She said they tried to use the least restrictive measures and move up if that did not work. She said Resident #34 was not able to use the assist bar when they tried in the past due to dexterity in his hand. Record review of an in-service sign in sheet dated 2/4/25 on use of restraints; assistive devices and equipment, use of side rails as an assistive device was conducted at the facility. During an interview on 02/05/25 at 12:14 pm RN H said she helped with care plans and assessments. She said she had been made aware of a resident that had fallen through the cracks with assessments but did not specify which resident. She said the assessment had been addressed and corrected. She said she primarily helped with care plans. She said bed rail assessments should be done at least quarterly. She said residents could be at risk of restraint or at risk for injury. During an interview on 2/5/2025 at 1:39 PM, the Administrator said she was made aware of Resident #16 having all the rails up on her bed on yesterday 2/4/2025. She said for all the hospital beds that were in the facility they removed the rails on yesterday 2/4/2025. She said the bed rails assessments were to be completed on admission, if an order was received, quarterly and if there were any significant changes that may prompt a need for one. She said residents could be at risk for entrapments, injury, and bodily harm if bed rails were used and could be a form of restraint. Record review of a facility policy titled Use of Side Rails as an Assistive Device dated 1/1/2024 indicated, .The use of side rails as an assistive device will be implemented based on individual resident assessments, ensuring safe promoting independence, and enhancing the overall well-being of residents. 1. Assessments and Documentation a. Initial assessment: conduct a comprehensive assessment of the resident's physical and cognitive status, mobility, and risk of falls. Document the need for side rails as an assistive device. b. Ongoing assessment: reassess the resident's condition quarterly and on an as needed basis and update the care plan as needed. 4. Alternatives to Side Rails a. Explore and document alternatives ensuring the least restricted device is being used. 6. Training and education a. Provide ongoing training for staff on the proper use, installation, and maintenance of side rails .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in locked compartments and permit only authorized personnel to have access to the keys for 1 of 6 residents (Resident #50) reviewed for medication storage. The facility did not ensure Caladryl lotion was not stored at the bedside for Resident #50 on [DATE]. This failure could place all residents at risk of misuse of medication and decreased quality of life. Findings included: Record review of a facility face sheet dated [DATE] for Resident # 50 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of influenza. Record review of a comprehensive MDS dated [DATE] for Resident #50 indicated that he had a BIMS score of 14 which indicated that he was cognitively intact. He required substantial/maximal assistance with most ADLs. He was always incontinent of bowel and bladder. MDS did not indicate any skin alterations. Record review of a physician's order summary report dated [DATE] for Resident #50 indicated that he did not have an order for Caladryl lotion. Record review of a comprehensive care plan dated [DATE] for Resident #50 indicated that he was not care planned to self-administer medications and the care plan did not address the use of Caladryl lotion. During an observation on [DATE] at 9:26 am a bottle of Caladryl lotion was observed on a bedside table in Resident #50's room. Resident was not in his room at this time. During an observation and interview on [DATE] at 10:13 am Resident #50 was observed in his room sitting in a wheelchair. He said he had recently returned to the facility from the hospital and since then he had had a rash on his lower back. He said he had been using the lotion to apply to the rash. He said he had been applying it himself. During an observation on [DATE] at 1:57 pm Caladryl lotion was still observed on bedside table in Resident #50's room. During an interview on [DATE] at 3:47 pm LVN E was shown the Caladryl lotion in Resident #50's room. She said his family must have brought it in. She said he did not have an order for it. She said he did have an order for hydrocortisone cream to apply to the rash. She said they did not have any residents allowed to self-administer any medication. She said there was a risk of other residents that may have dementia wandering into the room and possibly drinking it. She said anything that said keep out of reach of children should not be left unattended where residents have access to it. She immediately removed Caladryl lotion from resident's room. During an interview on [DATE] at 10:58 am ADON said medications should not be left unattended in resident's rooms. She said there could be a risk of improper usage of the medication, residents potentially using expired medication, and possible medication interactions since it would not be monitored by staff. She said administrative staff usually just take turns checking residents' rooms for any possible hazards. She said floor staff are also trained to check for any possible hazards as well. During an interview on [DATE] at 11:30 am DON said medications should be stored in the medication room or nurse cart. She said she was not aware of the medication in Resident #50's room until it was pointed out by the surveyor. She said no residents were allowed to keep medications in their rooms and no residents were allowed to self-medicate. She said there was a risk of other residents getting the medication. She said his sitter had brought him the medication and did not notify the facility. She said the medication was removed and stored in the medication room. During an interview on [DATE] at 11:44 am Administrator said nurses and CNAs should be making rounds and ensuring no medications are left in resident's rooms. She said everyone including housekeeping, laundry, dietary, etc. were all trained to know that medications were not supposed to be in residents' rooms. She said residents could be at risk of misusing medications, overdose, and interactions, especially since staff would not be aware they were using it. Record review of facility policy titled Medication Labeling and Storage dated 2001 read .The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys . and .Medication Storage: 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation 1. The facility failed to ensure foods stored in the freezer were labeled, dated, and sealed. 2. The facility failed to ensure dented cans were separated from non-dented cans. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During an observation on 02/05/2025 at 8:48 am, the following was identified by the DM in the freezer: *15-pound box of Smithfield bacon open/uncovered and not in a sealed container. *1 package of chili with no date or label. *1 package of sweet potato fries with no date or label. *1 package of hashbrowns with no date or label. *1 bag of curly fries with no date or label. *1 bag of Italian breaded zucchini sticks with no date or label. *1 bag of zucchini squash with no date or label. *1 bag of yellow squash with no date or label on it. *1 box of cheese sticks not sealed (packaging open). During an observation on 02/05/2025 at 8:54 am the following was identified in the pantry: *1 6lbs-10 oz dented can of tomato sauce not kept separate from non-dented cans During an interview on 2/05/25 at 1:40pm, the DM said food items should be checked immediately off the truck to make sure all items are good, not out of date, dated and labeled the same day and stored appropriately the same day of delivery. She said all dented cans should be separated from the non-dented cans . She said dates and labels tell the staff that food items are good and when to discard expired foods. During an interview on 2/05/25 at 1:50pm the DA G said kitchen staff are supposed to date and label food as it comes into the kitchen. She said all dented cans are to be separated from the non-dented cans . During an interview on 2/05/25 at 1:58pm the [NAME] said staff should label and date on the same day food arrives at the facility. She said all dented cans are to be separated from the non-dented cans. During an interview on 2/05/25 at 2:05pm DA F said food should be dated and labeled as soon as it's delivered to the facility and stored properly. She said if a can is dented it should not be stored with undented cans. During an interview on 02/05/25 at 10:57am ADON said she was not aware that food in the refrigerator or freezer was not dated or labeled. She said she was told on 2/4/25 that the condensation in the refrigerator and freezer causes the dates not to stay on the packages. She said food should be dated and labeled immediately upon arrival. She said that not properly dating, labeling, or storing foods provides a risk of expired products being served to residents and could cause food borne pathogens to be passed to residents and cause illness. During an interview on 02/05/25 at 11:51am Administrator said all foods should be dated immediately once the food is received at the facility. She said if food is removed from its original box the food should be immediately dated and labeled to assure food is served prior to the expirations date and the correct food is served. She said food not properly being dated, labeled or stored could cause food borne illness, cross contamination, and serving outdated foods. She said she would like to see everything dated/labeled and stored properly according to policy in the future to ensure resident safety. Record review of the facility Food Storage Policy dated 3/22/2017 titled Food Storage indicated, Frozen foods-All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded Food will be stored and handled to maintain the integrity of the packaging until ready for use. Record review of an in-service titled DIETARY INSERVICE dated 9/17/2024 stated *Food Storage. We ALL know that food must be labeled. Dated with use by dates and rotated appropriately. We ALL know that frozen foods must be sealed and dated Record review of the Food and Drug Code dated 2022 indicated, 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; 3-201.11 Compliance with Food Law. (C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 3 of 6 residents (Resident #16, Resident #26, and Resident #20) and 3 of 5 staff (CNA A, CNA C, and CNA D) reviewed for infection control. The facility failed to ensure CNA A washed or sanitized her hands when passing out meal trays to residents on Hall B on 2/3/2025. CNA A did not sanitize or wash her hands between glove changes when incontinent care was provided to Resident #16 on 2/4/2025. The facility failed to ensure a Yaunker suction tip (an oral suctioning tool) for Resident #20 was not left open and uncovered on a bedside table. The facility failed to ensure enhanced barrier precautions were in place for Resident #26. CNA C and CNA D did not wear appropriate PPE for enhanced barrier precautions when incontinent care was provided to Resident #26 on 2/4/25. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: 1.During an observation of meal service on 2/3/2025 from 11:59 AM to 12:20 PM, CNA A did not wash or sanitize her hands prior to entering/exiting rooms or handling meal trays for the next room for the following rooms on Hall B: room [ROOM NUMBER] took the meal tray into the room, set up tray and opened the utensils, room [ROOM NUMBER] placed tray on over bed table, room [ROOM NUMBER] placed tray on over bed table, room [ROOM NUMBER] set tray on over bed table, went back into room [ROOM NUMBER] when the resident called for her and asked for her to cut his steak up into pieces, exited the room and walked down the hallway to the linen cart and grabbed a towel and went into room [ROOM NUMBER] and placed the towel on the bed and washed her hands in the sink in the room, sat down by bed in a chair and fed resident in room [ROOM NUMBER] his lunch. During an interview on 2/3/2025 at 1:53 PM, CNA A said she had been employed at the facility for a month and worked 12-hour shifts on days from 6 am-6 pm. She said during the observation of passing lunch trays earlier, she should have sanitized or washed her hands between residents. She said she had not had any check offs by staff and had worked at the facility in the past a few times. She said she had hand sanitizer in her pocket and forgot to use it between residents. She said residents could get sick if staff did not wash or sanitize their hands after providing assistance to them. 2. Record review of an admission Record dated 2/4/2025 for Resident #16 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of diastolic congestive heart failure, dementia, malignant neoplasm of right breast (cancer in the breast), and type 2 diabetes. Record review of a care plan for Resident #16 dated 8/3/2022 indicated she had an ADL self-care performance deficit due to muscle wasting and atrophy with interventions for bed mobility: she required x1 staff participation. She had urine and bowel incontinence with interventions to provide pericare after each incontinent episode. Record review of an Annual MDS Assessment for Resident #16 indicated she had severe impairment in thinking with a BIMS score of 3. She required substantial/maximal assistance with rolling left and right. She was always incontinent of urine and bowel. During an observation on 2/4/2025 at 9:32 AM, in the room of Resident #16, CNA A was present to provide incontinent care. CNA A sanitized her hands, went into the hallway, and gathered supplies. Supplies were placed on a towel on the over bed table, and she washed her hands at the sink in the room. She placed gloves on both hands and pulled the linens down to the foot of the bed. She opened the brief and pulled it down between Resident #16's legs. CNA A removed a wipe from the package and wiped across the lower abdomen and placed it in the trash and removed another wipe and wiped down the vagina from top to bottom and placed the wipe in the trash. She rolled Resident #16 onto her left side and removed another wipe and wiped her rectal area from front to back and rolled an under pad underneath the resident along with a clean brief. She rolled the resident onto her right side and pulled the dirty brief and under pad and placed them in the trash and then she pulled the clean under pad and brief under the resident's buttocks. She removed her gloves and placed them in the trash. She did not wash or sanitize her hands and placed clean gloves on and secured the brief on Resident #16. She removed her gloves and placed them in the trash. Resident #16 was repositioned in bed and she placed linens back over the resident. She washed her hands in the sink in the resident's room. During an interview on 2/4/2025 at 9:47 AM, CNA A said during the incontinent care provided to Resident #16, she did not sanitize or wash her hands between glove changes. She said she should have changed her gloves after she removed the dirty brief and underpad and before she placed clean items on the resident. She said no one checked her off on skills or watched her perform incontinent care since she started about a month ago. She said she had sanitizer in her pocket but was nervous and forgot to use it. She said residents could be at risk for infections if staff did not wash or sanitize their hands. 3. Record review of a facility face sheet dated 2/4/25 for Resident #20 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of flaccid hemiplegia affecting left nondominant side (paralysis affecting the left side of the body due to neurological injury, often resulting from a stroke). Record review of a Quarterly MDS for Resident #20 dated 12/8/24 indicated that he had a BIMS score of 1, indicating that he had severe cognitive impairment. He was dependent with most of his ADLs. He was incontinent of bowel and bladder. Record review of a physician's order summary report dated 2/4/25 for Resident #20 indicated that he had the following physician's order dated 8/8/23: .May suction due to excessive secretions . Record review of a comprehensive care plan dated 12/10/23 for Resident #20 indicated that he had a terminal diagnosis and was receiving hospice services with interventions including to provide maximum comfort for the resident. During an observation on 2/3/25 at 9:30 am Resident #20 was observed lying in bed. He had a suction machine on his bedside table with a Yaunker suction tip attached to the tubing for the suction machine. The suction tip was uncovered, not bagged, and lying on the bedside table. Resident was unable to answer questions. During an observation on 2/3/25 at 2:00 pm the suction tip was still observed open but was now lying on top of the suction machine, still unbagged, unlabeled, and undated. During an interview on 2/3/25 at 3:30 pm LVN E said they do not have to suction Resident #20 very often, but they should always use a clean Yaunker when suctioning and it should not be left lying open on his bedside table or on top of the suction machine. During an interview on 2/3/25 at 4:00 pm ADON said the suction tip should not be lying open on the bedside table. She said they are scheduled for replacement on Sunday nights. She said it could cause the resident to be at risk for infection if the suction tip was not stored properly. 4. Record review of a facility face sheet dated 2/4/25 for Resident #26 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (lung and airway diseases that restrict your breathing). Record review of a quarterly MDS dated [DATE] for Resident #26 indicated that she had a BIMS score of 0, which indicated that she had severe cognitive impairment. She was dependent for all ADLs. She was always incontinent of bowel and bladder. She had an indwelling abdominal feeding tube. Record review of a physician's order summary report dated 2/4/25 for Resident #26 indicated that she did not have an order for enhanced barrier precautions in place. Record review of a comprehensive care plan dated 1/23/25 for Resident #26 indicated that she received all nutrition and fluids per G-Tube per MD orders. During an observation on 2/4/25 at 10:30 am CNA C and CNA D were observed to provide incontinent care for Resident #26. CNA C and CNA D did not wear appropriate PPE as required for enhanced barrier precautions. There was not a box of ppe outside of the resident's door or any sign that the resident was on enhanced barrier precautions. They did not wear a gown as required for enhanced barrier precautions. During a joint interview on 2/4/25 at 10:45 am CNA C and CNA D both said they had been trained on enhanced barrier precautions but did not have anyone on their hall at this time that required them. They said residents requiring them would have signs and boxes of PPE outside their door. They both said the facility had not told them Resident #26 required enhanced barrier precautions. During an interview on 2/4/25 at 11:00 am ADON said residents requiring EBP included residents with chronic open wounds and indwelling medical devices. During an interview on 2/5/25 at 11:15 am Administrator said she had misread the letter from CMS and did not realize that Resident #26 required EBP. They thought since she did not have secretions from the tube and she'd had it for so long that she did not require them. Record review of a training transcript for CNA A dated 2/3/2025 indicate she completed training on infection control and prevention on 1/5/2025 and hand hygiene on 1/7/2025. Record review of a nurse aide skills performance checklist for CNA A dated 1/14/2025 indicated she had skills check off conducted by the DON and was satisfactory with hand washing/use of hand sanitizer and with providing female perineal care. During an interview on 2/5/2025 at 10:56 AM, the ADON said she was made aware of CNA A not washing or sanitizing her hands between residents when passing meal trays. She said they conducted training with staff on hire on infection control by her and the DON. She said staff were supposed to sanitize their hands between passing meal trays and the facility had multiple sanitizing stations available along with pocket bottles of sanitizer for them to carry with them. She said when staff performed incontinent care hands should be sanitized or washed before care, when changing from dirty to clean and CNA A received that training during her check off on hire. She said she provided training at least quarterly on infection control and hand hygiene with the facility staff and more often if needed. She said residents could be at risk for the potential of organism related infections if staff did not wash or sanitize their hands. During an interview on 2/5/2025 at 11:30 AM, the DON said the ADON was responsible for training staff on infection control and conducted training as needed and yearly. She said she was made aware of CNA A not sanitizing her hands when she passed lunch trays on 2/3/2025 and was told about her not sanitizing her hands or washing them during incontinent care on 2/4/2025. She said hand hygiene should be done when going from dirty to clean, before and after care provided and when gloves were removed. She said hands should be sanitized between residents and before getting another tray. She said residents could be at risk for infections if staff did not sanitize or wash their hands. Record review of in-service dated 2/3/25 indicated the facility staff were trained on hand hygiene. Record review of in-service dated 2/4/2025 indicated the facility staff were trained on standard precautions and peri care. During an interview on 2/5/25 at 10:58 am ADON said residents could be at risk of having MDRO's introduced through indwelling medical devices if enhanced barrier precautions were not followed appropriately. During an interview on 2/5/25 at 11:44 am Administrator said the enhanced barrier precautions were now in place to protect Resident #26 from infections that could be spread from other residents since she had an indwelling medical device. She said the Yaunker suction tip should have not been left uncovered on the table as it could pose an infection risk. During an interview on 2/5/2025 at 1:39 PM, the Administrator said the ADON was responsible for training on infection control and was the Infection Preventionist for the facility. She said she was made aware of the incidents with CNA A on 2/3/2025 and 2/4/2025. She said hand hygiene should be done before care, during care, anytime going from dirty to clean, after care, and anytime as needed in between. She said there could be a risk for an increase in infections from bacteria and cross contamination if staff did not wash or sanitize their hands. She said they planned to continue to conduct hand hygiene audits monthly and would do them more frequently with new hires. Record review of a facility policy titled Handwashing/Hand Hygiene revised August 2019 indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: b. Before and after direct contact with residents; h. Before moving from a contaminated body site to a clean body site during resident care; m. After removing gloves; p. Before and after assisting a resident with meals . Record review of a facility policy titled Suctioning the Upper Airway (Nasopharyngeal or Oropharyngeal Suctioning) dated 2001 and revised in October 2023 read .General Guidelines: 5. Oropharyngeal suctioning is performed using aseptic technique (clean) . Record review of a facility policy titled Enhanced Barrier Precautions dated 2001 and revised in August 2022 read .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .d. providing hygiene; .f. changing briefs or assisting with toileting . and .EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 2 of 16 licensed nursing staff (ADON and RN A) reviewed for staff qualifications. 1. The facility failed to ensure the ADON's nursing license was not expired between [DATE] and [DATE]. 2. The facility failed to ensure RN A's nursing license did not expire as of [DATE]. These failures could place residents at risk for not receiving nursing services by a licensed nurse. The findings include: Record review of a personnel file for the facility indicated the ADON had been employed at the facility since [DATE] with an LVN nursing license. A copy of the Texas Board of Nursing license verification provided by the facility for the ADON indicated her license was current through [DATE]. Record review of the Texas Board of Nursing license verification dated [DATE] indicated the ADON was originally issued an LVN license on [DATE] and current issue date was [DATE] with an expiration date of [DATE]. Record review of a personnel file for the facility indicated RN A had been employed at the facility since [DATE] with an RN license. A copy of the Texas Board of Nursing license verification report dated [DATE] for RN A provided by the facility indicated her RN license would expire on [DATE]. The facility did not provide a verification check after that date. Record review of the Texas Board of Nursing license verification, dated [DATE], indicated RN A was originally issued an RN license on [DATE] and the license was currently delinquent with an expiration date of [DATE]. Record review of the facility's form titled Verbal Warning Record, dated [DATE], indicated RN A received verbal warning for practicing without a valid nursing license and read .employee was informed via phone by admin & DON she would be suspended until her license is reinstated. We will re-evaluate once it is renewed and was signed by the Administrator. During an interview on [DATE] at 1:30 PM, the Administrator said during the process of getting the requested employees' information it was discovered one of the nurses chosen, RN A, had a license that expired in October of 2023. She said they ran all the other nursing staff today to ensure compliance and they had not found any other expired licenses. She said RN A had been taken off the schedule effective immediately and terminated until she was licensed. The Administrator said the BOM was responsible for checking nursing licenses. During an interview on [DATE] at 3:40 PM, the DON said she was aware the ADONs license had expired because when the ADON realized it, she had come to her in a panic. The DON said she went through everything and made sure the ADON had not worked the floor and had not done any resident documentation. She said the Administrator was out that day and she did not report it to Administrator. She said the BOM was responsible for checking nursing licenses, but she just started doing them this month, the Administrator had been doing them prior. During an interview on [DATE] at 10:00 AM, the Administrator said she had been responsible for pulling licenses and background checks annually for nurses until August of 2023 when she handed it over to the BOM. She said RN A's license was current when she last checked in August of 2023. She said she had been checking the nursing licenses once a year. She said maybe she didn't train the BOM effectively and BOM did not know the background checks included the nursing licenses. She said it was ultimately her (administrator)'s responsibility to ensure the nursing licenses were current. During an interview on [DATE] at 10:15 AM, the BOM said she was responsible for running criminal background checks, OIG, EMR and NAR checks before hire and annually. She said she did not know she was also supposed to be verifying the nursing license as well. She said she learned that at the beginning of this month. She said going forward she would run them with the annual background checks. She said she would create some sort of system to check them monthly as well. She said she could not really think of any harm that could come to residents as a result of being cared for by unlicensed nurses. During a telephone interview on [DATE] at 11:40 AM, RN A said she thought she had renewed her license. She said she remembered renewing it and remembered paying her fee and she just never thought anything else about it. She said she did not know until the facility called her yesterday to let her know. She said she had since gone through all her bank statements but could not find any record of payment. She said she was working now on getting her license renewed. She said she could not think of any risks to residents by being cared for by an unlicensed nurse. During an interview on [DATE] at 1:10 PM, the DON said there were many risks to residents if they were cared for by unlicensed nurses. She said there could be a reason why they were not licensed, incorrect medications could be given, incorrect care could be provided. She said there was a reason for nurses to be licensed and went through the process of obtaining a license. She said going forward, licenses would be checked upon hire and annually. She said she would personally ensure all her nursing staff was licensed. She said she did not tell the Administrator about the ADON's license at the time, and she knew now that she should have done that. During an interview on [DATE] at 1:20 PM, the ADON said that time period was just very chaotic for her. She said she just forgot all about renewing her license. She said it was not something she would normally forget; she just was not in her normal frame of mind. She said she was sitting at her desk one day going through some files and saw a file with some of her CEU's and it hit her that she never renewed her license. She said she immediately told DON, and then she immediately got her license renewed. She said if nurses were not licensed and stayed up with their CEU's, the nurses may not provide competent care to residents. During an interview on [DATE] at 1:35 PM, the Administrator said she was not aware of either expiration until yesterday after the State Surveyor entrance. She said she was providing more training to the BOM, and they would work together to come up with a system to run licenses monthly to ensure this did not happen again. She said if nurses did not renew their license appropriately and keep their CEU's up to date, then they may not be aware of best practices. Record review of the facility policy titled Credentialing of Nursing Service Personnel, dated [DATE], read .Nursing service personnel who require a license or certification to provide resident care or treatment without direction or supervision within the scope of the individual's license or certification must present verification of such license or certification prior to or upon employment .a copy of annual license renewals/certifications - ran annually by HR or designee .should the investigation reveal the applicant does not hold a valid license employee will be placed on probation until license is reinstated

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (Resident #1) reviewed for abuse. The facility failed to prevent CNA A, on 9/04/24, from abusing Resident #1 when she purposefully tossed water on her. The noncompliance was identified as PNC. The noncompliance began on 09/04/24 and ended on 09/04/24. The facility had corrected the noncompliance before the survey began. The failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included: Review of the face sheet for Resident #1 reflected she was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder (mental illness), need for assistive personal care, lack of coordination and communication deficient (unable to communicate). Review of a Significant Change MDS Assessment for Resident #1 dated 7/4/24 indicated a BIMS score of 2 reflecting severe cognitive impairment. Resident #1 had physical behavioral symptoms directed toward others daily such as hitting, kicking, pushing, scratching, grabbing almost daily. Review of the Care Plan for Resident #1 with revisions dated 9/12/24 reflected focus of Resident #1 was at risk for psychosocial well-being related to incident with caregiver. Review of Nurses notes from 9/04/24 until this investigation indicated no changes in the actions, demeanor, or behaviors for Resident #1. During an interview on 09/25/24 at 9:45 am the DON said she received a call from Witness B needing to speak with her as soon as possible. Witness B came to her office and reported while Resident #1 was sitting at the dining table in the locked unit, CNA A walked by Resident #1 and tossed about a ½ cup of water from a Styrofoam cup onto the blanket Resident #1 was wrapped up in with some water splashing on her face. The DON asked when this occurred, she said it occurred right before CNA A left for the day, at 12:45pm to 1:00pm. The DON said she immediately went to the locked unit to perform a head-to-toe assessment on Resident #1. The DON said Witness B had already cleaned the water from Resident #1 when she arrived and was providing care to another resident. The DON said Witness C gave her statement regarding CNA A purposefully tossing water on Resident #1. The DON then reported the incident to the Administrator who is the Abuse Coordinator. The DON said she immediately completed head to toe assessments on the residents in the locked unit. She said that psychosocial assessments were completed as well that afternoon. During an interview on 9/25/24 at 10:00 am the Administrator stated Witness B and Witness C had confirmed CNA A had tossed water on Resident #1 on 9/04/24 at approximately 12:45 pm. The Administrator stated she was notified by the DON after Witness A and Witness B had reported the incident to the DON when she arrived back from lunch on 9/04/24 at 1:00pm to 1:15 pm. the facility investigation confirmed abuse and CNA A was suspended by phone, since she had left for the day immediately after the incident. The Administrator said Resident #1's representative and medical doctor were notified of the incident immediately. The Administrator stated ongoing assessments had confirmed Resident #1 had no negative outcome from the incident and was unable to determine if Resident #1 was aware that the incident had occurred. The Administrator said in-services were conducted on ANE, Dignity and dementia care on 9/04/24. During a phone interview on 9/25/24 at 11:58 am CNA A said she was terminated from employment at the facility after the incident on 09/04/24. CNA A said that Resident #1 was at the dining room table in the locked unit. CNA A said Resident #1 had grabbed her arm as she was walking by, and she unintentionally spilled the water on herself and the resident. CNA A said that she was not assigned care of Resident #1 due to the resident was difficult and Resident #1 preferred to be assigned ADLs by another CNA working at the facility. CNA A said she had been educated on ANE numerous times and she knew better than to mistreat any resident. She said she felt the witnesses did not see the whole incident as Witness B was standing behind her and Witness C was standing at the exit door. During an observation and interview on 9/25/24 at 12:15 pm, Witness B revealed Resident #1 was sitting at the dining table in the locked unit with a blanket wrapped around her with just her face in view. Witness B said that was how she was covered on 9/4/24 when CNA A intentionally tossed ½ cup of water from white foam cup onto the front of her blanket with some water getting on her face. Resident #1 looked up and smiled when her name was called. Resident #1 was unable to answer any questions about the incident involving CNA A. On 9/25/24 at 10:05 am 11:18 am and 1:00 PM three attempts were made to interview Witness C but the attempts were unsuccessful. Unable to leave a message. Record review of the facility investigation reflected the incident was reported on 9/04/24 and occurred on the afternoon of 9/04/24 as reported during interview with the DON and Administrator. Record review of a witness statement dated 09/04/24 signed by Witness B indicated Witness B had walked back onto the secured unit to clean the dining room. The statement reflected Witness B had just entered the dining room when CNA A was walking towards the exit door to the outside area holding a cup in her hand. As she was walking by Resident # 1, she gestured as if she was throwing the cup towards her and tossed water all over the resident and kept walking towards the door. Witness B documented that they reported what they saw to the DON. Record review of a witness statement dated 09/04/24 signed by Witness C indicated Witness C was standing at the smoking area door facing inside the dining room when she saw CNA A walk by Resident #1 and tossed water on her. Witness C immediately went to check on the resident and clean her up. Afterwards she called the DON to have her come to the unit. Record review of CNA A's Termination Statement dated 09/04/24 revealed CNA A was suspended per phone call on 09/04/24 and terminated on 09/04/24. Record review of the facility policy titled Dignity with revision date 2/2021 . indicated: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Record review of the Facility Policy titled Abuse Neglect dated 3/29/2018 indicated .the resident has a right to be free from abuse, neglect and misappropriation. ''Abuse is define as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Review of Abuse, Neglect and Exploitation In-service dated 09/04/24 revealed staff were in-serviced on abuse, neglect and exploitation, dementia care and dignity. Review of CNA A's employee record reflected she was hired 4/13/2023 and background checks were completed. Her last abuse prevention training was done 5/08/24 and there were no disciplinary actions. During an observation on 09/25/2024 at 9:35 AM revealed staff interacting at the facility respectfully with residents. During an interview on 09/25/2024 at 1:35 PM Resident #2 stated he thought the staff were competent and felt safe at the facility. He denied any abuse. During an interview on 09/25/2024 at 1:45 PM Resident #3 stated she felt safe and had no concerns for abuse or neglect. During interviews with staff present on morning and evening shifts 09/25/24 from 10:00 am until 3:15 pm, the staff were able to identify the abuse coordinator was the Administrator. The staff said that they would report any abuse immediately and had been trained on dignity and dementia care. During an interview on 09/25/2024 at 11:00 AM Witness B stated she was educated regarding the facility abuse and neglect policy and would notify their abuse coordinator, the Administrator. If she did not feel the situation was addressed by the abuse coordinator, she would notify HHSC. Review of Satisfaction Rounds by the Administrator dated 09/04/2024 revealed the DON completed satisfaction rounds with all residents with no additional concerns revealed. Review of Resident #1's Care plan dated 06/25/2024 revealed Resident #1's care plan was updated for recent trauma related to abuse for incident involving CNA A. The noncompliance was identified as PNC. The noncompliance began on 09/04/24 and ended on 09/04/24. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 5 residents (Resident #33) reviewed for care plans. The facility failed to ensure Resident #33's care plan reflected current resident code status within 7 days of the resident assessment. This failure could place residents at risk of not receiving appropriate care to meet their current needs. Findings include: Record review of a facility face sheet for Resident #33 dated [DATE] indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of traumatic subarachnoid hemorrhage (bleeding in the space between your brain and the thin tissues that cover and protect it). Record review of a Significant Change Comprehensive MDS assessment dated [DATE] indicated that Resident #33 had a BIMS score of 4, which indicates a severe cognitive impairment. Record Review of Texas Department of State Health Services Standard Out of Hospital Do-Not-Resuscitate Order Form for Resident #33 revealed it was fully executed on [DATE], meaning it had been signed by all parties and was in effect Record review of electronic medical record for Resident #33 indicated that he had a Do Not Resuscitate (DNR) code status, indicating that he did not wish to have CPR performed. Record review of physician orders dated [DATE] for Resident #33 indicated that he had the following order: Advanced Directive DNR dated [DATE]. Review of Resident #33's comprehensive care plan with Created date of [DATE] for code status revealed it included the following: * Code Status: Full Code * Goal: Resident/Responsible Party's decision for full Code will be honored through the next review date. * Interventions: Initiate BLS/CPR if Resident #33 is without heartbeat or not breathing. Notify EMS.; and Request for CPR to be initiated will be followed. During a joint interview on [DATE] at 09:25 AM LVN D and DON both said that Resident #33 was a DNR, and the form had just recently been completed and put into effect. During an interview on [DATE] at 4:00 pm DON said that she was responsible for updating the care plans and that Resident # 33's care plan should have been updated within 7 days of his significant change MDS, which was completed on [DATE]. She said that this was due to a breakdown in communication between staff. She said that she was unsure who actually placed the signed form in his paper chart, but that they had done so without communication to staff and that is why the care plan had not been updated. She said that she had corrected the care plan now and she would try and ensure that it did not happen again. She said she would find out where the breakdown occurred and implement education to ensure proper communication between staff in the future. She acknowledged that this put residents at risk of not receiving proper care. During an interview on [DATE] at 9:30 am, Administrator said that going forward she would be doing lots of education regarding communication. Record review of a facility policy titled Care Plans, Comprehensive Person-Centered dated 2001 with revision date of [DATE] read .The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual, or Significant Change in Status) . and .The comprehensive, person-centered care plan: a.) includes measurable objectives and timeframes; b) describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment . and .The interdisciplinary team reviews and updates the care plan: a) when there has been a significant change in the resident's condition .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet the needs for 1 of 6 residents (Resident #27) reviewed. The facility failed to ensure that Resident #27 received nectar thickened liquids as ordered. These failures could place residents at risk for aspiration. Findings include: Record review of a face sheet dated 1/16/2024 indicated Resident #27 was a [AGE] year-old female with an original admission date of 11/16/2018. Diagnosis include Chronic Obstructive Pulmonary Disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), History of transient ischemic attack (a temporary period of symptoms similar to those of a stroke), Osteoporosis (condition that causes bones to become weak and brittle), Alzheimer's Disease (changes in the brain that lead to deposits of certain proteins that causes the brain to shrink and brain cells to die). Record review of MDS assessment dated [DATE] indicated Resident #27 requires set up assistance with eating and moderate assistance with all other activities of daily living. Resident #27 has a BIMS score of 04, which indicates severely impaired cognition. Resident #27 is incontinent of bowel and bladder. Record review of hospital discharge record dated 1/10/2024 indicated that patient was released from the hospital after treatment for a urinary tract infection and healthcare acquired pneumonia. Record review of physician orders for Resident #27 had a diet order of regular diet pureed texture, nectar consistency dated 1/18/2024. Record review of speech therapy evaluation dated 1/18/2024. Reason for referral was related to decline in speech-language. Swallowing abilities require minimal close supervision, label closure mild, oral phase mild, and oral clearance mild. During observation on 1/22/2024 at 10:00 AM, Resident #27 was sitting in the dining room for activities and drinking coffee. No thickening agent was used in the coffee, and it was thin consistency. During an observation on 1 /23/2024 at 8:30 AM a water pitcher with water and ice, no thickener added on bedside table of Resident #27. During an interview on1/23/2024 at 8:35 AM with CNA A. CNA A said that if there is a change in a resident's diet, the nurses communicate the changes to the CNA staff. She said that there are no identifiers in the resident's room or outside the room to indicate of resident is on a therapeutic diet. CNA A correctly identified resident #27 as having an order for a therapeutic diet. She said that the water at the bedside was an accident and that the resident does not drink without assistance. She said that the resident could aspirate if the therapeutic diet was not followed. During an interview on 1/23/2024 at 8:45 AM with LVN C, LVN C said that any new orders including diet changes were verbally communicated to the CNA's and that it was placed on the 24 hour report to communicate between shifts. She stated that the department managers reviewed the 24-hour report in the morning meeting. She stated that if a nurse was off for several days, then the nurse would review the 24-hour reports and the chart for any new orders. LVN C stated that she was aware of the residents on her hall with therapeutic diets. She stated that the family member of Resident #27's roommate would place items on Resident #27's side of the room. She stated that if a resident was given regular liquids when they were ordered nectar consistency then there would be an increased risk of aspiration. During an interview on 1/23/2024 at 9:00 AM with Activity Director, the activities director said that she is told in the morning meeting when a resident has a change in diet and that she accommodates those needs during activities that have food or drink. She said that she was not aware that Resident #27 had a therapeutic diet. She stated that she had been off work the previous week when the change had occurred and was not aware of it. She said that the resident #27 was drinking regular consistency coffee as observed. She said that she did not have a list of residents with therapeutic diets and that if she was not told in the morning meeting, she was not aware of diet changes. She said that a resident could aspirate and get sick if a therapeutic diet was not followed. During an interview on 1/24/2024 at 10:00 AM with Speech Therapist, the Speech therapist said that she was currently treating Resident #27. She said that the Assistant Director of Nurses referred the patient to speech therapy after observing resident coughing during a meal while assisting resident. The speech therapist said that she recommended the change in the resident's diet from regular consistency to pureed texture and nectar thick liquids and the doctor approved the order. She said that the patient would return to a regular consistency because she was not exhibiting any signs of swallowing problems and that during evaluation and therapy the therapist noted the muscles used for swallowing to be strong. She said that the diet change was a precautionary measure and was allowing staff to observe the resident. She said that the resident did not need a medical swallow study to be performed at this time due to resident not meeting the criteria needed for the study. The speech therapist said that the resident returned from the hospital with health care related pneumonia and that the diagnosis could be the reason for Resident #27's occasional cough. She said that when she receives an order to change a resident's diet, she communicates the change to the charge nurse and/or director of nursing. She said that if the correct diet is not followed then a resident is at risk for aspiration. During an interview on 1/24/2024 at 11:30 AM with ADON, she said that she made the request for speech therapy to evaluate Resident #27. She said that she was assisting the resident during lunch and that the resident began to cough after drinking some fluids. She said that since the resident had been hospitalized and has had a decline she requested the evaluation. She said that she was aware that the resident was recovering from pneumonia but wanted to make sure that Resident #27 was not having any swallowing issues. During an interview on 1/24/2024 at 1:00 PM with DON. The DON said that when a resident has a diet change, the order is put into electronic charting system. A communication sheet is completed and given to the dietary staff. She said that during the morning meeting all new orders and changes are discussed with the department heads. The activities director is part of the morning meeting. She said that the activities director has access to the electronic charting system and is able to review any new orders. She stated that if the activities director is not at work, then the activities director is responsible for identifying any changes in orders and updating diet changes. She said that moving forward the facility will come up with a process where written communication will be done. She said that residents are at risk for aspiration and choking if diet is not followed. Review of Therapeutic Diets policy dated October 2017 noted Snacks will be compatible with the therapeutic diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, 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 6 residents (Resident # 28) reviewed for infection control. CNA A failed to perform proper hand hygiene while providing incontinent care to Resident #28 on 01/23/2024. This failure could place residents at risk of exposure to communicable diseases and infections. Findings: Record review of a facility face sheet indicated Resident #28 admitted to the facility on [DATE] with diagnosis of heart failure. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #28 had a BIMS of 11 indicating moderately impaired cognition, required moderate assistance with toileting hygiene and was always incontinent of bowel and bladder. Record review of comprehensive care plan dated 01/03/2024 indicated Resident #28 had an ADL self-care deficit and bowel and bladder incontinence and to perform incontinent care. During an observation on 01/23/24 at 10:33 am CNA A provided incontinent care to Resident # 28. During incontinent care CNA A did not wash or sanitize her hands in between glove changes and upon completion of incontinent care. CNA A repositioned Resident #28 and made the bed without performing hand hygiene following incontinent care. During an interview on 01/23/24 at 10:43 am CNA A stated she had been a CNA for 7 years and employed at the facility a year. She stated she was trained on hire and again in December 2023 on infection control measures including handwashing and incontinent care. She stated she should have washed or sanitized her hands with each glove change and after care was given and by not doing so could lead to infections. During an interview on 01/23/24 at 11:58 am, the ADON stated she completed the skills checkoff for CNA A on 12/14/2023 and she was competent on proper infection control measures and handwashing at that time. She stated the CNA's were trained to wash or sanitize their hands before and after glove changes and before completing any other task to prevent infections. During an interview on 01/23/24 at 12:00 pm, the DON stated she and the ADON were responsible for training CNA's on incontinent care and infection control. She stated the CNA should have washed or sanitized their hands between glove changes and before performing task with the resident to prevent infections. She stated she expected infection control measures were followed. During an interview on 01/24/2024 at 10:05 am, the administrator stated the ADON was responsible for oversight and training of the CNA's regarding infection control and hand hygiene. She stated overall she and the DON were responsible for ensuring the policies and procedures were followed daily. She stated she expected all staff to follow infection control and hand hygiene measures with every task to prevent the spread of infections. Record review of a facility policy titled Perineal Care dated February 2018 indicated, .10. remove gloves, 11. wash and dry hands, 12. reposition the bed covers . Record review of a facility policy titled Handwashing/Hand Hygiene dated August 2019 indicated, .7. use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: m. after removing gloves, 8. Hand hygiene is the final step after removing and disposing of personal protective equipment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the drug regimen review recommendations from the pharmacy consultant were acted upon for 7 of 16 residents (Residents #209, #40, #308, #10, #6, #44 and #208) reviewed for drug regimen review. -The Facility did not follow up on the pharmacy consultant's recommendations for Gradual Dose Reduction (GDR) dated 01/11/2023 for Resident #209, #40 and #308 until 05/03/2023, four months after original recommendation. -The Facility did not follow up on the pharmacy consultant's recommendations for Gradual Dose Reduction (GDR) dated 05/10/2023 and 05/11/2023 for Resident #10, #6, #44 and #208 until 07/10/2023 and 07/11/2023, two months after original recommendation. -The Facility did not develop policies and procedures to address the timeframes of the medication regimen review (MRR). These failures could place residents at risk for medication errors, unnecessary medications, and incorrect administration. Findings include: Record review of facility face sheet dated 01/24/24 indicated Resident #209 was a [AGE] year-old female admitted on [DATE] with diagnosis of depression (mental health disorder that affects mood). Record review of quarterly MDS assessment dated [DATE]/23 indicated Resident #209 had a BIMS of 9 indicating moderately impaired cognition and section N indicated she received an antidepressant. Record review of facility face sheet dated 01/24/24 indicated Resident #40 was a [AGE] year-old female admitted on [DATE] with depression (mental health disorder that affects mood) and weakness. Record review of quarterly MDS assessment dated [DATE] indicated Resident #40 had a BIMS of 12 indicating moderately impaired cognition and section N indicated she was taking an antidepressant. Record review of facility face sheet dated 01/24/24 indicated Resident #308 was a [AGE] year-old female admitted on [DATE] with diagnosis of anxiety (nervousness) and depression (mental health disorder that affects mood) and muscle wasting. Record review of quarterly MDS assessment dated [DATE] indicated Resident #308 had a BIMS of 12 indicating moderately impaired cognition and section N indicated she was taking an antianxiety medication and antidepressant. Record review of facility face sheet dated 01/24/2024 indicated Resident #10 was a 57 -year-old male admitted on [DATE] with diagnosis of depression (mental health disorder that affects mood) and insomnia (inability to sleep). Record review of quarterly MDS assessment dated [DATE] indicated Resident #10 had a BIMS of 15 indicating intact cognition and section N indicated he was receiving an antidepressant. Record review of facility face sheet dated 01/24/24 indicated Resident #6 was a [AGE] year-old male admitted on [DATE] with diagnosis of depression (mental health disorder that affects mood), history of falls and muscle weakness. Record review of quarterly MDS assessment dated [DATE] indicated Resident #6 had a BIMS of 11 of indicating moderately impaired cognition and section N indicated he was taking an antidepressant. Record review of facility face sheet dated 01/24/24 indicated Resident #44 was an 86 -year-old female admitted on [DATE] with diagnosis of depression (mental health disorder that affects mood) and muscle weakness. Record review of quarterly MDS assessment dated [DATE] indicated Resident #44 had a BIMS of 01 of indicating severely impaired cognition and section N indicated she was taking an anti-anxiety medication. Record review of facility face sheet dated 01/24/24 indicated Resident #208 was a [AGE] year-old male admitted on [DATE] with diagnosis of Insomnia (inability to sleep) and pain. Record review of quarterly MDS assessment dated [DATE] indicated Resident #208 had a BIMS of 15 indicating intact cognition and section N indicated he was taking a hypnotic. Record review of documents titled Consultant Pharmacist's Monthly Report for [Facility], dated January 2023 to December 2023 reflected the pharmacist had made medication regimen review recommendations for the residents' physician to review. The record review of pharmacy medication regimen review Note to Attending Physician/Prescriber revealed 7 of 16 residents reviewed had recommendations/ interventions that were not executed timely as indicated below: Resident #209 GDR recommendation dated 01/11/23 for Paxil 20 mg, decrease Paxil to 10mg. Resident #209 had been receiving Paxil (antidepressant) used to treat a depressed mood, since April 2022. Recommendation was received declined and signed on 05/03/23, four months after origination date. Resident #40 GDR recommendation dated 01/11/23 for Zoloft 150mg, decrease to Zoloft 125 mg. Resident #40 had been receiving Zoloft (antidepressant) used to treat a depressed mood for one year. Recommendation was received accepted and signed on 05/03/23, four months after origination date. Resident #308 GDR recommendation dated 01/11/23 for Remeron 15mg, decrease Remeron to 7.5mg. Resident #308 had been receiving Remeron (antidepressant) used to treat a depressed mood for one year. Recommendation was received declined and signed on 05/03/23, four months after origination date. Resident #10 GDR recommendation dated 05/10/23 for Trazodone 120 mg, decrease Trazadone to 50mg. Resident #10 had been receiving Trazodone (antidepressant) used to treat insomnia (unable to sleep) since April 2022. Recommendation was received accepted and signed on 07/11/23, two months after origination date. Resident #208 GDR recommendation dated 05/11/23 for Tylenol PM 500-25 mg two tablets at bedtime, decrease Tylenol PM to one tablet. Resident #208 had been receiving Tylenol PM used to treat insomnia (unable to sleep). GDR indicated there was no documentation of episodes of insomnia for resident #208. Recommendation was received accepted and signed in agreement on 07/11/23, two months after origination date. Resident #6 GDR recommendation dated 05/11/23 for Zoloft 50mg, decrease to Zoloft 25 mg. Resident #6 had been receiving Zoloft (antidepressant) used to treat a depressed mood for one year. Recommendation was received declined and signed on 07/11/23, two months after origination date. Resident #44 GDR recommendation dated 05/11/23 for Buspar 10 mg, decrease Buspar to 5mg. Resident #44 had been receiving Buspar (antidepressant) used to treat (depressed mood) since April 2022. Recommendation was received accepted and signed on 07/10/23, two months after origination date. During an interview on 01/23/24 at 12:00 p.m. the ADON said she had been in her position for just a few months. The ADON said the DON is responsible for sending the gradual dose reduction requests completed by the pharmacist and she completed them in the absence of the DON. She said that not following up on them timely could cause an adverse effect from unnecessary dosages but most of the time the physician declined the recommendations because they were already on a therapeutic dose and decreasing the dosages would cause more negative behaviors. During an interview on 01/23/24 at 3:30 p.m., the DON said she had worked at the facility since 4/17/2017 and was responsible for obtaining the completed pharmacy reviews for gradual dose reductions. The DON said not following up on recommendations timely could cause a delay in needed medication changes or other requested interventions. The DON said the recommendations made in January 2023 were not received signed until 5/3/23, four months later. The DON said the facility had a turnover of Medical Directors during that time period and she was having difficulty getting them executed. She said declinations or new orders were not obtained for the January recommendations until May of 2023, after the next pharmacy review was conducted and beyond the recommendation of 30 days. She said the problem had not been addressed during QAPI meetings. She said the GDR should be addressed before the next pharmacy review was conducted. During an interview on 01/23/24 10:00 a.m., The Administrator said she had been employed with facility for the past year and the DON was responsible for completion of the MMR Process including GDR. The Administrator said her expectation would be they are implemented before the next pharmacy review was conducted. The Administrator said that the resident could suffer an adverse effect if the responses were not followed up on timely. During an interview on 01/24/2024 at 9:54 a.m. the Contract Pharmacist said he had been consulting at the facility for 14 years. He said he visited the facility monthly to perform pharmacist duties including medication regimen reviews and recommendations. He stated within 7 days of his visit he uploads his notes and recommendations into the google drive file and emails the DON and Administrator the information. He stated that ideally the recommendation should be sent to the physician and returned within 14 days, but it is usually 30 days. He stated that if a physician does not respond to the pharmacy recommendation within 30 days he sends another recommendation asking for a response. He stated the resident could suffer an adverse effect if recommendations were not acted upon timely. Record review of facility policy revised July 2022 titled Tapering Medications and Gradual Drug Dose Reduction indicated, After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences. 1. All medications shall be considered for possible tapering. Tapering that is applicable to psychotropic medications are referred to as gradual dose reductions. 2. Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs .Policy interpretation and implementation 5. The physician will review periodically whether current medications are still necessary in their current doses; for example, whether an individual's condition or risk factors are sufficiently prominent or ensuring that they require medication therapy to continue in the current dose, or whether those conditions and risks could potentially be equally well managed or controlled without certain medications, or with a lower dose. The policy did not address time frames for the different steps in the process. Record review of an undated Consultant Pharmacist Reports policy, documentation and communication of consultant pharmacist recommendations policy indicated, The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapy are communicated to those with authority and/or responsibility to implement the recommendations and responded to in an appropriate and timely fashion . C. Recommendations are acted upon and documented by the facility staff and /or the prescriber. If the prescriber does not respond to recommendation directed to him/her (within a reasonable time frame/within 30 days), a reminder may be used. If the prescriber does not respond to the recommendation after the reminder (within 60 days) the Director of Nursing and/or the consultant pharmacist may contact the Medical Director.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 1 of 4 halls (D hall) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature on 1/24/2024 to residents on D hall for the breakfast meal. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings include: During initial interviews on 1/22/2024 from 9:26 am to 10:28 am on D hall, residents who ate meals in their rooms voiced concerns about the food being served cold. During an observation on 1/24/2024 at 7:50 am a test tray was on a meal cart with D hall meals. All meal trays arrived on hall D at 7:51 AM. CNA B began passing meal trays at 7:54 AM and the final tray was passed out at 8:20 AM. During an observation on 1/24/2024 at 8:20 AM a test tray obtained from the same cart as the D hall meal trays after the resident trays were passed, and food temperatures were checked by the dietary manager with surveyor and administrator present. Food temperatures were: Oatmeal- 109 degrees F. Scrambled eggs- 108 degrees F., Sausage patty- 89 degrees F., Bread (wrapped in foil)- 106 degrees F. Acceptable parameters for food temperatures for hot foods should be 135 degrees F or higher. During an interview on 1/24/2024 at 8:40 AM , the administrator said that department supervisors usually assist with passing meal trays on D hall, but because they were doing other tasks related to the survey, they did not assist with the meal service this morning. During an interview on 1/24/2024 at 10:30 AM the dietary manager said that she has requested plate warmers in the past to help keep the food warm for the residents that eat in their room. She said that she has gotten complaints in the past about the food being served cold to residents who dine in their rooms. She said that she makes sure that the food is hot when it is put on the cart but is unable to control how quickly the meals are served once the cart leaves the kitchen. She said that serving food cold could cause the residents not to eat and lose weight. During an interview on 1/24/2024 at 11:00AM, the administrator said that she was planning to interview residents that ate their meals in their rooms and determine if the temperature of the meals were a consistent problem. She said that she then planned to take any concerns and discuss them with the department heads in the morning meeting to come up with solutions that would address any problems. She said that she expected the meal trays to be served in a timely manner. She said that food not served at the proper temperatures could lead to food borne illnesses and malnutrition. Record review of policy titled Food and Nutrition Services, the policy statement is Each resident is provided with a nourishing, palatable, well-balanced diet .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 2 of 5 residents reviewed for call lights. (Resident #41 & #49). The facility failed to ensure Resident #41 and #49's emergency call light in the bathroom would reach the floor. The call light cords were gathered and secured with a rubber band. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings include: Record review of a facility face sheet for Resident # 41 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. Record review of a Quarterly MDS assessment for Resident # 41 dated 1/13/24 indicated that he had a BIMS score of 2 which indicated severe cognitive impairment. Section GG indicated that he was independent in transferring on and off the toilet. Section H indicated that he was always continent of bowel and bladder. Record review of a Care Plan dated 10/10/22 for Resident # 41 indicated that he was at risk for falls with an intervention included to be sure the resident's call light is within reach. Record review of a facility face sheet dated 1/23/24 for Resident # 49 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with subsequent readmission on [DATE] with diagnosis of dementia. Record review of a Comprehensive MDS assessment dated [DATE] for Resident #49 indicated that he had a BIMS score of 0 which indicates that he had severe cognitive impairment. Section GG indicated that he was independent with transferring on and off the toilet. Section H indicated that he was always continent of bowel and bladder. Record review of a Care Plan dated 4/30/23 for Resident # 49 indicated that he had the following intervention: Toileting: Provide education on call light use, safety and proper body mechanics. During an observation and interview on 1/22/24 at 9:33 am the bathroom call light in Resident #41's room was observed to be too short. The string appeared to be new and gathered and secured with a rubber band. It was approximately 3 to 4 inches in length and was not reachable from the floor. Resident #41 said that he did use the restroom by himself but could not remember if he had ever needed to use the light. During an observation and interview on 1/22/24 at 9:53 am the bathroom call light in Resident #49's room was observed to be too short. The string appeared to be new and gathered and secured with a rubber band. It was approximately 3 to 4 inches in length and was not reachable from the floor. Resident #49 said that he was independent and did use the restroom by himself. He denied having suffered any falls and says he has not needed to use the light. During an observation and interview on 1/22/24 at 2:50 pm, CNA E said that it could be a problem if a resident fell. He fixed the strings in the restrooms during our observation in both resident's rooms. He said that both residents do go to the bathroom independently. He said that Resident #41 needs assistance, but sometimes he does go by himself. During an interview on 1/22/24 at 3:00 pm Administrator said that if a resident were to fall, they would not be able to reach the call light. She said that the call lights were recently replaced on the unit, and it was possible that some of them had not been unwrapped upon installation. During an interview on 1/23/24 at 12:02 pm Maintenance Director said that he had been employed there since May of 2023 and said that the call light system in the unit was replaced sometime around September of 2023 and some strings may have been missed and not been unraveled. He said that he had checked the rest of the call lights in bathrooms on the unit, but that CNA D had already fixed them. Record review of a facility policy titled Answering the Call Light dated 2001 with a revision date of March 2021 read .Explain to the resident that a call system is also located in his/her bathroom .and .be sure the call light is within easy reach of the resident .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility did not label or date a bag of unknown substance in the freezer, whipped topping, and diced peppers, did not dispose of cheesecake, lettuce, chicken wings and shrimp, and did not cover drinks stored in walk in cooler. These failures could place residents at risk for food-borne illnesses. Findings included: During an observation on 01/22/2024 at 9:00 AM in the kitchen, In the upright refrigerator a container labeled cheesecake dated 1-6-2024. A zipper top bag with unknown substance in freezer with no label or date. The walk-in cooler contained a bag of shredded lettuce dated 1-16-2024, brown in appearance and a closed bag of whipped topping with no date. A cart with drinks in plastic glasses were uncovered. In walk in freezer, a closed container of diced peppers with no date. A zipper bag of chicken wings and shrimp with severe frost bite. In pantry, a zipper bag of spaghetti noodles dated 11/19/23 open and zipper seal open to air. The bag of whipped topping package directions state that it is good for 2 weeks once defrosted. During an interview on 1/22/2024 at 9:45 AM , the dietary manager said everyone who worked in the kitchen was responsible for ensuring foods were labeled and dated properly. She stated that she does not always know where to find the expiration dates on items. She states that items are to be labeled with contents and date that item is placed in refrigerator or freezer with a used by date. Use by date is 72 hours after opening item. Dietary manager states that any expired items or items that are not labeled are to be discarded. Dietary manager states that residents could become ill if they consume items that have expired. 01/24/24 9:00AM interview with Cook. The [NAME] said all items placed in the refrigerator or freezer should be placed in a zipper bag, labeled with contents and date that item was opened or prepared. [NAME] stated that any items that are not dated should be thrown away and any items not used in a 72-hour period should not be used and thrown away. [NAME] states that residents could get sick if they eat food that is old. 01/24/24 9:15 AM Interview with Dietary Aide. The Dietary Aide said items that are stored in the refrigerator and freezer are placed in a zipper bag or in a container with a lid. She states that a label with the contents, date and use by date are placed on the container or bag. Dietary aide states that if items are not labeled properly then the residents could receive food that will make them sick. 01/24/2024 10:00 AM interview with the administrator. Administrator states that all items in the refrigerator and freezer should be labeled as stated in the policy. She states that items that are not labeled or have expired should be thrown out. The administrator states that her expectations are that the kitchen staff labels all items in the kitchen according to the policy and that the staff remove any items that are out of date and that the items be checked on a routine basis. Review of the facility's undated Leftover storage policy states, Leftovers are properly stored immediately .labeled and dated as to use by and are dated as to a four-day use by date, adding four days to the present date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident or legal representatives right to participate in the development and implementation of his or her person-centered plan of care, for 1 of 5 Residents (Resident #1) reviewed for care plans. The facility did not include the correct representatives for Resident #1 (representative D and representative E) in the initial plan meeting on 9/21/23 to discuss Resident #1's care . This failure could cause residents or representatives to not be able to participate in the planning of their care, not receiving the care they want or need, and not being informed of all services offered by the facility. The findings included: Record review of order summary dated 11/15/23 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] from acute care with a diagnosis including chronic pulmonary edema (fluid in the lungs), hypertension (high blood pressure), Heart failure (inability of the heart to pump) depression (low mood), muscle weakness, and unsteadiness on feet. Record review of the MDS dated [DATE] indicated Resident #1 was usually understood by other and understood others. The MDS indicated Resident #1 had a BIMS of 6 and was cognitively impaired. The MDS indicated Resident #1 required set up assistance of one person with bed mobility, transfers, dressing, eating, and toileting. The MDS indicated Resident #1 required one-person physical assist with personal hygiene. Record review of the face sheet dated 11/15/23 indicated Resident #1's primary representative was Resident #2 (spouse) and listed two additional contacts (representative D and representative E). Record review of the initial care plan last revised 9/14/23 indicated Resident #1 was at risk for social isolation related to being new to the nursing home. Record review of the care plan conference report dated 9/21/23 indicated Resident #1 had a care plan conference on 9/21/23 with two of Resident #2's (spouse of Resident #1) representatives (representatives F and G) in attendance. Record review of resident profile dated 11/15/23 indicated Resident #2 was a 91 -year-old female admitted to the facility on [DATE] with a diagnosis including chronic pulmonary disease (lung disease), muscle weakness, and unsteadiness on feet. Resident #2 had four (4) contacts listed including Resident #1 as spouse. None of the contacts listed for Resident #2 were listed as a representative of Resident #1. Record review of the MDS dated [DATE] indicated Resident #2 was usually understood by other and understood others. The MDS indicated Resident #2 had a BIMS of 11 and had moderate cognitive impairment. During an interview on 11/15/23 at 8:14 a.m. Resident #1's representative D (POA) said she had not been contacted to attend the initial comprehensive care plan conference for Resident #1 on 9/21/23. Representative D of Resident #1 said the representatives for Resident #2 (Resident #1's spouse) had been invited by the Social Worker and attended the initial care plan for Resident #1's conference by mistake and that was a violation of Resident #1's rights. Representative D stated she would like the matter investigated. During an interview on 11/15/23/10/23 at 2:00 p.m. the MDS Coordinator said she had only been in her position for a few weeks. The MDS Coordinator said she was responsible for ensuring care plans were completed. The MDS Coordinator said residents' representatives were routinely invited to care plan meetings. The MDS Coordinator said it was important to involve residents' representatives in care plan meetings because it was their loved one's care and an inter-departmental meeting that would inform residents and families of different services the facility had to offer they might not be aware of. During an interview on 11/15/23 at 2:18 p.m. the Administrator said care plans were performed on admission, quarterly, and with a change in condition. The Administrator said residents and their families/responsible parties were invited to care plan meetings. The Administrator said Resident #1's care plan meeting was scheduled by the Social Worker, but she failed to follow the correct procedure of notification. The Administrator said the representatives for Resident #2 had been invited and attended Residents #1's care plan conference by mistake. The Administrator said she was made aware of the incident by Resident #1's representative D. The Administrator said she investigated the incident. The Administrator said the Social Worker was no longer employed by the facility. The Administrator said it was important for residents, families, or designated representatives to attend care plan meetings to be able to voice their opinions and to be able to take part in their own care. Record review of the facility's policy Care Plans, Comprehensive-Centered dated December 2016 indicated, .1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .3 The IDT includes .e. the resident's legal representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 2 of 5 residents reviewed for misappropriation of property. (Resident #3 and Resident#4). The facility failed to prevent a diversion (misappropriation ) of Resident #3's methocarbamol tablets (used to treat muscle spasms and pain) a total of 60 tablets in two blister packs filled 5/23/23. One blister pack of the two packs dated 5/23/23 was observed in custody at the Sheriff's department containing 22 of 30 tablets and Resident #4's bottle of amoxicillin capsules (used to treat infection) was observed in custody at the Sherriff's department on 11/15/23, after being turned in by complainant. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity. Findings included: 1.Record review of Resident #3's face sheet, dated of 11/15/23, indicated he was [AGE] years old, admitted on [DATE], readmitted on [DATE]. He had diagnoses including history of fracture of the left femur (broken bone in the upper leg), low back pain and muscle weakness. Record review of Resident #3's quarterly MDS, dated [DATE], indicated he had adequate hearing and vision, could understand and was understood by others, and had intact cognition with a BIMS score of 15. Record review of Resident #3's care plan, with an admission date of 07/05/2023 and revision date of 11/05/2023 indicated Resident #3 was at risk for pain with a history of pain. Record review of Resident #3's order summary report dated 11/15/23, indicated active orders as of 11/15/23 included an order to administer methocarbamol oral tablet 500mg one tablet by mouth every 8 hours as needed for pain. Record review of Resident #3's MAR for May, June, July, August, September, and October indicated no administration of methocarbamol 500mg by mouth. MAR for the month of November, indicated he received methocarbamol 500mg one tablet by mouth, once on 11/12/23. 2. Record review of Resident #4's face sheet, dated of 11/15/23, indicated he was [AGE] years old, admitted on [DATE]. He had diagnoses including history of pneumonia (lung infection), weakness and pain. Record review of Resident #4's quarterly MDS, dated [DATE], indicated he had impaired hearing and vision, could rarely understand, and was usually understood by others, and had severe cognitive impairment. Record review of Resident #4's order summary history indicated no previous order for amoxicillin 500mg since admission to the facility. During a phone interview on 11/14/23 at 11:18 a.m. complainant said he had discovered medications in a closet at his home ( the complainant's home) on 9/29/23 and turned them into the Sheriff's department. The complainant said he had taken the medications to the Sheriff's department and made a report concerning the medications and LVN A. The complainant said he discovered a box of blister packaged medications (25 to 30 cards) in his closet at his home after LVN A had moved out of his home. The complainant expressed concern that LVN A was stealing medications from the nursing facility she was currently employed at or had taken medications from other nursing facilities she was previously employed in [NAME] and Huntington. During an interview on 11/14/23 at 2:00 p.m., Deputy B said he would meet with this investigator at the Sheriff's department on 11/15/23 to examine the medications in the evidence file turned in by the Complainant against LVN A. Deputy B said that he had not brought any formal charges against LVN A since there were no narcotics, only medications classified as dangerous drugs. Deputy B said LVN A had said she had worked for Home Health Agencies during the Covid (a severe acute respiratory virus) pandemic and had not destroyed these medications yet. Deputy B said LVN A said the agencies had told her she keep these medications since none were narcotics. Deputy B said he had been contacted by the Board of Nurse Examiners concerning this case but there were no charges filed against LVN A at this time. During an interview on 11/14/23 at 3:00 p.m. the Administrator said she had no reason to suspect LVN A had taken any medications from the facility. No residents had complaints of unrelieved pain and no staff had reported any cards missing of dangerous drugs. The Administrator said she would call LVN A and put her on suspension for this investigation. During an interview and observation at the Sherriff's department with Deputy B on 11/15/22 beginning at 10:00 a.m. The evidence file contained one blister pack card of Methocarbamol 500mg tablets containing 8 of 30 tablets, label indicated issue date 5/23/23 one of two cards total 60 tablets, label indicated prescribed for Resident #3, currently residing in the facility (label indicated Methocarbamol belonged to the facility). The evidence file contained one bottle of amoxicillin 500mg caplets dated 1/16/23 prescribed for Resident #4, currently residing at the facility. 1- vial of unlabeled Zofran 4 mg per 2 ml injectable, 2- vials of unlabeled Phenergan 25mg/ml for injection, 32 additional medication blister packs of po medications were observed dates of ranging from 2018 to 2022, none of the additional blister packs belonged to any resident that resides or had previously resided at the nursing facility being investigated. During an interview and observation with LVN H on 11/15/23 at 12:30 a.m. a new blister pack of Methocarbamol 500mg belonging to Resident #3 was observed in the medication cart with a fill date of November 23. One tablet was missing for dose administered on 11/12/23. LVN H said Resident #3 gets routine pain medication and rarely asks for PRN pain medications. LVN H said she had never given Resident #3 his Methocarbamol 500mg po prn for muscle spasms or pain. LVN H said if the Methocarbamol 500mg was filled with 60 tablets on 5/23/23, Resident #3 should still have the two blister packages left due to non-use, since there were no tablets signed as being administered on the MAR since it was filled in May. The Medication was refilled in November of 2023 with one tablet signed out as administered 11/12/23. During an interview with Resident #3 on 11/15/22 at 12:40 p.m., Resident #3 said his pain is controlled by his scheduled medications. Resident #3 said he was started on the Methocarbamol a long time ago after he fractured his leg. Resident #3 said he had muscle spasms in his thigh in the hospital due to the injury and he came back to the facility with orders to continue as needed. Resident #3 said he thinks it has been several months since he requested anything for muscle spasms or uncontrolled pain. During an interview with Resident #4's representative on 11/15/22 at 1:00 p.m., the representative said the prescription for amoxicillin had been provided to the facility when the resident admitted in January, after he had been in the hospital. The representative said Resident #4 did not take any of the amoxicillin because he went into the hospital for his infection. Resident #4's Representative said she had given the medication to the admitting nurse for documentation and destruction. Resident #4 said she didn't know how the bottle ended up at the Sheriff's office unless someone had taken it from the facility. During a phone interview on 11/15/23 at 1:30 p.m. LVN A said she had taken the medications now in custody of the Sherriff's department from various nursing facilities she had worked at. LVN A said she did not remember taking any medications belonging to Resident #3 and Resident #4 or any other residents at the facility she was currently employed. LVN A said she knows she should have not taken the drugs and knows she will lose her job. LVN A was crying and remorseful about taking residents medications. She said the board of nursing has already been in contact with her. During an interview on 11/15/23 at 2:00 p.m. the Administrator said she would be reporting LVN A to the board of nursing and will prepare papers for termination. The Administrator said she would not employee anyone that had a history of stealing and would be in servicing all staff on misappropriation. She said in servicing on facility policies regarding misappropriation, medication destruction and an audit of medication would be completed. Record review of the facility's Identifying Exploitation, Theft and Misappropriation of Resident Property policy with a date of April 2021 indicated, .4. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. 5. Examples of misappropriation of resident property include: . f. drug diversion (taking the resident's medication) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental and psychosocial needs for 1 of 12 residents (Resident #34) reviewed for care plans. Resident #34 did not have appropriate interventions for a DNR documented in the care plan and electronic [NAME] (summary of ordered interventions) in Point Click Care (electronic medical record). This failure could place residents at risk for inappropriate interventions by staff when reading information in the clinical record, (that is inaccurate or incomplete) which could delay emergency treatment or incur unwanted treatment. Findings: Review of Resident #34's physician's order summary dated [DATE] revealed she was [AGE] years old and admitted on [DATE] with diagnoses including Anorexia (Not Eating), Hypertension (High Blood pressure) and Age-Related Cognitive Decline. The Orders included a prescriber written order dated [DATE] for a DNR. Record review of Resident #34's EMR in PCC indicated the Code Status was DNR. Record Review of Texas Department of State Health Services Standard Out of Hospital Do-Not-Resuscitate Order revealed it was fully executed on [DATE]. Record review of Resident #34's Baseline Care Plan dated [DATE] indicated Code Status of DNR. Review of Resident #34's comprehensive care plan with revision date [DATE] for code status revealed it included the following: Goal: Resident is a FULL CODE status. Goal: Resident/Representative part decision for full Code will be honored through the next review date. Interventions: Initiate BLS/CPR if Resident #34 is without heartbeat or not breathing. Notify EMS. During an Interview, record review and observation on [DATE] at 09:29 AM, LVN B said that she would view the Profile or [NAME] in PCC, the EMR, if she needed to know the code status of a resident, if she found someone not breathing or without a pulse and she would have someone verify in the chart if they were available. LVN B said that there was a listing on the Crash Cart (a cart that contains supplies used during CPR), that reflects the Code Status of the Residents also and it was updated frequently. LVN B accessed Resident #34's profile and DNR was listed in PCC. LVN B accessed the [NAME] for Resident #34, which included: [NAME]: o Initiate BLS/CPR if Resident #34 is without a heartbeat or not breathing. Notify EMS. [LVN, CNA, PT, SW] H Shows on [NAME]. o Notify the charge nurse immediately if the resident is not breathing or does not have a heartbeat. [LVN, CNA, PT, SW] H Shows on [NAME] Continued interview with LVN B on [DATE] at 09:29 AM revealed the [NAME] does not match, she said we would not initiate CPR or notify the charge nurse that the resident is not breathing and she would correct it right away. LVN B said she would never look at the care plan for code status, but the care plan should be accurate. LVN B reviewed the latest care plan and she said it has Full Code. LVN B said that needs to be changed and she can correct it. LVN B said the Care Plan flows to the [NAME] and staff of all disciplines do access the [NAME], and it could cause problems if incorrect. During an interview on[DATE] at 09:46 a.m. with the DON and ADON revealed the DON said that the ADON completes the care plans and the DON is ultimately responsible for all care plans. The DON said she had just reviewed Resident #34's Care plan and she would change it today since it was not accurate. The DON said all records should be accurate and reflect the resident's wishes. The DON said Records including the Care Plan should reflect interventions that are accurate from MD orders and DNR status. Inaccurate care plans increase the risk of a resident receiving inappropriate interventions. During an interview on [DATE] at 10:02 a.m. the ADM said that the DON and ADON are responsible for Care Planning. Review of facility policy, undated, titled Advance Directives and Advance Care Planning Procedure revealed upon admission 1) admitting charge nurse will obtain an order for code status. After admission: 1) Social worker will meet with the newly admitted resident or representative within 72 hours of admission to verify the code status and document the discussion/education in the chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents needing respiratory care were provided such care consistent with professional standards of practice for 1 of 2 residents (Resident #25) reviewed for respiratory care and services. Resident #25 used oxygen at night and had a water bottle on her oxygen concentrator dated 10/03/22 with orders for oxygen tubing and supplies to be changed at least weekly. This deficient practice could place residents who receive respiratory care and services, at risk of developing respiratory infections and complications. Findings Included: Clinical record review of Resident #25's face sheet dated 11/07/22 indicated resident #25 was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses including: Urinary tract infection, edema (swelling), hypertension, chest pain, and chronic atrial fibrillation (irregular heart rate & rhythm). Record review of MDS dated [DATE] revealed that Resident #25 had a BIMS score of 12, indicating that she had moderate cognitive impairment. During an observation and interview on 11/06/22 at 11:08 AM, Resident #25 was observed sitting up on the side of her bed, oxygen tubing and nasal cannula noted on the bed beside her. She said that she had just taken it off, and that she wore it at night while sleeping. The oxygen bottle on the concentrator was dated 10/3/22, and no date was noted on the tubing. Resident #25 said that she wore it every night and said that she thought it was changed 2 or 3 weeks ago. Record review of physician orders dated 11/7/22 revealed that Resident #25 had the following order .O2 @ 2LPM via NC; may titrate to keep O2 saturation above 92% as needed . and .oxygen tubing and supplies to be changed weekly and prn . Record review of care plan dated 11/7/22 stated .(Resident #25) has oxygen therapy . and .oxygen at 2LPM per nasal cannula PRN . During an interview on 11/08/22 at 11:30 AM, LVN B said the charge nurse on night shift is responsible for ensuring that tubing and bottles are changed weekly. During an interview on 11/07/22 at 1:04 PM, the ADON said that tubing and concentrator bottles should be changed every 7 days and that the risks included possible development of respiratory infections. During an interview on 11/8/22 at 09:30am, the DON said that the concentrator bottles were to be changed weekly, every 7 days, due to the increased risk of dryness in the nasal cavity and increased risk of infection if the nasal cavity gets dry and cracked. She said she would be in-servicing nursing staff on checking and changing bottles and tubing weekly. She said that going forward, she would expect night shift to change tubing and concentrator bottles weekly, as per policy. Record review of facility policy titled [Facility] Departmental (Respiratory Therapy) Prevention of Infection Policy, undated, stated .pre-filled sterile humidification water bottle will be marked with date and initials upon opening and changed and discarded every 7 days and prn .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain clinical records that were complete and/or accurate for 1 of 12 residents (Resident #34) reviewed for advanced directives. Resident #34 did not have appropriate interventions for a DNR documented in the care plan and electronic [NAME] (summary of ordered interventions) in Point Click Care (electronic medical record). This failure could place residents at risk for inappropriate interventions by staff when reading information in the clinical record, (that is inaccurate or incomplete) which could delay emergency treatment or incur unwanted treatment. Findings: Review of Resident #34's physician's order summary dated [DATE] revealed she was [AGE] years old and admitted on [DATE] with diagnoses including Anorexia (Not Eating), Hypertension (High Blood pressure) and Age-Related Cognitive Decline. The Orders included a prescriber written order dated [DATE] for a DNR. Record review of Resident #34's EMR in PCC indicated the Code Status was DNR. Record Review of Texas Department of State Health Services Standard Out of Hospital Do-Not-Resuscitate Order revealed it was fully executed on [DATE]. Record review of Resident #34's Baseline Care Plan dated [DATE] indicated Code Status of DNR. Review of Resident #34's comprehensive care plan with revision date [DATE] for code status revealed it included the following: Goal: Resident is a FULL CODE status. Goal: Resident/Representative part decision for full Code will be honored through the next review date. Interventions: Initiate BLS/CPR if Resident #34 is without heartbeat or not breathing. Notify EMS. During an Interview, record review and observation on [DATE] at 09:29 AM, LVN B said that she would view the Profile or [NAME] in PCC, the EMR, if she needed to know the code status of a resident, if she found someone not breathing or without a pulse and she would have someone verify in the chart if they were available. LVN B said that there was a listing on the Crash Cart (a cart that contains supplies used during CPR), that reflects the Code Status of the Residents also and it was updated frequently. LVN B accessed Resident #34's profile and DNR was listed in PCC. LVN B accessed the [NAME] for Resident #34, which included: [NAME]: o Initiate BLS/CPR if Resident #34 is without a heartbeat or not breathing. Notify EMS. [LVN, CNA, PT, SW] H Shows on [NAME]. o Notify the charge nurse immediately if the resident is not breathing or does not have a heartbeat. [LVN, CNA, PT, SW] H Shows on [NAME] Continued interview with LVN B on [DATE] at 09:29 AM revealed the [NAME] does not match, she said we would not initiate CPR or notify the charge nurse that the resident is not breathing and she would correct it right away. LVN B said she would never look at the care plan for code status, but the care plan should be accurate. LVN B reviewed the latest care plan and she said it has Full Code. LVN B said that needs to be changed and she can correct it. LVN B said the Care Plan flows to the [NAME] and staff of all disciplines do access the [NAME], and it could cause problems if incorrect. During an interview on[DATE] at 09:46 a.m. with the DON and ADON revealed the DON said that the ADON completes the care plans and the DON is ultimately responsible for all care plans. The DON said she had just reviewed Resident #34's Care plan and she would change it today since it was not accurate. The DON said all records should be accurate and reflect the resident's wishes. The DON said Records including the Care Plan should reflect interventions that are accurate from MD orders and DNR status. Inaccurate care plans increase the risk of a resident receiving inappropriate interventions. During an interview on [DATE] at 10:02 a.m. the ADM said that the DON and ADON are responsible for Care Planning. Review of facility policy, undated, titled Advance Directives and Advance Care Planning Procedure revealed upon admission 1) admitting charge nurse will obtain an order for code status. After admission: 1) Social worker will meet with the newly admitted resident or representative within 72 hours of admission to verify the code status and document the discussion/education in the chart.

Based on observations, interviews 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 2 unit refrigerators (#2) and 1 of 2 storage rooms (#1). 1. Med Pass fortified dietary supplement was observed on 11/06/2022 in the #2 medication storage unit refrigerator used for resident snacks and dietary nourishment supplements that had expired on 11/2/2022. 2. Six containers of Med Pass fortified dietary supplement with expiration date of 11/02/2022 were observed on 11/06/2022 in the #1 medication storage cabinet. These failures could place residents at risk for food-borne illness. Findings: During an observation of medication storage #1 on 11/06/22 at 11:00 AM revealed six containers of Med Pass fortified dietary supplement were located in the cabinet with an expiration date of 11/02/2022. The DON was present and removed the product from the cabinet and placed it in the trash. During an observation of medication storage #2 on 11/06/22 at 11:25 AM revealed the unit refrigerator for nutritional supplement storage had one opened container of Med pass fortified dietary supplement present. The bottle was opened and dated on 11/02/2022 with an expiration date of 11/02/2022. The DON was present and removed the dietary supplement from the unit refrigerator and disposed of it in the trash. During an interview on 11/06/22 at 11:30 AM, the DON stated she had just received that shipment a few months ago and was not aware it had expired. The DON stated it is the charge nurse's responsibility to check the unit refrigerators for expired dietary supplements or snacks before distributing to residents. The DON stated the DM orders the Med Pass dietary supplement, and places it in medication storage. The nurses are responsible for it once it is placed in the medication storage unit. The DON stated it had been over a year since the last in-service with nurses regarding checking unit refrigerators for expired products. The DON stated she would retrain the nurses and put in place a system to monitor the unit refrigerators for expired dietary supplements and snacks. DON stated the risk could be sickness or infection. During an interview on 11/07/22 at 02:58 PM LVN A stated the charge nurses distribute the dietary supplements and shakes. LVN A stated all nurses are responsible for checking the expiration date before giving any snack or dietary supplement. LVN A stated she has had training on checking expiration dates before distributing supplements to residents. LVN A stated the risk could be sickness to the residents. During an interview on 11/07/2022 at 03:01 PM, the DM stated she orders the Med Pass dietary supplement for the nursing department but once it is delivered, the DON stocks it in the medication storage room. The DM stated after that she only reorders when the DON tells her the stock is low. During an interview on 11/08/2022 at 09:09 AM, the ADM stated that the DON and ADON are responsible for ensuring the nursing staff are checking for expired products and following the policy for nutritional supplements. The ADM stated she expects the policy and procedure to be followed. Record Review of undated facility policy titled, Med Pass Fortified Nutritional Shake Program stated, .Procedure #4 Med pass will be delivered from dietary to the nourishment refrigerator located at the nursing unit. If the Med Pass remains in the nourishment refrigerator the stock will be rotated, #5. Med Pass needs to be kept refrigerated, V. Sanitation Issues, cover. label, and refrigerate opened containers of Med Pass products and discard after 4 days .