**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or quality of life, recognizing each resident's individuality for 2 of 6 residents (Resident #49 and #18) observed for resident rights. - LVN B failed to provide Resident # 18 and Resident #49 with full privacy while performing blood glucose check with insulin administration on 11/20/2024. This failure could place residents at risk of not being treated with dignity and respect. Findings included: Resident #49 Record review of Resident #49's facility face sheet, dated 11/20/2024, reflected Resident #49 was admitted to the facility on [DATE] with a diagnoseis which included hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, type 2 diabetes mellitus with diabetic chronic kidney disease, epilepsy, unspecified, not intractable, without status epilepticus, and acquired absence of right leg below knee ., Record review of Resident #49's comprehensive care plan, dated 8/16/2024, reflected Resident #49 had bowel and bladder incontinence and required incontinent care from staff. Record review of Resident #49's quarterly MDS assessment, dated 8/21/2024, reflected Resident #49 had a BIMS score of 14, which indicated no impaired cognition and was dependent on staff for toileting and accu- checks. During an observation on 11/20/24 at 10:55 AM of a blood glucose check for Resident #49, LVN B entered Resident #49's room to perform blood glucose check. LVN B did not close the entrance door and did not pull the privacy curtain between Resident #49 and Resident#4's roommate, who was also in the room. On the door side of the room, the privacy curtain was not pulled, during care and left Resident #49 exposed. Resident #18 Record review of Resident #18's facility face sheet, dated 11/20/2024, reflected Resident #18 was admitted to the facility on [DATE] re-admitted [DATE] with a diagnosies which included: end stage renal disease (kidney can no longer filter waste from your blood), hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease ( kidney getting very close to failure or have already failed), diabetes mellitus ( increased glucose in the blood) due to underlying condition with diabetic retinopathy ( an eye condition that can cause vision loss and blindness in people who have diabetes) without macular edema ( swelling in part of the retina ( the light -sensitive layer of tissue at the back of your eye), and legal blindness ( having central visual acuity of 20/200 or worse in your better eye, even with corrective lenses). Record review of Resident #18's comprehensive care plan, dated 8/16/2024, reflected Resident #18 had bowel and bladder incontinence and required incontinent care from staff. Record review of Resident #18's quarterly MDS assessment, dated 9/27/2024, reflected Resident #18 had a BIMS score of 14, which indicated no impaired cognition and was dependent on staff for toileting and accu-checks. During an observation on 11/20/24 at 11:01 AM of a blood glucose check for Resident #18,. LVN B entered Resident #18's room, the resident was sitting on the wheelchair by the A bed closed to the door., LVN B did not pulled the privacy curtain before checking the blood glucose, blood glucose was 350mg/dl and 10 units of Insulin SQ given to Resident #18's abdomen without pulling the curtain. During an interview on 11/20/24 at 12:42 PM, Resident # 49 said the staff did not usually pulled the privacy curtains. He said he would be embarrassed if someone saw him naked. During an interview on 11/20/24 at 1:50 PM, the DON said every person employed at the facility was responsible for ensuring resident rights and dignity. She said the privacy curtain should always be pulled to provide the resident with full privacy and expected that to occur with each resident encounter during care. She said by not respecting resident rights and dignity it could cause embarrassment if they were exposed during care. During an interview on 11/20/24 at 1:53 PM, the Administrator said resident rights and dignity were the responsibility of every employee. He said during resident personal care like incontinent care the privacy curtain should always be pulled to avoid exposing the resident. He said he expected all staff to maintain dignity for every resident and by not doing so it could cause embarrassment. Record review of the facility policy titled Resident Rights - Dignity and Respect: Revised date 05/2007, 10/2015, Policy: It is the policy of this facility that all residents be treated with kindness, dignity, and respect: Procedures: .Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the resident from passers-by. People not involved in the care of the Resident shall not be present without the resident's consent while they are being examined or treated. Staff members shall knock before entering the Resident's room . Highlights: Dignity and respect, daily activity schedules, privacy, care, and treatments, reporting violations and grievances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission, including initial goals based on admission orders, physician orders, dietary orders, and social services for 1 of 18 (Resident #5) reviewed for baseline care plans. -Resident #5 did not have a baseline care plan completed within 48 hours when they admitted on [DATE]. This failure could lead to residents not receiving individualized services and care upon admission. Findings: Record review of Resident #5's face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Their medical diagnoses included paroxysmal atrial fibrillation (irregular heartbeat), malignant neoplasm of transverse colon (colon cancer), hypertension (high blood pressure), muscle weakness, neuropathy, chronic kidney disease (stage 2, mild), dysphagia (difficulty swallowing), and cognitive communication deficit (difficulty communication due to impaired cognition). Record review of Resident #5's MDS (a resident assessment and care screening form) dated 09/18/2024 revealed a BIMS score (a short interview to determine cognitive status) of 11, indicating mild cognitive impairment. Further review showed that Resident #5 was totally dependent on staff for showering or bathing self and lower body dressing. She also required total assistance for toilet transfers and going from sitting to standing. Resident #5 used a wheelchair at the facility. Record review of Resident #5's Initial Care Plan completed on 9/16/2024 at 3:56pm revealed the following areas were triggered: -cognition: at risk for impaired cognitive function/dementia or impaired thought processes r/t -ADLs: ADL Self Care Performance Deficit r/t, will maintain current level of function in bed mobility, transfers .toilet use and personal hygiene -Infection: has infections and maintain standard precautions when providing resident care Record review of Resident #5's care plan dated 10/07/2024 revealed a focus area of: -Resident #5 has actual impairment to skin integrity and will be free of injury through the review date, with interventions including: encouraging good nutrition and hydration in order to promote healthier skin, monitor/document location of skin injury, report abnormalities, failure to heal, s/sx of infection, and use Enhanced Barrier Precautions. In an interview with LVN G on 11/21/2024 at 9:43am, who was the MDS Nurse, she said that an RN would initiate the baseline care plan for new admitting residents and the MDS Nurses would then approve the plan. In an interview with the DON on 11/21/2024 at 10:25am, she said that nursing staff were usually doing conference meetings with residents to go over their baseline care plans and go over what the residents want and have a plan with them. The DON said there was not much risk to residents not having a baseline care plan within 48 hours since nurses know what residents need related to care and aides know about what diets and orders they have. The DON said that she could see how preferences could be important when having a care plan within a specific timeframe as it related to resident care. The DON said she was shocked that Resident #5's baseline care plan wasn't completed within the allotted timeframe since nursing management go over resident plans every morning. In an interview with CNA N on 11/21/2024 at 1:19pm, she stated that the nurses would tell her how to care for a resident and other important things to keep in mind based on their care plan. She said in addition to the care plan, the DON will communicate to CNAs what a resident wants. Record review of the Resident Assessments policy last reviewed January 2022, it stated that residents will be assessed, and findings documented in their clinical record and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop comprehensive care plan within seven days after completion of the comprehensive assessment, for one (Resident #52) of 18 residents reviewed for comprehensive care plans as evident by: The facility failed to ensure that Resident #52's care plan was updated to address her blood pressure medications. This failure could place residents on high blood pressure medication at risk for not getting the therapeutic value of their mediations. Findings Included: Record review of Resident #52's face sheet dated 11/20/2024 revealed she was a 67- year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's diseases , COPD (difficulty breathing) , hypertension (high blood pressure), hypotension (low blood pressure), anxiety disorder (worry or fear), hyperlipidemia (high levels of fat in the blood), protein calorie malnutrition (inadequate amount of protein and calories to meet nutritional needs), gastro esophageal reflux disease (heart burn), Emphysema (enlargement of air spaces in the lungs), and Type 11 diabetes (high blood sugar). Record review of Resident #52's Quarterly MDS dated [DATE] revealed she had a BIMS score of 10 which meant minimum cognitive impairment. Record review of Resident #52's quarterly MDS revealed the resident needed minimum assistance with ADLs and was incontinent of bowel and bladder. Record review of Resident #52's physician consolidated orders dated November 2024 revealed an order for Midodrine 10mg by mouth two times a day. Hold if SBP was greater than 130 and DBP greater than 90. Amlodipine 5 mg by mouth one time a day. Hold if SBP was less than 110 and DBP was less than 60. Record review of Resident #52's care plan initiated 5/30/2024 and last updated/revised 10/26/2024 revealed no documentation that the resident was care planned for Midodrine for hypotension and Amlodipine for hypertension. Observation on 11/19/2024 at 1:30 pm revealed Resident #52 was in bed; she was clean and groomed with no offensive odor. She was alert and oriented with some confusion but could make her needs known. In an interview with Resident #44 on 11/19/2024 at 1:30pm she said she was not abused or neglected. She said her only problem was that she did not get her medication for sleep on time the previous night. In an interview on 11/21/2024 at 3:30pm with MDS Coordinator J she said care plans were updated when there were changes in a resident's condition or medications. She looked at Resident #52's care plan and said the care plan did not address Resident #52's blood pressure medications. She said that she was going to update the care plan to address Resident #52's blood pressure medications . Record review of the Resident Assessments policy last reviewed January 2022, it stated that residents will be assessed, and the findings documented in their clinical record and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 18 residents (Resident #16) reviewed for pharmacy services. ADON A failed to follow physician's orders when Resident #16's blood pressure was above the prescribed parameters for November 2024. This failure could lead to residents being prescribed medications without indication and placed residents who required blood pressure monitoring at risk of not receiving the care and services ordered by the physician which could lead to a decrease in their overall health. Findings included: Record review of Resident #16's face sheet dated 11/19/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included essential hypertension. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #16 had a BIMS score of 15 which indicated cognition was intact. She had a diagnosis of hypertension. Record review of Resident #16's care plan dated 11/20/24 did not show any interventions for hypertension. Record review of physician orders dated November 2024 indicated Resident #16 was prescribed Midodrine HCL oral tablet 10 mg three times daily for hypotension. Hold if SBP greater than 130 or DBP greater than 70. Record review of the MAR dated November 1 -19, 2024 indicated on the following dates and times Resident #16 was administered midodrine 10 mg: 11/01/24 at 6:00 a.m., B/P (blood pressure) was 124/88, 11/03/24 at 6:00 a.m., B/P was 106/74, 11/05/24 at 6:00 p.m., B/P was 140/80, 11/09/24 at 6:00 a.m., B/P was 121/72, 11/18/24 at 6:00 a.m., B/P was 124/83, 11/18/24 at 12:00 p.m., B/P was 139/72. Interview with Resident #16 on 11/19/24 at 9:28 AM, she said she did not sleep well last night because her blood pressure was high. Resident #16 said the medication that was given to her yesterday may have caused her blood pressure to rise. She said the facility was able to regulate her blood pressure and she did not have to go to the hospital. Record review of the nurse's notes for Resident #16 dated November 1 through November 19th, 2024, gave no indication of notifying the physician when blood pressure medication was administered outside of the parameters. Interview with the DON on 11/19/24 at 3:21 pm, she said ADON A administered the medication outside the parameters. ADON A notified the physician but did not document it. The DON stated the physician has seen elevated blood pressure for Resident #16 after she smoked. Interview with ADON A on 11/21/24 at 10:00 am, she had worked at the facility for 3 years. ADON A said she was the nurse on duty on 11/18/24 when she administered the midodrine. She said the physician was in the facility that day and she verbally asked him if she could give Resident #16 her medication because she was outside of the required parameters. ADON A said she did not think to put a note in Resident #16's chart when she had the medication cart. She said the risk could be it could give the next shift an unclear assessment and Resident #16's BP could have elevated even more. ADON A said the expectation was the Med-Aides administer medications and notify the charge nurse to update the records. She said the ADONs check charts to see if there was anything to follow-up on for the residents. Interview with the DON on 11/21/24 at 10:20 am she stated she had worked at the facility since 2/16/23. She said the expectation was when the BP was outside of parameters was to report it to the nurse on duty and the nurse would call the physician. The DON said the risk to the resident was the blood pressure would continue to rise and result in hospitalization or use extra medication to bring the BP down. Record review of the facility's Physician Orders policy last reviewed August 2023, it stated that it is the policy of the facility that drugs shall be administered only upon the order of a person duly licensed and authorized to prescribe such drugs and in accordance with the resident's plan of care. All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. Record review of the Medication Administration policy, not dated, read in part . it is the policy of this facility to accurately prepare, administer, and document oral medications .take vital signs if required, hold drugs if indicated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 6 residents (Resident #75 and Resident #2) reviewed for pharmacy services with 3 errors out of 30 opportunities from 2 of 2 staff (MA C and MA E) and a medication error rate of 10%. 1. The facility failed to ensure MA A administered the correct dosage of Candesartan tab 32 mg 1 po (medicine used to treat hypertension, systolic hypertension, left ventricular hypertrophy and delay progression of diabetic nephropathy) and Claritin-D 24 Hour Oral Tablet Extended Release 24 Hour 10-240 MG (Loratadine &Pseudoephedrine = medicine used to relieves common allergy symptoms such as sneezing, runny nose, itchy, watery eyes and itchy nose or throat, plus sinus congestion and pressure, and nasal congestion all day) per physician orders for Resident #75. 2. MA B failed to administer the following medication for Resident #2' Autologous Serum Eyedrops ( a treatment for dry eyes that are made from a patient's own blood) as ordered by the physician. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: 1. Record review of Resident #75's face sheet dated [DATE] revealed the resident was admitted to the facility on [DATE], diagnoses included: acute kidney failure, essential (primary) hypertension ( high blood pressure), dementia (c changes in thinking, remembering, and reasoning in a way that affects daily life and activities), unspecified severity, without behavioral disturbance, psychotic disturbance ( a group of symptoms that indicate a severe mental disorder that causes a person to lose touch with reality), mood disturbance, and anxiety, osteoarthritis ( is a chronic disease that occurs when the cartilage in joints breaks down, causing bones to rub together, this can lead to pain, stiffness, swelling, and the formation of bony spurs)., depression ( a serious mood disorder mood disorder that can impact how a person feels, thinks, and acts. It can cause a persistent feeling of sadness and loss of interest in activities that were once enjoyable), and malignant neoplasm ( abnormal tissue growth or tumor, that is cancerous and can spread to other parts of the body). Record review of Resident#75's admission date MDS assessment dated [DATE] revealed a BIMS score of 14, which indicated the resident was not cognitively impaired. It also revealed the resident needed total care assist with ADLs with two staff assistance. Observation on [DATE] at 9:47 AM during medication administration with MA C for Resident # 75. MA C was observed preparing and administering Resident # 75's medications by giving Resident #75 Candesartan tab 32 mg 1 tablet and Allergy relief (Loratadine) 10 mg 1 tablet with other medication by mouth. Record review of Resident #75's physician's order summary report revealed the following orders: . order dated [DATE] Candesartan Cilexetil Oral Tablet 32 MG, (Candesartan Cilexetil) Give 1 tablet by mouth one time a day for HTN. Hold for SBP < 110 or Pulse < 60 and was discontinued [DATE]. . New order dated [DATE] Candesartan Cilexetil Oral Tablet 8 MG (Candesartan Cilexetil) Give 1 tablet by mouth one time a day for HTN Hold for SBP < 110 or Pulse < 60. . order dated [DATE], Claritin-D 24 Hour Oral Tablet Extended Release 24 Hour 10-240 MG (Loratadine &Pseudoephedrine) Give 1 tablet by mouth one time a day for Allergy symptoms. Record review of Resident #75's MAR for [DATE] revealed Candesartan Cilexetil Oral Tablet 8 MG (Candesartan Cilexetil) Give 1 tablet by mouth one time a day for HTN Hold for SBP < 110 or Pulse < 60. Record review of Resident #75's MAR for [DATE] revealed Claritin-D 24 Hour Oral Tablet Extended Release 24 Hour 10-240 MG (Loratadine &Pseudoephedrine) Give 1 tablet by mouth one time a day for allergy symptoms. In an interview with MA C on [DATE] at 4:21PM regarding Candesartan (Cilexetil) wrong dose given to Resident #75, she said it was her fault she did not check the dosage and was very sorry and also for not giving Claritin -D24 was always look at the parenthesis of Loratadine and that was why she giving Resident #75's her Loratadine. MA A said she did not think the facility had Clarintin-D24, she would let the DON know. MA C said not giving the right medication and right dosage could result in the resident's medication not working as it was supposed to and she would be more careful checking medication. MA C said she had in-services on medication administration. Observation of MA C's medication cart revealed Candesartan 8mg blister packet intact and Candesartan 32 mg blister rubber band together. 2. Resident #2 was admitted on [DATE] and was readmitted on [DATE] with the diagnoses: vascular dementia ( a condition that affects the brain's ability to think, remember, and behave, caused by poor blood flow to the brain) unspecified severity, other recurrent depressive disorders, hyperlipidemia ( high fat in the blood), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormones), anemia (when your body does not have enough healthy red blood cells or they do not function properly), bilateral blepharitis eyelid ( a common eye condition that causes inflammation of the eyelids, resulting in redness, irritation, and itchiness), keratoconjunctivitis sicca (a condition that causes inflammation of the cornea and conjunctiva due to a lack of tears), not specified as Sjogren's (an autoimmune disorder in which the system that normally fights infection and disease in the body mistakenly attacks its own healthy tissues), bilateral presence of intraocular lens, age-related nuclear cataract, right eye, central corneal ulcer need for assistance with personal care personal history of (healed) traumatic, fracture, overactive bladder, other abnormalities of gait and mobility, memory deficit following cerebral infarction, and dysphasia following cerebral infarction. Record review of Resident# 2''s quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 which indicated moderately impaired cognition. It also revealed the resident needed total care assist with ADLs with two staff's assistance. Record review of Resident #2's physician's order summary report revealed the following order: . order dated [DATE] Autologous Serum Eye drops 50% 1 drop both eyes QID while awake. Family was to provide medication. Record review of Resident #2's MAR for [DATE] revealed Autologous Serum Eye drops 50% 1 drop both eyes QID, while awake. Family was to provide medication. In an interview with MA E on [DATE] at 4:40 PM regarding the Autologous serum eyedrop that was not administered to Resident # 2, MA E stated and it was initialed as given. MA E said she gave it earlier and she had the medication in the refrigerator in the medication room in a cup. The medication room refrigerator was checked with MA E and RN A and there, the medication was found. Interview with Resident #2 on [DATE] at 4:50 PM she said, she did get her 2nd eye drop and she was not getting her 2nd eye drop at all. Telephone interview with the Pharmacist on [DATE] at 5:11 PM, she said Autologou serum eyedrops 50% 1 drop both eyes QID. She said Autologou was picked up on [DATE] and it should be expired after 90 days. She said the medication had no preservation when opened, and it could cause infection. In an interview with the DON on [DATE] at 10:10 AM, regarding why the MA C had the errors,. the DON said it was shocking., She said MA C was OCD (obsessive compulsive disorder) about these things. She said the ADON might need to pull medications after they were d/c, since that should've been the nurses responsibility. She said they had the pharmacist audits monthly and she didn't know why it didn't get caught. The DON was asked at the point what system the facility had in place for changing dose/gave wrong dose or d/c doses? The DON said d/c doses or changed dose medication should be put in medication room. She said they had pharmacy audits and didn't know why it didn't get caught during the audit. DON said for Claritin error, she thought they didn't have it but it was on the MAR and the facility had Claritin in the building. She said MA C did check the medication room for Claritin and eye drop for Resident#2. The DON said, the ADON went and checked the medication room and saw the packet for eye drops and saw the highlighted part with start date of [DATE] and a white thing/sticker that says discard after this date and it seemed to be conflicting dates. And the resident's family goes to Dallas for the resident's doctor's appointment so that shouldn't have happened since the family was crazy about the resident's medications. The DON said Resident #2 was alert and knows when she doesn't get her medications so it's was shocking that she wasn't getting it. Resident #2's daughter has camera in her room and see if the eye drops was given, and I tried calling the daughter to check the camera but she didn't pick up so she left a voicemail and will try again. The DON said her expectation was for the MA to have the MARs on the cart and check every medication, and make sure the staffs were giving the right medication of Claritin for example and doing more training. The DON said, they have been doing training. Med aides get yearly check off, but they need to implement some more check off throughout the year. She said they also have spot checks, but we will need to do more checks. Record review of the facility's policy titled Physician orders dated Revised 05/2021: Policy: It is the policy of this facility that drugs shall be administered only upon the order of a person duly licensed and authorized to prescribed such drugs. -It is the policy of this facility to accurately implement orders in addition to medication orders ( treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care: Procedures .6. Medication, treatment, or related procedure orders are transcribed in the medical record accordingly. 7. Orders for medications must include: Name and strength of the drug; Quantity or specific duration of therapy; Dosage and frequency of administration; Route of administration if other than oral;, and Reason or problem for which given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility must ensure residents were free of any significant medication errors for two (Residents #44, and #52) of eighteen residents reviewed for medications. - The facility failed to follow physician's orders by administering blood pressure medications when Resident #44 and Resident #52's blood pressure were out of the prescribed parameter that it should be held. These failures could place residents at risk of not getting the therapeutic outcomes of their blood pressure medications, that could caused, increased negative side effects, and decline in health status. Findings Included Resident #44 Record review of Resident #44's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included lack of coordination (impaired balance), muscle weakness (decreased strength in the muscle), dementia (memory loss), seizures (uncontrolled jerking), depression (mental illness), psychotic disorder (a mental disorder that disconnect from reality), hypertension (high blood pressure), and schizophrenia (disorder that affects a person's ability think, feel, and behave clearly). Record review of Resident #44's Quarterly MDS dated [DATE] revealed she had a BIMS score of 11 which meant minimum cognitive impairment. Further review of Resident #44's quarterly MDS revealed the resident needed minimum assistance with ADLs and was incontinent of bowel and bladder. Observation on 11/20/2024 at 12:45pm revealed Resident #44 in the dining room eating his lunch. Resident was alert and oriented with some confusion. He was self-fed. In an interview with Resident #44 he was not abuse or neglected. He said said he had no issues with his medications. Record review of Resident #44's physician consolidated orders dated November 2024 revealed an order for carvedilol 3.125 mg by mouth two times a day. Hold if SBP was less than 130 and DBP less than 70 and heart rate less than 60. Record review of Resident #44's November MARs revealed that on the following Carvedilol 3.125mg was not held as ordered by the physician. 11/01/2024 in the AM the resident's blood pressure was 128/88. 11/13/2024 in the AM the resident's blood pressure was 113/71. 11/16/2024 in the AM the resident's blood pressure was 117/64. 11/18/2024 in the AM the resident's blood pressure was 122/68. 11/04/2024 in the PM the resident's blood pressure was 125/68. 11/05/2024 in the PM the resident's blood pressure was 120/73. 11/08/2024 in the PM the resident's blood pressure was 127/84. 11/11/2024 in the PM the resident's blood pressure was 121/66. 11/16/2024 in the PM the resident's blood pressure was 121/70 11/18/2024 in the PM the resident's blood pressure was 117/67 In an interview on 11/21/2024 at 12:20pm with Medication Aide C she said that she was not the one who gave Resident #44 his medication on the dates when they were documented as not held. She said if there was no indication on the MARs that the medication was held or it was given then it would be hard to say it was not given or it was given. She said if a medication was given when it was to be held it could cause the blood pressure to drop lower and the resident could pass out. In an interview on 11/21/2024 at 12:25pm with RN A he said when medications were given it should be documented on the MARs. He said if medications have parameters in which they should be held, then they should document on the MARs with a number. He said if blood pressure medications were not held when it was to be held then it could cause the resident's blood pressure to drop lower and the resident could get dizzy and passed out. He said his expectations of Med Aides were to follow the physician's order and inform the nurse when blood pressure was too low. He said if the Med Aide reported low blood pressure to him, he would recheck the blood pressure and based on the result he would inform the physician. Resident #52 Record review of Resident #52's face sheet dated 11/20/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's diseases , COPD (difficulty breathing) , hypertension (high blood pressure), hypotension (low blood pressure), anxiety disorder (worry or fear), hyperlipidemia (high levels of fat in the blood), protein calorie malnutrition (inadequate amount of protein and calories to meet nutritional needs), gastro esophageal reflux disease (heart burn), emphysema (enlargement of air spaces in the lungs), and Type 11 diabetes (high blood sugar). Record review of Resident #52's Quarterly MDS dated [DATE] revealed she had a BIMS score of 10 which meant minimum cognitive impairment. Record review of Resident #52's quarterly MDS revealed the resident needed minimum assistance with ADLs and was incontinent of bowel and bladder. Observation on 11/19/2024 at 1:30 pm revealed Resident #52 was in bed; she was clean and groomed with no offensive odor. She was alert and oriented with some confusion but could make her needs known. In an interview with Resident #52 on 11/19/2024 at 1:30pm she said she was not abuse or neglected. She said she did not have any problems with her medication. Record review of Resident #52's physician orders dated November 2024 revealed order Midodrine 10mg by mouth two times a day. Hold if SBP was greater than 130 and DBP greater than 90 and heart rate less than 60. Record review of Resident #52's November MARs revealed that on the following dated Midodrine 10mg was not held as ordered by the physician. 11/02/2024 in the AM the resident's blood pressure was 133/72. 11/12/2024 in the AM the resident's blood pressure was 140/56. In an interview on 11/21/2024 at 11:48pm with LVN L he said that the medication aides should not give medication when it was supposed to be held. He said that if the medication was held too frequently, the expectation of the medication aides were to let the nurse know and they would call and inform the doctor about the medication to see what he wants to do. In an interview on 11/21/2024 at 12:05pm with Med Aide E she said she usually reported to the nurse when the blood pressure medication was to be held and document it on the MARs. She said she did not know what happened, why she did not indicate on the MAR's that the medication was held. She said that if the blood pressure medication was not held when it was supposed to be held it could cause the blood pressure to get higher and could cause the resident to get dizzy. She said moving forward she will have to focus more when passing her medication and not be distracted. Record review of the facility's Physician Orders policy last reviewed August 2023, it stated that it is the policy of the facility that drugs shall be administered only upon the order of a person duly licensed and authorized to prescribe such drugs and in accordance with the resident's plan of care. All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. Record review of the Medication Administration policy, not dated, read in part . it is the policy of this facility to accurately prepare, administer, and document oral medications .take vital signs if required, hold drugs if indicated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 18 residents (Resident #64) reviewed for medication administration. -The facility failed to ensure that Resident #64's MAR was accurate and complete with no blanks for Levothyroxine (for thyroid dysfunction). This failure could place all resident at risk of not getting medications as ordered by their physicians that could lead to residents not getting the therapeutic effect of their medications. Findings Included: Record review of Resident #64's face sheet dated 11/20/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included acute embolism and thrombosis of right calf (blood clot forming in a blood vessel and break free), skin infection (bacteria, fungus viruses on the skin), hyperparathyroidism (excess of the hormone made by four small gland in the neck), hyperthyroidism (over production of hormone), dysphagia (difficulty swallowing), depressive disorder ((mental disorder) , anxiety (a feeling of worry and fear), psychotic disturbance (mental disorder that causes people to lose touch with reality), and vascular dementia (memory loss). Record review of Resident #64's admission MDS dated [DATE] revealed a BIMs score of 08 indicating resident was moderately impaired for cognition for decision making, for ADL's she was substantial/maximal assistance, and was always incontinent of bowel and occasionally incontinent of bladder. Record review of Resident #64 physician's order dated 10/08/2024 revealed an order for Levothyroxine 25mcg 1 tablet by mouth once a day for thyroid. Record review of Resident #64 MARs for October 2024 and November 2024 revealed there were blanks for 10/31/2024 and 11/18/2024. In an interview on 11/21/2024 at 3:40pm with RN F she stated that there should be no blanks on the MARs. She said when residents were given medications the nurse or medication aide should document ited on the MARs. She said if the resident refused his/her medications it should be documented on the MARs and the reason/reasons why the medication was not given. She looked at the MAR and said thyroid medication, usually would be given by the night staff. She said blanks on the MARs madekes it difficult to determine if the medication was given or not given and the resident could go without their medications or being overdosed if there were blanks on the MARs. In an interview with the DON on 11/21/2024 at 3:50pm she said her expectations ofor nurses and medication aides were to document on the MARs when medications were administered or not administered . Record review of the undated policy and procedure on Medication Administration - Oral read in part . Policy: It is the policy of this facility to accurately, prepare, administer, and document oral medication. Record review of the facility's policy/procedure-Nursing Clinical dated 05/2007 read in part . Section: Documentation Subject: Charting and Documentation. Definition of Records: The resident's clinical record is a concise account of treatment, care, and response to care, signs and symptoms and progress of the resident's condition. It is also necessary to include data needed for identification and communication with family and friends. Complete history of resident and present illness is required under current law and regulations at the time of admission.

**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 1 (Resident #10) of 1 resident observed for wound care. RN A failed to properly wash or sanitize his hands after changing his gloves when providing wound care to Resident #10. This deficient practice placed 18 residents who received wound care at risk for cross contamination and/or spread of infection. Findings included: Record review of Resident #10's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves), muscle weakness, metabolic encephalopathy (a group of neurological disorders that occur when the brain is affected by a chemical imbalance in the blood), need for assistance with personal care, Felty's syndrome (a rare complication of rheumatoid arthritis characterized by an enlarged spleen and low white blood cell count), contracture of the right hand, and contracture of the left hand. Record review of Resident #10's comprehensive care plan, dated 10/2/24, indicated Resident #10 had wounds on right medial buttocks-hydrocolloid and left medial sacrum-hydrocolloid and was receiving treatment for his wounds. Record review of the quarterly MDS dated [DATE] indicated Resident #10 had a BIMS of 15 which indicated cognition was intact. The MDS indicated Resident #10 was at risk of developing pressure ulcers/injuries. Resident #10 required skin treatments that used applications of nonsurgical dressings and applications of ointments/medication. Record review of physician orders dated 11/21/24 indicated Resident #10 had an order for non-pressure wound to left medial sacrum, apply triad paste every day and night shift. Resident #10 also had an order for non-pressure wound to right buttock, apply triad paste every day and night shift. Observation on 11/20/24 at 11:38 am, revealed RN A and ADON A assisted Resident #10 with wound care. Resident #10 was lying in bed on pressure relief mattress on his back. Further observation of wound revealed unstageable wound to right upper buttock and left medial buttock. ADON A said the wound was in-house acquired due to shearing while moving the resident in bed. RN A prepared set-up treatment dressing at Resident #10's bed side table, using 4x4 gauzes he cleaned the left medial buttock twice, then changed gloves without washing hands or using hand sanitizer. RN A put on clean gloves, picked up wet 4x4 gauzes soaked in normal saline and cleaned right upper buttock wound twice, changed gloves without washing hands or using hand sanitizer. RN A donned clean gloves, scoop Triad Hydrophilic wound dressing Hydrophile cream applied to right upper buttock and left medial buttock and then placed a clean brief on resident. Interview with ADON A on 11/20/24 at 11:54 am, regarding Resident #10's wound care, she stated RN A did not use hand sanitizer or wash hands after he changed gloves. Interview with RN A on 11/20/24 at 12:00 pm, he said he was very nervous, and he knew he could spread infection if he did not perform hand washing . Interview with ADON A on 11/21/24 at 10:00 am she said the expectation when nurse's perform wound care was to follow infection control protocols, make sure orders were followed, assess resident for pain and new wounds, and report changes. ADON A said the facility had an in-service on infection control earlier that week. She said the risk to the resident was it could potentially introduce new infections. Interview with DON on 11//21/24 at 10:20 am she said the expectation for staff when they provide care was to wash their hands after changing gloves. She said the facility had many in-services on infection control. She said the risk to the resident was possible infection. Record review of the facility's Infection Control policy dated 7/20/22 read in part . it is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions .standard precautions include gloves are worn when contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment are anticipated, and hand hygiene . Review of the CDC website on 10/22/24: https://www/cdc.gov/clean-hands/hcp/clinical-safety/index.html indicated: Know when to clean your hands- immediately before touching a patient, before moving from work on a soiled body site to a clean body site on the same patient, after touching patient or patient's surroundings, after contact with blood, body fluids, or contaminated surfaces, immediately after glove removal. The facility provided a weekly skin assessment list of residents with wounds dated 11/13/24 and revealed 18 residents received wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen be free from unnecessary drugs without adequate indications for its use for 1 of 18 (Resident #2) reviewed for unnecessary medications. -The facility failed to have a medical diagnosis for Resident #2 before he was prescribed Lantus Subcutaneous Solution 100 Unit/ML from 05/28/2024 to 06/04/2024. This failure could lead to residents being prescribed medications without indication and place residents at risk of unnecessary side effects and a decline in overall health. Findings included: Record review of Resident #2's face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Their medical diagnoses included: dementia, hypertension (high blood pressure), muscle weakness, dysphagia (difficulty swallowing), pain in right hip, syncope and collapse (fainting), and unsteadiness on feet. Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 8, indicating moderate impaired cognition. Further review showed Resident #2 required set up or clean-up assistance for oral hygiene, eating, upper and lower body dressing, and personal hygiene. Resident #4 required supervision with showering or bathing self. Resident #2 was total independent or most transfers except for shower transfers where he required setup or clean-up assistance. Record review of Resident #2's comprehensive care plan revealed Resident #2 was resistive to care r/t Dementia and refused showers, skin assessments and weights. He had a goal of cooperating with care through the next review date and interventions which included educating resident/family/caregivers of the possible outcomes of not complying with treatment of care, encouraging as much participation/interaction by the resident as possible during care activities, and praise when behavior is appropriate. Further review showed no care plan areas related to diabetes or refusing labs. Record review of Resident #2's Medical Diagnoses since admission revealed no diagnosis of Type 2 Diabetes Mellitus. Record review of Resident #2's hospital visit before admission on [DATE] revealed no diagnosis of Type 2 Diabetes Mellitus. Record review of Resident #2's physician notes revealed: -On 5/27/202, MD A saw Resident #2 and wrote, He is seen today for a skilled visit. His blood sugars have been elevated. He is on sliding-scale insulin. We are going to start him on Lantus 7 units daily. We will reassess blood sugars in the next visit. He denies any acute complaints today. -On 06/03/2024, MD A saw Resident #2 and wrote, He is seen for a follow-up of diabetes. We started him on insulin at the last visit. I was notified by nursing that he had refused insulin and blood sugar tracks . He does not believe he has diabetes. I spoke with him today and I informed him based on his recent labs that the patient is diabetic and that we are recommending insulin at this time. -There were no other physician notes mentioning elevated blood sugars or diabetes. Record review of Resident #2's MAR dated May and June 2024 revealed he was ordered Lantus subcutaneous (injection given under the skin) Solution 100 Unit/ML and to inject 7 units subcutaneously one time a day for dm (diabetes mellitus) with an Order start date of 5/28/2024 and a Discontinued date of 06/04/2024. Resident #2 refused insulin seven times from 05/29/2024 to 06/04/2024. Record review of Resident #2's lab history revealed one lab on 09/11/2024 which revealed an A1C level (test used to measure high blood sugar) of 5.4% which was within the normal limits of 3.9 to 5.9. There were no other labs in Resident #2's record. In an interview with LVN G on 11/21/2024 at 9:43am, she was the MDS Nurse, LVN G stated that doctors would give facilities a diagnosis and either the nurse or the MDS nurse would add the diagnosis right away into the system. She said MDS nurses were not the ones entering in medication into the system. LVN G was requested to locate Resident #2's Type 2 Diabetes Mellitus diagnosis but was unable to provide it. In an interview with the DON on 11/21/2024 at 10:25am, she stated that when Resident #2 was prescribed Lantus, the facility was not getting physician notes in a timely manner, so they were unable to catch that the resident was prescribed Lantus without an associated diagnosis. She stated that if they did, they would have caught it. The DON said there was no real risk she could see to the resident getting Lantus without a diagnosis because his nurses would have checked his blood sugars before administering insulin and would have contacted his doctor with any issues or concerns. She also said all of Resident #2's labs would be in the system as the facility had merged paper and electronic copies of labs the previous year. Interview with Resident #2 on 11/21/2024 at 10:57am, he stated that he was educated on diabetes, insulin, and the risks of refusing treatment with MD A and that Resident #2 refused further insulin since he never had and did not have diabetes. Interview with MD A on 11/21/2024 at 11:35am, MD A said that Resident #2's blood sugars were high back then and that they were elevated so MD A started him on insulin. MD A said he educated Resident #2 on diabetes and how having it can affect the heart, kidneys, nerves, and other risks but that the resident was adamant that he didn't have it and said he will live with the consequences. MD A said typically when ordering Lantus and other medications, there had to be a diagnosis, since you can't order any medication without stating a diagnosis. MD A did not know why there was no diagnosis in Resident #2's medical records but that since Resident #2 refused it, the diagnosis would not show up. MD A also said that he didn't know if Resident #2 made dietary changes instead, but his numbers were better now. In an interview with LVN L on 11/21/2024 at 1:46pm, he stated that MD A assessed Resident #2 for diabetes and started the resident on Lantus but Resident #2 claimed he was not diabetic so the facility discontinued the order. LVN L said he cannot give medications without a diagnosis, but unsure why there was no diagnosis in Resident #2's medical records. LVN L said all of Resident #2's labs should be in the resident's records and the facility switched to keeping digital records so there was no paper copy . He said if there is no labs in Resident #2's record, it means the resident did not do them as he had a history of refusing blood draws for labs. Interview with RN A on 1/21/2024 at 1:50pm, he stated that residents should have a diagnosis corresponding to their medications. RN A said insulin should only be used for diabetes. RN A stated he worked a different hall so he did not work with Resident #2. RN A said all labs should be in the resident's medical record and that the facility transferred all paper copies of labs to the digital system so it's all there.

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 in 1 of 1 kitchen reviewed for food procurement in that: -Food items were found in the kitchen's cooler with expired and beyond the use by date. -Food items in the walk-in cooler and freezer were not sealed. -Cleaned baking sheets, pans, utensils, and divided platesd had food particles on them. -Menu item on the steam table was not at the correct holding temperature. -The facility failed to ensure that the floor of the dry storage room was free of paper and other debris. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease. Findings included: Observation of the facility's kitchen and interview on 11/19/2024 between 9:30 am and 10:15 am with the Dietary Manager revealed the following: Divided plates with food particles and drinking glasses with white stains were stored with clean divided plates and drinking glasses. Holding pans and baking sheets with food particles in them were stored with clean pans and baking sheets. Serving utensils with dried food particles on them were stored with clean utensils. In the walk in Cooler were three zip lock bags with deli ham open not sealed. There was a bottle of yellow mustard with best used date 9/27/2024. There was a bottle with tartar sauce with best used date October 2024. There was a plastic container with Tuna Salad dated 11/13 -11/16/2024. In the walk-in freezer were two boxes: 1 box with Salisbury steak and the other with turkey sausage opened and not sealed. The dry storage room had an accumulation of pieces of plastic, papers, dust, and dirt on the floor . In an interview on 11/19/2024 at 9:55am with the Dietary Manager she said that left over food stored in the cooler should be used within three days. She said she did not know why it was not used by the used date of 11/16/2024. Further interview with the Dietary Manager on 11/19/2024 at 10:00 am she said the expectation of the staff was to be checking the pans, plates, and utensils to ensure they were cleaned before they were stored. They should sealed open food packages and discard expired food items. She said she was going to ensure the dry storage was cleaned immediately. She said she did not know what happened, why the pans, plates, utensils, baking sheets, and pans were not checked before they were put away. Observation on 11/20/2024 at 12:27 pm of the steam table for lunch revealed one menu item corn dog was 120 degrees Fahrenheit. This menu item was removed from the steam table and reheated to 165 degrees Fahrenheit. In an interview on 11/21/2024 at 12:55pm with the Dietary Manager she said that foods that were off temperature could lead to food borne illness. She said resident could get sick (vomitting and diarrhea) from eating off temperature foods. She said the menu item corn dog was at the correct temperature when it was placed on the steam table. She said she would have to think of a way to ensure that menu items, like corn dogs, maintain the correct holding temperature throughout service. She said she would be in-servicing staff to ensure utensils, pans, pots, plates, and bowls were clean and had no food particles in them before they were stored. Also, they would be in-serviced that hot/cold foods should always be at the correct holding temperature throughout meal service and the poen food packages should be sealed, labeled and dated. The facility presented the Texas Food Establishment Regulations dated August 2021 as the facility policy. The TFER documented in part . Store TCS food at an internal temperature of 41°F (5°C) or lower or 135°F (57°C) or higher. Store frozen food at temperatures that keep it frozen. Make sure storage units have at least one air temperature measuring device. It must be accurate to +/- 3°F or +/- 1.5°C. The U.S. Public Health Service, Food Code, dated 2013, noted the following regarding marking the date of food when prepared and when the original container was opened: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking 2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section. The Food and Drug Administration Codes October 2015, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated: . (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide all necessary information and any other documentation to ensure a safe and effective discharge for 1 of 3 residents reviewed for discharge. (Resident #74) The facility failed to complete a discharge summary which indicated Resident #74 had transferred to the behavioral facility. This deficient practice could affect the safety of residents discharged from the facility due to improper discharge. Findings Include: Record review of Resident #74's face sheet, dated 09/27/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #74 had diagnoses which included metabolic encephalopathy (chemical imbalance in the blood), schizoaffective disorder (mood disorder) and unspecified dementia (memory impairment). Record review of Resident #74's discharge MDS assessment dated [DATE] indicated Resident #74 did not have a BIMS score. Section A of the MDS indicated discharge assessment-return not anticipated and the type of discharge was planned. Section E of the MDS indicated Resident #74 had physical and verbal behavior symptoms directed toward others and that occurred 1-3 days. Section H of the MDS indicated Resident #74 had an active diagnosis of anxiety, schizophrenia (mood disorder), psychotic disorder (mood disorder) and metabolic encephalopathy (chemical imbalance in the blood). Record review of Resident #74's care plan revised on 07/07/23 indicated psychotropic medications were used for unspecified psychosis. The interventions included to administer medications as ordered and report any side effects to the physician. Record review of Resident #74's order summary report, dated 09/27/23, indicated Resident #74 was taking alprazolam (medication used to treat anxiety and panic disorder) 0.25mg for anxiety as needed, Aricept (medication used to treat Alzheime's disease) 1mg daily for dementia, Ativan (medication used to releive anxiety) 0.5mg daily for agitation, and Seroquel (antipsychotic used to treat schizoprenia, bipolar disorder, and depression) 25mg twice daily for mood disorder. Record review of Resident #74's progress notes, dated 07/09/23, revealed the following: Resident sent out to hospital for mental health evaluation, then returned to the facility to room [ROOM NUMBER]B. Staff had given report to the behavior facility regarding resident's care and estimated time of transfer was for 07/10/23 at 8AM. Record review of Resident #74's progress notes, dated 07/10/23, revealed resident #74 was transferred to the behavioral facility for behaviors. During an interview on 9/27/23 at 9:50 AM, the MDS Coordinator stated Resident #74 was marked on the MDS as having a planned discharge because Resident #74 went to the hospital, returned to the facility, and then transferred to a behavioral facility. The MDS Coordinator stated she did know who was responsible for completing the discharge summary, but planned discharges were reviewed in the IDT meetings. The MDS Coordinator stated Resident #74 required a referral to transfer to a psychiatric facility and therefore it was a planned discharge. During an interview on 9/27/23 at 9:07 AM the DON stated Resident #74 was transferred to a psychiatric hospital and not expected to return to the facility and Resident #74 would have been an unplanned discharge. The DON stated going to a psychiatric hospital could not be planned, even though the facility had to send a referral and the MDS assessment should have indicated a non-planned discharge. The DON stated the floor nurse would have been responsible for completing the discharge summary and then medical records would have been responsible for making sure the physician signed it. The DON stated discharges were reviewed in the IDT meeting. The DON stated the importance of making sure the MDS was correct, was to make sure everything was done correctly and to make sure residents had everything they needed once they were discharge home. During an interview on 9/27/23 at 5:06 PM, the ADM stated he expected Resident #74 to have a discharge summary to ensure proper documentation and continuity of care. Record review of the facility's policy titled, Criteria for Transfer and Discharge, revised 1/2022, indicated, If a transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, the resident's physician shall document the following in the resident's medical record: a) The specific resident need that cannot be met; b) Facility attempts to meet the resident needs; and c0 The service available a the receiving Facility to meet the needs. The policy also indicated, The physician will sign the Discharge Summary of the form for the physician to sign when a person is discharged or transferred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an accurate MDS was completed for 1 of 18 residents reviewed for MDS assessment accuracy. (Resident #55) The facility failed to accurately reflect Resident #55's restraint status on the MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #55's physician summary report indicated an [AGE] year-old male admitted on [DATE] with a diagnosis of dementia (brain disorder), depression (low mood) and acute kidney failure (not able to filter waste from the blood). Record review of Resident #55's quarterly MDS assessment dated [DATE] indicated Resident #55 was usually understood and usually understood others. The MDS indicated Resident #55 had a BIMS score of 7 indicating severely impaired cognition. Section P of the MDS indicated Resident #55 used trunk restraints (a restraint that aimed to to avoid compensatory trunk movement and to facilitate the developement of normal motor patterns in the affected upper limbs) less than daily in the bed. Record review of Resident #55's care plan dated 8/22/22 did not indicate restraints. During an observation and interview on 09/25/23 at 10:43 AM, Resident #55 was lying in bed with grab bars up on the upper part of the bed. Resident #55 stated the grab bars helped him with getting out of the bed and denied having any complaints. During an observation on 09/26/23 at 09:58 AM, Resident #55 was in bed sleeping bed. The bed was in low position and grab bars were up on the bed. During an interview on 09/27/23 at 9:50 AM, the MDS Coordinator stated Resident #55 should not have been marked as having a trunk restraint on the MDS assessment. The MDS Coordinator stated she was responsible for completing the MDS and corporate randomly checks the MDS assessments 3 times a month. The MDS coordinator stated she had received training on the MDS from a sister facility. The MDS Coordinator stated the importance of making sure the MDS assessment was accurate was so it reflected the residents' true care and if it was not correct, then the patient could have lost some of their benefits. During an interview on 9/27/23 at 3:07 PM, the DON stated she expected the MDS assessment to be completed accurately and it should not have been marked as a trunk restraint. The DON stated not completing the MDS assessment accurately could make it look like the facility was restraining Resident #55 and that could look like abuse. During an interview on 09/27/23 at 5:06 PM, the ADM stated he expected the MDS assessments to be completed accurately. The ADM stated the importance of making sure the MDS was accurate was so the facility was reporting it properly and to reflect what was going on with the residents. The ADM stated if the MDS was not accurate, it could also be a billing error During an interview on 9/27/23 at 3:07 AM, the DON stated the facility did not have a policy for MDS assessment and they followed the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 6 (Resident #326) residents reviewed for care plans. The facility failed to ensure staff followed Resident #326's care plan by not administrating her prescribed medication as ordered. This failure could place residents at risk of not receiving necessary medication and services. Findings included: Record review of Resident #326's face sheet, dated 09/27/23 indicated Resident #326 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), Atrial fibrillation (also known as A Fib - is an irregular and often very rapid heart rhythm), and hypertension (high blood pressure). Record review of Resident #326's entry MDS assessment, dated 05/31/23, did not indicate anything about cognition or memory. Resident #326 required total assistance with bathing, extensive assistance with toileting, and dressing, limited assistance with bed mobility, and personal hygiene, and set-up assistance with transfers and eating. The MDS indicated Resident #326 received an antibiotic medication. Record review of Resident #326's comprehensive care plan, dated 05/27/23 indicated Resident #326 had an infection. The intervention of the care plan was to give the antibiotic as ordered by the physician. Record review of Resident #326's physician order dated 05/27/23 indicated: Give Cephalexin Oral Tablet 500 MG (Cephalexin) Give 1 tablet by mouth three times a day for CELLULITIS (swelling in legs) for 6 days. Record review of Resident #326's medication administration (MAR) record dated 05/01/23 through 05/31/23 revealed the following orders: Cephalexin Oral Tablet 500 MG (Cephalexin) Give 1 tablet by mouth three times a day for CELLULITIS. The MAR did not indicate Resident #326 received her antibiotic on 05/27/23 or 05/28/23. She only received 2 doses on 05/29/23. During an interview on 09/27/23 at 10:06 a.m., LVN E said she was Resident #326's nurse on 05/29/23. She said she could not remember anything about her medications not being at the facility or any concerns about her medication. She said she was not aware of what Resident #326's care plan stated. She said they should have administrated Resident #326's medication as ordered. During an interview on 09/27/23 at 4:07 p.m., ADON B said she could not remember any concerns with Resident #326's medication. She said Resident #326 had an order for Cephalexin (antibiotic) and she should have received her medication. She said she was unaware of what Resident #326 care plan stated but could go review if needed. She said if Resident #326 had on her care plan for her antibiotics to be given as ordered then her medication should have been given. She said failure to follow the care plan could lead to missed medication. During an interview on 09/27/23 at 4:34 p.m., the DON said she was not aware of Resident #326 missing her medication. She said if Resident #326's care plan indicated she was to receive her antibiotic, she should have received her antibiotic. The DON said it was important to follow the care plan because it was a part of the resident's plan of care. During an interview on 09/27/23 at 4:50 p.m., the Adm said he expected the nurses to give all prescribed medication. He said the DON/ADONs were responsible for ensuring staff followed care plans. He said if care plans were not being followed then we could potentially not meet the resident's needs. A record review of the facility's Comprehensive Person-Centered Care Planning policy, dated 01/2022, revealed, Policy: It is the policy of this facility that the interdisciplinary team(IDT) shall develop a comprehensive person-centered care plan for each resident .The IDT will develop a baseline care plan for each resident within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meets professional standards of quality care. A record review of the facility's Physician Orders policy, dated 05/2007, revealed, Policy: It is the policy of this facility that drugs and treatment shall be administered or carried out upon the order of a person duly licensed and authorize to prescribe such drugs and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 of 2 (Resident #57) residents reviewed for intravenous fluids. The facility failed to ensure Resident #57 received PICC (a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) line dressing changes as ordered. This failure could affect residents by placing them at risk for infection. Findings included: Record review of Resident #57's face sheet, dated 09/27/23 indicated Resident #57 was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Pneumonia (an infection that affects one or both lungs), Methicillin-resistant Staphylococcus aureus (MRSA-a cause of staph infection that is difficult to treat because of resistance to some antibiotics), Chronic obstructive pulmonary disease (COPD- an inflammatory lung disease that gets worse over time), Diabetes mellitus (DM-a disease of inadequate control of blood levels of glucose), and hypertension (high blood pressure). Record review of Resident #57's admission MDS assessment, dated 08/20/23, indicated Resident #57 was understood and understood others. Resident #57's BIMS score was 15, which indicated she was cognitively intact. Resident #57 required supervision with toileting, personal hygiene, transfers, dressing, bed mobility, bathing, and eating. The MDS indicated Resident #57 received intravenous (IV) medications. Record review of Resident #57's comprehensive care plan, dated 08/24/23 indicated Resident #57 required IV medication related to infection. The interventions of the care plan were for staff to provide IV medications as ordered, check dressing at the site daily, monitor/document/report to the physician as needed for any signs or symptoms of infection and manage all IV equipment with aseptic technique. Record review of Resident #57's physician orders dated 9/13/23 indicated: Peripheral intravenous care, change IV dressing every 7 days on Sunday night shift and as needed if wet, soiled, saturated, or loose. During an observation and interview on 09/25/23 at 5:15 p.m., Resident #57 was sitting at the dining room table. Resident #57's PICC line dressing had a date of 09/07/23, no identified initials of a nurse who last changed the dressing, and was partially peeled away from her arm on all four sides. Resident #57 said she could not remember when her dressing was changed but said it needed to be changed because it was coming loose. During an interview on 09/27/23 at 9:59 a.m., Resident #57 said LVN K changed her PICC line dressing the previous night (09/26/23) because it had not been changed according to the date since 09/07/23. LVN E was in the room and heard Resident #57 say her last PICC line dressing was dated 09/07/23. LVN E said PICC line dressings should be changed every 7 days or every 3 days if they do not have a Bio patch (a protective Disk with CHG protects the insertion site and releases CHG, a powerful skin antiseptic over a 7-day period). She said the risk of not changing the PICC line dressing as ordered could lead to infection or complications. During an attempted phone interview on 09/27/23 at 2:59 p.m., LVN K did not answer the phone. During an interview on 09/27/23 at 04:07 p.m., ADON B said nurses should follow the order for PICC line dressing changes. She said she was not sure what their policy said but expected nurses to change a PICC line dressing every 7 days and as needed. She said it was important to look at the site daily to ensure no infection or issues with the lines. ADON B said administration nurses were to ensure nurses were changing PICC line dressing as ordered. She said if the PICC line dressing were not changed it could lead to complications or infection. During an interview on 09/27/23 at 4:07 p.m., the DON said Resident #57 told her that the date on her PICC line dressing was dated 09/07/23. She said PICC line dressing changes were supposed to be changed every 7 days and as needed if soiled or dislodged. She said she was responsible for ensuring all nurses were competent in IVs and dressing changes. She said she had not asked nurses prior to 09/27/23 if they had IV training. She said going forward, she would ensure all nurses had IV training prior to working with residents who required IV services. She said if nurses were not changing dressing as ordered it could cause complications and lead to infections. During an interview on 09/27/23 at 4:38 p.m., the Adm said he expected nurses to have the training they needed for any IVs. He said the DON/ADON was responsible for ensuring nurses were certified in IV therapy. The Adm said without proper training a nurse could cause infection or a negative outcome. A record review of the facility's policy IV Medication Administration, dated 05/2007 indicated, It is the policy of this facility to provide venous access for the administration of fluids and or medication. It is the policy of this facility that IV drugs shall be administered by a registered nurse or IV-certified licensed nurse. All solutions must be labeled in accordance with established procedures governing all labeled IV solutions. All dressings should be labeled with the date, time, and nurse's initial. Central vascular access dressing: the transparent dressing is a preferred type for ease of observation this should be changed twice a week unless it becomes solid or nonadherent to the skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for residents' needs for 1 of 2 licensed staff (LVN D) reviewed. The facility failed to ensure LVN D, was competent in providing care for the peripherally inserted central catheter (PICC - a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy) for Resident #57. This failure could potentially affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills and competencies to provide safe care and minimize infections. Findings included: Record review of Resident #57's face sheet, dated 09/27/23 indicated Resident #57 was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Pneumonia (an infection that affects one or both lungs), Methicillin-resistant Staphylococcus aureus (MRSA-a cause of staph infection that is difficult to treat because of resistance to some antibiotics), Chronic obstructive pulmonary disease (COPD- an inflammatory lung disease that gets worse over time), Diabetes mellitus (DM-a disease of inadequate control of blood levels of glucose), and hypertension (high blood pressure). Record review of Resident #57's admission MDS assessment, dated 08/20/23, indicated Resident #57 was understood and understood others. Resident #57's BIMs score was 15, which indicated she was cognitively intact. Resident #57 required supervision with toileting, personal hygiene, transfers, dressing, bed mobility, bathing, and eating. The MDS indicated Resident #57 received intravenous (IV) medications. Record review of Resident #57's comprehensive care plan, dated 08/24/23 indicated Resident #57 required IV medication related to infection. The interventions of the care plan were for staff to provide IV medications as ordered, check dressing at the site daily, monitor/document/report to the physician as needed for any signs or symptoms of infection, and manage all IV equipment with aseptic technique Record review of Resident #57's physician orders dated 9/13/23 indicated: Peripheral intravenous care, change IV dressing every 7 days on Sunday night shift and as needed if wet, soiled, saturated, or loose. During an observation on 09/26/23 at 3:31 p.m., LVN D had hung Resident #57's IV Vancomycin antibiotic and was flushing her PICC line. LVN D said she could not remember if she had IV training but knew she had not received IV training since employed by this facility and does not remember anyone asking her about her IV certification. During an interview on 09/27/23 at 4:38 p.m., the DON said they had IV training at the facility back in June 2023 and LVN D was not employed during that time. She said she had not asked LVN D or any new hires prior to 09/27/23 if they had IV training. The DON said she was aware LVNs needed to be trained on IVs and going forward would ensure all nurses had IV training prior to working with residents who required IV service. She said they did competencies on hire, yearly, and as needed. The DON said it was important for LVNs to have the proper training on IVs to prevent infection. During an interview on 09/27/23 at 4:38 p.m., the Adm said he expected nurses to have the training they needed to give IV meds. He said he was aware LVNs had to be certified to administer medication or work with residents who required IV services. He said the DON/ADON was responsible for ensuring nurses were certified in IV therapy. The Adm said without proper training someone could mess up the IV medication or dressing changes and cause infection or negative outcomes. Record review of competencies skills revealed LVN D had been checked off on different types of skills on 08/04/23 but no IV competency or IV certification was in her file. Record review of a Competency of Nursing Staff policy dated 01/22 indicated, It is the policy of this facility to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to ensure residents safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessment and individual plans of care. #1 Within 30 days of the date of hire the nursing staff member shall complete the orientation competency assessment for the appropriate job category to meet the needs of the facility resident population in accordance with the facility assessment. #5 Each nursing staff member shall complete an annual competency assessment and additional competency assessment as needed based on the resident population's needs in accordance with the facility assessment. #8 Records of each staff development program shall be maintained. Record review of www.bon.texas.gov/practice_bon_position_statements_content.asp: It is the opinion of the Board that the LVN shall not engage in IV therapy related to either peripheral or central venous catheters, including venipuncture, administration of IV fluids, and/or administration of IV push medications, until successful completion of a validation course that instructs the LVN in the knowledge and skills applicable to the LVN's IV therapy practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent infections for 1 of 2 residents reviewed (Resident #51) for infection control practices. The facility failed to ensure CNA F and CNA G changed their gloves or performed hand hygiene appropriately while providing incontinent care for Resident #51. This failure could place any resident at the facility at risk for infection due to improper care practices. Findings included: Record review of Resident #51's face sheet, dated 09/05/23 indicated Resident #51 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic obstructive pulmonary disease (COPD- an inflammatory lung disease that gets worse over time), Diabetes mellitus (DM-a disease of inadequate control of blood levels of glucose), and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning). Record review of Resident #51's quarterly MDS assessment, dated 08/08/23, indicated Resident #51 was understood and understood others. Resident #51's BIMs score was 08, which indicated she was moderately cognitively impaired. Resident #51 required total assistance with bathing; extensive assistance with toileting, personal hygiene, transfers, dressing, bed mobility; and set-up assistance with eating. The MDS indicated Resident #51 was incontinent of bowel and bladder. Record review of Resident #51's comprehensive care plan, dated 06/03/23 indicated Resident #51 had an ADL self-care performance deficit related to muscle weakness, unsteady gait, COPD/asthma, and oxygen dependence. Resident #51 had the potential for bowel/bladder incontinence related to confusion, a history of urinary tract infection, and impaired mobility. The interventions of the care plan were for staff to provide dignity by ensuring privacy, check as required for incontinence, wash, rinse, and dry perineum, and monitor for any signs/symptoms of urinary tract infection. During an observation on 09/25/23 at 10:25 a.m., CNA F and CNA G were providing incontinent care for Resident #51 who had an incontinent episode. CNA F wiped Resident #51 using up and down and down and up strokes while cleaning the vaginal area and then changed gloves without sanitizing her hands. CNA G was observed to wipe the buttock down the center only and no other part of Resident #51's buttock which contained urine. CNA G applied barrier cream and applied a brief without changing her gloves or hand hygiene. During an interview on 09/25/23 at 10:49 a.m., CNA G said she did not realize she did not change her gloves or perform hand hygiene while performing incontinent care for Resident #51. CNA G said she knew she should have performed hand hygiene between clean and dirty sources to prevent infections. CNA G said she had been checked off by the ADON/DON for incontinent care and hand washing. During an interview on 09/25/23 at 3:49 p.m., CNA F said she did not realize she wiped front to back and then back to front while cleaning Resident #51's vaginal area. She said she should never wipe upward because she was pushing bacteria into Resident #51's vagina which could cause bacteria to grow. CNA F said she did not perform hand hygiene in between each glove change. She said it was important to perform hand hygiene to prevent cross-contamination. She said she was checked off for incontinent care and handwashing by the teacher who taught the CNA program at the facility. During an interview on 09/27/23 at 4:07 p.m., ADON B said she expected staff to perform incontinence care the proper way. She said she expected staff to perform hand hygiene anytime they went from dirty to clean. ADON B said all administration nurses were responsible for ensuring residents were cleaned properly to prevent infection and skin issues. She said they did competencies upon hire, yearly, and as needed. During an interview on 09/27/23 at 4:34 p.m., the DON said she expected staff to change their gloves between clean and dirty and to use hand hygiene between glove changes. She said she was the overseer of CNAs. She said they did competencies upon hire, yearly, and as needed. The DON said failure to do appropriate incontinence care could cause skin issues and lead to infections. During an interview on 09/27/23 at 4:50 p.m., the Adm said he expected all staff to use proper hand hygiene techniques between dirty and clean areas with all care. The Adm said the DON/ADON was responsible for ensuring staff were trained on infection control. He said improper hygiene could place the resident at risk for skin issues and UTI infections. Record review of competencies skills revealed CNA F had been checked off on hand washing and peri-care on 03/29/23. Record review of competencies skills revealed CNA G had been checked off on hand washing and peri-care on 03/29/23. Record review of the facility policy titled, Hand Hygiene, dated 05/07 indicated, It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff. Hand washing is considered the most single procedure for preventing nosocomial infection. Although antiseptics and other hand-washing agents do not sterilize the skin, they can reduce microbial contamination depending on the type and the amount of contamination, the agent used, the presence of residual activity, and the hand-washing technique followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Residents #326) reviewed for medications. The facility failed to administer medications as prescribed for Resident #326. This failure could place residents at risk of not receiving the therapeutic effects of their medications including a diminished health status. The findings included: Record review of Resident #326's face sheet, dated 09/27/23 indicated Resident #326 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), Atrial fibrillation (A Fib - is an irregular and often very rapid heart rhythm), and hypertension (high blood pressure). Record review of Resident #326's entry MDS assessment, dated 05/31/23, did not indicate anything about cognition or memory. Resident #326 required total assistance with bathing, extensive assistance with toileting, and dressing, limited assistance with bed mobility, and personal hygiene, and set-up assistance with transfer and eating. Record review of Resident #326's comprehensive care plan, dated 05/27/23 indicated Resident #326 had an infection. The intervention of the care plan was to give the antibiotic as ordered by the physician. Record review of Resident #326's medication administration record (MAR) dated 05/01/23 through 05/31/23 revealed the following orders: Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet by mouth one time a day for ANALGESICS. The MAR did not indicate Resident #326 received this medication on 05/28/23 or 05/29/23. Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth at bedtime for CHOLESTEROL. The MAR did not indicate Resident #326 received this medication on 05/27/23 or 05/28/23. Cephalexin Oral Tablet 500 MG (Cephalexin) Give 1 tablet by mouth four times a day for CELLULITIS (swelling of the legs) for 6 days. The MAR did not indicate Resident #326 received her antibiotic on 05/27/23 or 05/28/23. She only received 2 doses on 05/29/23. Furosemide Tablet 20 MG Give 1 tablet by mouth one time a day for CHF (heart failure). The MAR did not indicate Resident #326 received this medication on 05/28/23 or 05/29/23. Lantus Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 30 units subcutaneously one time a day for DM (diabetic). The MAR did not indicate Resident #326 received this medication on 05/28/23 or 05/29/23. On 05/30/23 blood sugar reading was 250. Lisinopril Oral Tablet 2.5 MG (Lisinopril) Give 1 tablet by mouth one time a day for HTN (high blood pressure). The MAR did not indicate Resident #326 received this medication on 05/28/23 or 05/29/23. Myrbetriq Oral Tablet Extended Release 24 Hour 25 MG (Mirabegron) Give 1 tablet by mouth one time a day for BLADDER SPASM. The MAR did not indicate Resident #326 received this medication on 05/28/23 or 05/29/23. Plavix Oral Tablet 75 MG (Clopidogrel Bisulfate) 1 tablet by mouth one time a day for anticoagulant. The MAR did not indicate Resident #326 received this medication on 05/28/23 or 05/29/23. Potassium Chloride ER Tablet Extended Release 10 MEQ Give 1 tablet by mouth one time a day for a supplement. The MAR did not indicate Resident #326 received this medication on 05/28/23 or 05/29/23. Seroquel Oral Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth two times a day for antipsychotics. The MAR did not indicate Resident #326 received this medication on 05/27/23, 05/28/23, or a 9 a.m. dose on 05/29/23. Trazodone HCI Oral Tablet 50 MG (Trazodone HCI) Give 1 tablet by mouth at bedtime for Insomnia. The MAR did not indicate Resident #326 received this medication on 05/27/23 or 05/28/23. During an interview on 09/27/23 at 9:53 a.m., the MA H said she remembered Resident #326 and something about her leg but could not remember anything about her medications. She said she worked Monday through Friday. She looked at the MAR and said she was not at the facility over the weekend of 05/27/23 and 05/28/23 but verified no initials for 05/27/23, 05/28/23, and some medication initials on 05/29/23. She said she gave all the medication on Tuesday 05/30/23. During an interview on 09/27/23 at 10:06 a.m., LVN E said she was Resident #326's nurse on 05/29/23. She said she could not remember anything about her medications not being at the facility or any concerns about her medication. She said the medication aides usually gave residents their medications. She looked at the MAR and verified Resident #326 did not receive her insulin on 05/29/23. She said if she did not give the insulin, it had to be a reason but she could not remember why since it was back in May 2023. LVN E looked at Resident #326's nurse notes and she did not see any indications as to why her medications or insulin was not given. During a phone interview on 09/27/23 at 2:15 p.m., admitting RN N said he could not recall Resident #326 because he was an agency nurse and he went to several facilities. He said the medication aides gave the medications and the nurses gave the insulin. He said he did not recall the medication aide letting him know anything about Resident #326's medication not being at the facility. He said the insulin was not scheduled on his shift. He said if a resident had an order for medications, then the medications should have been given. During an attempted phone interview on 09/27/23 at 3:40 p.m., attempted to reach LVN L the medication aide who worked on 05/27/23 and 05/28/23 with no answer. During an interview on 09/27/23 at 4:07 p.m., ADON B said she could not remember any concerns with Resident #326's medications. She said the hospice company was good about writing orders when a resident was admitted to the facility and providing medications. She said she was not sure why Resident #326 did not receive her medication. ADON B said she expected medication to be given as ordered. She said the resident could have adverse effects if medication orders were not followed correctly. During an interview on 09/27/23 at 4:34 p.m., the DON said Resident #326 was admitted on Saturday 05/27/23 and left on Wednesday 06/01/23. She said she did not remember any issues with Resident #326's medication. She said hospice usually provided hospice residents with their medication. She said if Resident #326 did not have her medications on admission, they should have reached out to hospice or pulled her medication out of the emergency kit located in the facility. She said either way, Resident #326 should not have missed her medications. The DON looked at Resident #326's MAR and verified she did not receive any of her prescribed medication on her first 2 days of stay at the facility. The DON said they usually run a medication report daily and review it during the standup meeting daily to ensure residents' medications were given. She said she did not know how they missed Resident #326's missing her medication. The DON said if residents missed medication, it could cause adverse effects on their health. During an interview on 09/27/23 at 4:50 p.m., the Adm said he expected the nurses to give all medication prescribed. He said the DON/ADONs were responsible for ensuring residents received their medication as ordered. He said if a resident does not receive their medication, they could potentially have a negative outcome. A record review of the facility's Physician Orders policy, dated 05/2007, revealed, Policy: It is the policy of this facility that drugs and treatment shall be administered or carried out upon the order of a person duly licensed and authorize to prescribe such drugs and treatment. A record review of the facility's Medication Administration policy, dated 05/2007, revealed, Policy Statement: It is the policy of this facility to accurately prepare, administer and document oral medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 4 residents (Residents #21, #25, and #42) reviewed for hospice services. The facility did not ensure Residents #21, #25, and #42's hospice records were a part of their records in the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings included: 1.Record review of Resident #21's face sheet, dated 09/26/23, indicated she was a [AGE] year-old female that was admitted to the facility on [DATE] with a diagnosis of (COPD) Chronic obstructive Pulmonary Disease (lung disease that causes difficulty with breathing), Type 2 Diabetes (blood sugar disorder) and End Stage Renal Disease (gradual loss of kidney function). Record review of Resident #21's MDS assessment dated [DATE] indicated Resident #21 was usually understood and usually understood others. The MDS did not indicate a BIMS (Brief Interview for Mental Status) score. Special Treatments, Procedures, and Programs of the MDS did not indicate Resident #21 was on hospice care. Record review of Resident #21's care plan revised on 04/22/23 indicated she had a terminal prognosis related to Parkinson's and was on hospice care. The interventions included physician consult and social services for the resident while in the facility. Record review of Resident #21's order summary report dated 9/26/23 indicated no lab draws due to hospice status started on 02/06/23 and to notify hospice of any changes in condition dated 06/05/23. Resident #21's order summary revealed she was admitted to hospice on 3/21/23. Record review of Resident #21's hospice binder, accessed on 09/26/23, revealed no updated nursing visit since 05/09/23 and no updated plan of care since 5/15/23-07/13/23. 2. Record review of Resident #25's face sheet, dated 09/27/23 indicated Resident #25 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Osteomyelitis (a serious infection of the bone that can be either acute or chronic), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), and anxiety (feelings of nervousness, panic, and fear). Record review of Resident #25's quarterly MDS assessment, dated 06/15/23, indicated Resident #25 was usually understood and usually understood others. Resident #25 required total assistance with bathing, toileting, personal hygiene, and eating; extensive assistance with transfers, dressing, and bed mobility. The MDS indicated Resident #25 received hospice service. Record review of Resident #25's comprehensive care plan, dated 06/07/23 indicated Resident #25 had a terminal prognosis related to senile degeneration of the brain and was on hospice. The interventions of the care plan were for staff to encourage the resident to express her feelings, encourage support of family, and work with the hospice team to ensure the resident's needs were met. Record review of Resident #25's physician's order dated 06/02/23 indicated: Admit to hospice, diagnosis: Senile Degeneration of the Brain. Record review of Resident #25's hospice binder, accessed on 09/26/23, revealed no updated plan of care since 08/30/23. 3.Record review of Resident #42's undated face sheet indicated he was a male that admitted to the facility 6/29/22. Record review of the physician's orders dated 9/26/23 indicated Resident #42 had diagnoses that included: Dementia (loss of intellectual functioning, impairment of memory), paraplegia (paralysis of legs and lower body), major depression, severe with psychotic symptoms (persistent sadness and lack of pleasure, with a loss of reality). Record review of the quarterly MDS dated [DATE] indicated Resident #42 had no speech, was rarely or never understood by others, and sometimes understood others. Section C of the MDS indicated Resident #42 was unable to complete the BIMS interview, indicating severe cognitive deficits. Section O of the MDS indicated hospice care. Record Review on 9/26/23 of Resident #42's hospice binder did not contain an updated POR or nurse communications (visits). Record review of a physician's order dated 6/29/22 for Resident #42 indicated: Admit to [Name] Hospice, diagnosis: Senile Degeneration of the Brain. During an interview on 09/26/23 at 03:10 PM, Resident #21's hospice nurse stated the hospice liaison was responsible for making sure the hospice binder had current nursing notes and plan of care every 2 weeks. The hospice nurse stated the importance of updating the hospice binder was to make sure the facility had back up information and that the hospice staff member had spoken to the facility staff every visit to discuss the resident. During an interview on 09/26/23 at 2:50 PM, the DON stated she did not find any current nursing notes or plan of care in Resident #21's hospice binder. The DON stated the hospice nurse should have made sure the hospice binder was up to date and the facility's social worker was responsible for making sure the binder was up to date. The DON stated the importance of making sure the binder was current was to make sure the patient was taken care of, and things were not missed. During an interview on 09/26/23 at 8:26 AM, the SW stated she had just started working at the facility the previous week and admissions was responsible for making sure the binders were up to date prior to her starting. The SW stated she had not checked the binders to make sure they were current, and she had not received training at this time from a sister facility. The SW stated the importance of making sure the hospice binder was current was so they could verify patients were getting seen by the hospice company. During a record review and interview on 9/26/23 at 3:10 PM, LVN A said she did not see any communications or visit notes in Resident #42's hospice binder. She said she did not see an updated POC in his hospice binder and the most updated POC in his binder was dated 6/9/23 - 8/7/23. She said there were no nurses notes in Resident #42's binder from the RN Case Manager for his hospice company. LVN A said that was the only hospice binder she was aware of, and if they had communications/nurse visits or an updated POC, they would be in the binder, and they were not. During an interview on 9/26/23 at 3:20 PM, the DON said she could not find any hospice communications in Resident #42's hospice binder. She said when the hospice nurses came to see Resident #42, they did not leave documentation, but would communicate verbally with the staff nurses which was not documented in the hospice binder or facility notes. During an interview on 9/27/23 at 8:11 AM, the DON said the Hospice POC for Resident #42, in his hospice binder, was dated 6/9/23 - 8/7/23. She said there were no nurse's notes in the hospice binder. She said hospice communications were important for continuity of care for the resident. She said the SW was responsible for making sure the hospice updated the POC's and put the nurse's notes in the hospice binder. She said she did not oversee that the SW completed this, but the administrator did. During an interview on 09/27/23 at 8:16 AM, the DON said the prior admission person was supposed to keep the hospice books updated but had recently changed to the social worker being responsible. She verified the last plan of care for Resident #25 was 08/30/23. During a phone interview on 09/27/23 at 8:26 AM, the hospice nurse said they had a plan of care meeting every 2 weeks. She said she was responsible for ensuring Resident #25's facility's book was updated. She said she had Resident #25's most recent plan of care in her car, but did not realize the plan of care ended on 08/30/23. She said it was important to update the plan of care for continued care. During an interview on 9/27/23 at 8:35 AM, the Admissions Coordinator said she had worked at the facility for 8 days. She said she was not responsible and had not been told by anyone she was responsible for hospice POC's or hospice communications for residents. She said she did not know what the prior Admissions Coordinator's responsibilities were. During an interview on 9/27/23 at 10:15 AM, the CNA Coordinator who answered the phone for [Name] Hospice said the RN Case Manager for Hospice was responsible for making sure the nursing notes and updated POC's were in the hospice binder in the facility. During an interview on 9/27/23 at 10:23 AM, the RN Case Manager for Resident #42 for Hospice said she had not printed out the new Plan of Care (POC) for Resident #42 and did not realize the old one dated 6/9/23-8/7/23 was the newest one in the facility. She said it was her fault it had not been updated in the facility binder. She said having the updated POC in the facility was important because things changed quickly with hospice residents and all staff needed to know about any changes. She said in the absence of an updated POC in the facility, they would not know what to adhere to. The Hospice RN Case Manager said continuity of care was very important for the care of the resident. She said she did her nurse's notes every time she came to the facility, but they were electronic notes and only in their (hospice) computer system. She said she gave a verbal report every time she came in the facility to Resident #42's nurse so that they knew about anything new or any changes. During a phone interview on 09/27/23 at 10:31 AM, the prior admission person said she was not responsible for keeping the hospice charts together. She said she thought the ADON kept up with hospice charts. She said she did help correlate care with hospice and family but never the facility hospice charts. During an interview on 9/27/23 at 12:38 PM, LVN D said written communication from hospice to the facility was important for continuity of care so the facility would know what was going on and to be aware of any changes. She said a verbal report would not be sufficient because it would not be communicated to all nursing staff. During an interview on 9/27/23 at 12:44 PM, ADON B and ADON C both said written communications were very important for the hospice nurse for a hospice resident because that was how they communicated orders or concerns to the facility. ADON B said the absence of written communication could cause missed communication on different levels of care regarding medications, treatment, or ADL care. ADON C said if a hospice nurse gave only a verbal report, things could be misinterpreted, and new information would not get to all staff. During an interview on 9/27/23 1:05 PM, the DON said written communications from hospice were also important to let them know the hospice nurses and their CNAs were going to the facility to see their residents. During an interview on 9/27/23 at 1:24 PM, the ADM said hospice should have kept their books updated for Resident #42 and Resident #21. He said it was important to have nurses notes and a current POC so that the staff knew what was going on with that resident. The ADM said not having those things could cause a slew of potential problems. The ADM said because one would not know if anything was new with hospice, the facility could provide services that were harmful without realizing it. He said the SW was responsible for making sure the hospice binders were up to date, but she just got that assignment. He said he doubted she had time to check or do them yet. He said before the SW, it was the Marketer's responsibility, but she walked out 9/18/23. He said he thought the SW was up to date on the hospice binders, but realized she did not. He said he expected hospice binders to be up to date. During a record review on 9/27/23 at 1:57 PM, the ADM provided a new Hospice POC dated 8/23/23 - 10/21/23 for Resident #42. During a record review on 09/27/23 at 4:01 PM, the ADM provided a new plan of care for Resident #25 dated 09/27/23 through 10/13/23. During an interview on 09/27/23 at 4:07 PM, ADON B said the facility should have a binder for all residents who were on hospice. She said the binders should contain when they were admitted to hospice, why they were admitted to hospice (such as diagnosis), code status (full code or do not resuscitate (DNR), a list of medications provided by hospice, progress notes, and their plan of care. She said she was not sure who was responsible for ensuring hospice charts were updated. She said it was important to have hospice charts updated for continuity of care. Record review of the facility's policy on End of Life Care; Hospice, revised 12/2019, revealed Collaboration with Hospice will include processes for orienting staff to facility policies and procedures which may include: resident rights, documentation and record keeping requirements .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 10 residents (Resident #109) on the COVID-19 unit reviewed for a homelike environment. The facility failed to ensure Resident #109's room and bathroom were clean. These failures could place residents at risk for a diminished quality of life and a diminished clean well-kept environment. 1. Record review of the face sheet dated 07/27/22 indicated Resident #109 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including COVID-19 and dementia without behavioral disturbance. Record review of the admission 5-day MDS dated [DATE] indicated Resident #109 was admitted on [DATE] from another nursing facility. The MDS did not address Resident #109's BIMS (Brief Interview for Mental Status) score and required ADL assistance. The MDS had not been completed and was in process. Record review of the admission record dated 07/22/22 indicated Resident #109 was alert to time, place and person but unable to follow simple commands. Resident #109 was able to walk and had no behavioral problems. During an observation and interview on 07/25/22 at 5:39 p.m., Resident #109 was on the COVID-19 unit in room [ROOM NUMBER]-B. Resident #109 opened his bathroom door. There was dried dark brown feces smeared on the bathroom floor in front of the toilet and extended to the bathroom door then out of the bathroom approximately 3 feet, onto the floor of Resident #109's room. Resident #109 walked out of the bathroom and laid down in his bed. Resident #109 did not have shoes on and was wearing socks. Resident #109 said, when asked about the feces on his floor, he could walk and use the bathroom by himself and did not need anyone to help him. Resident #109 said he was fine, and everything was okay, when asked again about the feces. Resident #109 was unable to be interviewed. During an observation on 07/26/22 at 6:06 p.m., Resident #109 was on the COVID-19 unit sitting on his bed in room [ROOM NUMBER]-B wearing shoes. There was dried dark brown feces on the floor in front of the bathroom door. Resident #109's bathroom door was closed and locked. During an observation and interview on 07/26/22 at 6:10 p.m., LVN N said she was the charge nurse on the COVID-19 unit and worked the 6 p.m. to 6 a.m. shift. LVN N said Resident #109 had feces on the floor in front of his bathroom door and it had been there for a while because it was dried. LVN N said Resident #109 had a colostomy bag (a plastic bag that collects fecal matter from the digestive tract through an opening in the abdominal wall called a stoma) and does not call staff when it needs to be emptied. LVN N said Resident #109 must have spilled feces on the floor trying to empty it himself. LVN N said the nursing staff had access to the designated cleaning cart on the COVID-19 unit if they needed it to clean. LVN N said she had access to the cleaning cart and was going to get it to clean up Resident #109's floor. During an interview on 07/27/22 at 5:31 p.m., the Maintenance Supervisor said he managed housekeeping and was responsible for the cleanliness of the facility. The Maintenance Supervisor said the COVID-19 unit is cleaned daily and at the end of a housekeepers shift because they are not allowed to come back to the cold zone (an area designated for residents not infected with COVID-19) until the next day. The Maintenance Supervisor said, from the time housekeeping staff cleans the COVID unit until they return the following day, he expected the nursing staff to clean the unit if they needed to. The Maintenance Supervisor said there was a designated cleaning cart on the COVID-19 unit for the nursing staff to use. The Maintenance Supervisor said he was not aware Resident #109 had dried feces on his floor for two days. The Maintenance Supervisor said the feces must have been there for a while because they were dry, and it should have been cleaned up before then. The Maintenance Supervisor said a resident's room should be clean and sanitary and Resident #109's room was not. During an interview on 07/27/22 at 5:40 p.m., the DON said she was responsible for managing the nursing staff. The DON said the COVID-19 unit was cleaned once a day by the housekeeping staff and she expected the nursing staff to clean the unit until the housekeeping staff cleaned it again. The DON said there was a designated cleaning cart on the COVID-19 unit for the nursing staff if they needed to clean the unit. The DON said she was not aware Resident #109 had dried feces on his floor for two days. The DON said the feces must have been there for a while because they were dry, and it should have been cleaned up before then. The DON said a resident's room should be clean and sanitary and Resident #109's room was not. Record review of the facility Resident Rights policy dated 10/04/2016 indicated, .Safe Environment. You have a right to a safe, clean, comfortable and homelike environment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish based on the comprehensive assessment and consistent with the resident's needs and choices for 1 of 19 residents (Resident # 24) reviewed for activities of daily living. The facility failed to assess Resident # 24's need for communication assistance to effectively communicate with staff. This failure could place residents at risk for decline and diminished quality of life. Findings included: Record review of physician orders dated 07/27/2022 indicated Resident #24 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy (loss of muscle leading to muscles shrinking and weakening), cerebral infarction (lack of adequate blood supply to brain cells depriving them of oxygen and vital nutrients causing parts of the brain to die off), hemiplegia(muscle weakness or partial paralysis on one side of the body) and hemiparesis(muscle weakness or partial paralysis on one side of the body) following unspecified cerebrovascular disease affecting the left non-dominant side. Record review of the MDS dated [DATE] indicated Resident #24 needed or wanted an interpreter to communicate with a doctor or health care staff and indicated preferred language Spanish. Resident #24 required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene and supervision for locomotion and eating. The MDS indicated Resident #24 understood and was able to make himself understood. The MDS indicated Resident #24's cognition was moderately impaired (BIMS score of 8). Record review of the care plan dated 04/29/2021 revealed that Resident #24 had communication barriers related to Spanish speaking and required language support. Record review of the care plan revealed staff were to provide Resident #24 auxiliary aides to assure equal access to language/communication as needed, such as a simple communication board. Record review revealed staff were to utilize language link with Resident #24 if staff and family were unable to assist verbal with communication due to language barrier. The baseline care plan revealed Resident #24 did not have social services and mental health needs addressed nor social services goals and activities. During an observation 07/25/2022 at 3:43 p.m., Resident #24 was lying in bed looking up at the ceiling. Resident #24 yelled for help (in Spanish), approximately 5 minutes later CNA B came to Resident #24's room and asked resident what he needed (in English). Resident #24 stated (in Spanish) he needed help getting in his wheelchair and going to the bathroom. CNA B stood there and looked at Resident #24 and Resident #24 started sitting up in bed on his own and CNA B asked Resident #24 where he was trying to go. Resident #24 stated (in Spanish) that he really needed to go to the bathroom he could not wait any longer, or he was going to urinate on himself. CNA B did not understand Resident #24 and looked at surveyor. Surveyor interpreted Resident #24's request to CNA B. No communication board was observed in Resident #24's room. During an interview with Resident #24 on 07/26/2022 at 9:50 a.m., Resident #24 said staff did not use a communication board when attempting to communicate with him and did not use the language link. Resident #24 said he could not report his needs to staff because they did not understand him. Resident #24 said at times his family visits and were able to assist him with reporting his needs to staff, but his family did not visit him often. Resident #24 said he felt lonely due to not having anybody to communicate with him. Resident #24 said he tried to do as much as possible for himself without assistance from staff because when he requested assistance, staff had a hard time understanding him. During an observation and interview on 07/26/2022 at 10:40 a.m., LVN M came to Resident #24's room and Resident #24 started talking to LVN M. LVN M looked at surveyor and said he never understood what Resident #24 said. During an interview with CNA B on 07/27/2022 at 4:40 p.m., CNA B said she communicated with Resident #24 by pointing at things and at times tried using google on her cell phone to interpret. CNA B said she did not use the communication board, did not know where the communication board was and did not use the language link. CNA B said she did not know if Resident #24's needs were being met due to not being able to communicate with him. CNA B said Resident #24 not having his needs met could make him feel like he was not noticed and make him depressed. During an interview with LVN A on 07/27/2022 at 5:10 p.m., LVN A indicated she knew key words in Spanish and used communication board to communicate with Resident #24 and she did not use the language link. LVN A said most staff at the facility could not communicate with Resident #24. LVN A said not being able to communicate with Resident #24 could cause him to be frustrated and not have his needs met. During an interview with the administrator on 07/27/2022 at 5:50 p.m., the administrator said prior to admission all residents were screened to ensure staff could adequately care for and communicate with the residents. The administrator said he expected staff to use the language link to assist with communication with limited English proficiency residents. The administrator said it was important to have communication with the residents to give them proper care. The administrator said not being able to communicate with the residents could place the resident at harm emotionally and the resident would not be able to let staff know what they needed for adequate treatment. During an interview with the DON on 07/27/2022 at 6:35 p.m., the DON said she expected staff to use the communication board, family, and the translator line to communicate with Resident #24. The DON said she monitored how the staff communicated with Resident #24 by in-servicing staff on how to communicate with him. The DON said not being able to communicate with Resident #24 could cause Resident #24 to not have his needs met. Record Review of the facilities Language Access Policy revised March 2020, . 9. provide, in a timely manner and free of charge, auxiliary aids (as defined in appendix A) and services to individuals with impaired sensory, manual, or speaking skills. 10. Use only qualified interpreters for language access services (definition of qualified interpreter may be found in appendix A). a. excludes bilingual/multilingual staff members with the exception of those taking and passing an assessment . 13. Not require individuals to provide their own interpreters . 15. Not require adult friends or family to serve as interpreters except in the event of an emergency, or if the limited English proficiency individual specifically requests that the accompanying adult interpret or facilitate communication the accompanying adult agrees to provide such assistance and reliance on that adult for such assistance is appropriate under the circumstances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 out of 16 residents reviewed for accident hazards. (Resident #22) The facility failed to ensure Resident #22's oxygen cylinders was securely stored. This failure could place residents at risk of injury. Record review of the order summary report dated 07/27/22 indicated Resident #22 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including essential hypertension (force of the blood against the artery walls is too high), atrial fibrillation (irregular, often rapid heart rate) and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the order summary report dated 7/27/22 indicated Resident #22 received O2 at 2-4 LPM via nasal cannula PRN for SOB with a start date 6/21/22. Record review of the MDS dated [DATE] indicated Resident #22 understood others, made himself understood. The MDS indicated Resident #22 was moderately cognitive impaired (BIMS score of 12). The MDS indicated he required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene: total dependent with bathing and independent with eating. The MDS indicated Resident #22 did not become short of breath or trouble breathing with exertion. The MDS indicated Resident #22 did not receive oxygen therapy. Record review of the care plan dated 7/25/22 indicated Resident #22 received oxygen therapy. The care plan interventions were to monitor for s/sx of respiratory distress and report to MD PRN: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis (excessive, abnormal sweating), headaches, lethargy, confusion, atelectasis (partial or complete collapse of the lung), hemoptysis (coughing up blood), cough, pleuritic pain (sharp chest pain when breathing deeply), accessory muscle usage (contraction of any muscle other than the diaphragm during inspiration or use any muscles during expiration), skin color and provide oxygen as ordered. During an observation on 7/25/22 at 3:40 p.m., an oxygen cannister was placed in the upright position of Resident #22's recliner. During an observation and interview on 7/26/22 at 3:11 p.m., an oxygen cannister was leaning on the arm of Resident #22's recliner. During an observation on 7/27/22 at 8:15 a.m., an oxygen cannister was lying under a grey blanket in Resident #22's recliner. During an interview and observation on 7/27/22 at 11:35 a.m., LVN A said she was the 6a-6p charge nurse for Resident #22. LVN A said Resident #22 uses O2 as needed for SOB. LVN A said she was unsure why the cannister was in Resident #22's recliner. LVN A removed the tank and gave it to the ADON to place in the oxygen storage room. LVN A indicated she was aware unsecured oxygen cylinder could become harmful if it were to fall. LVN A indicated oxygen cylinders should be stored in the oxygen storage room on a cannister rack. LVN A said this failure could cause an explosion jet propelled. During an interview on 7/27/22 at 4:15 p.m., CNA B said she was the 2p-10p CNA for Resident #22. CNA B said Resident #22 wears O2 PRN. CNA B said she saw the cannister in Resident #22's recliner on 7/25/22 and 7/26/22 but thought hospice placed it there. CNA B said she should have reported it to the charge nurse. CNA B indicated she was aware unsecured oxygen cylinders could become harmful if it were to fall. CNA B indicated oxygen cylinders should be stored in the oxygen storage room on a cannister rack. CNA B said this failure could cause death or harm if it was to fall over. During an interview on 7/27/22 at 4:30 p.m., CMA C said she was the med aide for Resident #22 on the 6a-2p shift and the CNA for Resident #22 on the 2p-10p shift. CMA C said she had seen Resident #22 wear his O2 before. CMA C said she was unsure why the oxygen cannister was in Resident #22's recliner. CMA C indicated oxygen cylinders should be stored in the oxygen storage room on a cannister rack. CMA C indicated she was aware unsecured oxygen cylinders could become harmful if it were to fall. CMA C said this failure could cause an explosion. During an interview on 7/27/22 at 6:55 p.m., the DON said she was unaware of the oxygen cylinder in Resident #22's recliner. She said the cylinders should be stored in the oxygen storage room on a cannister rack when not in use. The DON said all staff were responsible for ensuring cylinders were stored in the oxygen room on the cannister rack. The DON said she was responsible for monitoring to ensure this does not happen. The DON said angel rounds were done every morning by her and the administrative department to ensure there were no environmental risks. The DON said this week she could not say if rounds were done since everyone was out of normal for survey. The DON said she was aware unsecured oxygen cylinders could become harmful if it were to fall. The DON said this failure could cause an explosion. Record review of the facility's policy titled Oxygen Storage dated 6/2016 indicated . it is the policy of this facility to provide a safe environment for each resident. To enable the facility to promote safety, oxygen will be stored according to state regulations . oxygen tanks will be stored upright in oxygen racks and if need to be transported, will be done in a wheeled tank holder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided such care, consistent with professional standards of practices for 1 of 5 residents (Resident #13) reviewed for respiratory care. The facility failed to ensure Resident #13's nasal cannula tubing was changed weekly. The facility did not store a nebulizer a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask in a plastic bag when it was not in use. These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. Findings included: Record review of the order summary report dated 07/27/22 indicated Resident #13 was a [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential hypertension (force of the blood against the artery walls is too high) and atrial fibrillation (irregular, often rapid heart rate). Record review of the order summary report dated 7/27/22 indicated Resident #13 received O2 at 2 LPM continuous for SOB with a start date 5/28/22. The report indicated to change O2 tubing every night every Sunday and to keep inside plastic bag when not in use with a start date 7/10/22. Record review of the MDS dated [DATE] indicated Resident #13 understood others, usually made himself understood. The MDS indicated Resident #13 was severely cognitively impaired (BIMS score of 2). The MDS indicated he required extensive assistance with bed mobility, dressing, toileting, and personal hygiene: total dependent with bathing and supervision with eating. The assessment indicated Resident #13 transferred 1-2 times during the assessment period. The MDS did not indicate if Resident #13 became short of breath or trouble breathing with/without activity. The MDS indicated Resident #13 was receiving oxygen therapy. Record review of the care plan dated 4/28/21 indicated Resident #13 had altered respiratory status, difficulty breathing related to sleep apnea. The care plan interventions were to provide oxygen as ordered. The care plan indicated resident received oxygen therapy. The interventions were to monitor for s/sx of respiratory distress and report to MD PRN: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color and provide oxygen as ordered. During an observation on 7/25/22 at 3:25 p.m., Resident #13 was lying in bed and oxygen was in use via nasal cannula. The nasal cannula was dated 7/11/22. During an observation on 7/26/22 at 8:05 a.m., Resident #13 was lying in bed and oxygen was in use via nasal cannula. The nasal cannula was dated 7/11/22. There was a nebulizer mask on top of Resident #13's closet not covered. During an observation on 7/26/22 at 3:12 p.m., Resident #13 was lying in bed and oxygen was in use via nasal cannula. The nasal cannula was dated 7/11/22. There was a nebulizer mask on top of Resident #13's closet not covered. During an observation on 7/27/22 at 8:16 a.m., Resident #13 was lying in bed and oxygen was in use via nasal cannula. The nasal cannula was dated 7/11/22. There was a nebulizer mask on top of Resident #13's closet not covered. During an observation and interview on 7/27/22 at 5:22 p.m., LVN A said she was Resident #13's 6a-6p charge nurse. She said nursing staff on Sunday nights were responsible for changing and labeling tubing. LVN A said all staff were responsible for making sure it was done. LVN A said she was unaware that Resident #13's nasal cannula tubing was dated 7/11/22 and a nebulizer mask was uncovered on top of his closet. LVN A said Resident #13 had not received a nebulizer treatment since he came back from the hospital. LVN A said the nebulizer mask belonged to another resident that was in the room prior to Resident #13. LVN A said Resident #13 did not require nebulizer treatments at this time. LVN A said the mask should have been in a plastic bag and discarded. LVN A said it was important to change the tubing so other staff would know when it was changed last. LVN A said the potential risk was source of infection. During an interview on 7/27/22 at 5:37 p.m., LVN D said nursing staff on Sunday nights were responsible for changing and labeling tubing. LVN D said all staff were responsible for making sure it was done. LVN D said the nebulizer mask should have been stored in a bag while not in use and if it did not belong to the resident it should have not been in the room. LVN D said it was important to change the tubing so other staff would know when it was last changed. LVN D said the potential risk was an upper respiratory infection. During an interview on 7/27/22 at 6:55 p.m., the DON said nursing staff on Sunday nights were responsible for changing and labeling tubing. The DON said angel rounds were done daily. She said it was her responsibility to make sure the nursing staff were properly checking and dating the respiratory equipment. The DON said this week she could not say if rounds were done since everyone was out of normal for survey. The DON said she expected nebulizers be stored in bags when not in use. The DON said if the nebulizer did not belong to Resident #13 it should had not been in his room uncovered. The DON said these failures could cause a respiratory infection. Record review of the facility's oxygen policy tilted Oxygen Equipment revised on 5/2007 indicated it is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner . tubing should be replaced every week . when mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 19 residents (Resident #40) reviewed for medication storage. The facility did not keep medication being administered under the direct observation of the person administering medications. Resident #40 had unlabeled medications in a plastic pill pouch on her bedside table. This failure could place residents at risk for health complications and not receiving the intended therapeutic benefit of their medication. Findings included: Record review of the order summary report dated 07/27/22 indicated Resident #40 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), Sjogren's syndrome (chronic autoimmune condition characterized by degermation of the salivary and lachrymal glands, causing dryness of the mouth and eyes), and idiopathic epilepsy (group of seizure disorders that come about from abnormal electrical activities in the brain). Record review of the order summary report dated 7/27/22 indicated Resident #40 was ordered to receive 3 Zonisamide 100mg (3 capsules by mouth at bedtime) for seizures with a start date 3/30/22, ASA 81 mg (one tablet by mouth once a day) for pain with a start date 3/30/22, Co Q10 (1 capsule by mouth once a day with meals) for supplement with a start date 3/30/22, Vitamin C 500 mg (1 tablet by mouth once a day) for supplement with a start date 3/30/22, Iron 325 mg (65Fe) (1 tablet by mouth once a day) for supplement with a start date 3/30/22, Vitamin B12 1000 mg (1 tablet by mouth once a day) for supplement with a start date 3/30/22, Citalopram 20 mg ( 1 tablet by mouth once a day) with a start date 3/30/22, Potassium Chloride 10meg ( 1 tablet by mouth two times a day, 2 tab by mouth on PM pass) for supplement with a start date 3/30/22, Memantine 10 mg (1 tablet two times a day with meals) for Alzheimer's with start date 3/30/22, Leveitracetam 500 mg (1 tablet by mouth once a day) for seizures with a start date 3/30/22, and Leveitracetam 500 mg (1/2 tablet by mouth once a day) for seizures with a start date 3/3122. Record review of the MDS dated [DATE] indicated Resident #40 understood others, made herself understood. The MDS indicated Resident #40 was severely cognitively impaired (BIMS score of 6). The assessment indicated Resident #40 was independent with bed mobility, transfers, eating and toileting: supervision with personal hygiene and required extensive assistance with bathing. Record review of the care plan dated 3/30/22 indicated Resident #40 had impaired cognitive function /dementia or impaired thought processes related to dementia. The care plan intervention was to administer medications as ordered. During an interview and observation on 7/25/22 at 3:00 p.m., Resident #40 was sitting in her recliner eating candy. 14 pills in a plastic pill pouch were observed sitting on her bed side table. There were 3 green and white capsules, 1 yellow colored oval tablet, 1/2 yellow colored oval, 1 gray colored oblong tablet, 1 white oblong tablet, 1 tan colored tablet, 1 pink colored round tablet, 1 green colored round tablet, 2 white round tablets, 1 burgundy colored oval capsule, and 1 yellow colored round tablet. Resident #40 said after she finished eating her candy, she would take her vitamins, but the other pills should be taken at 7p for seizures. During an interview on 7/25/22 at 3:41 p.m., CMA K said she did not work full time at this facility. She said she was with an agency. CMA K stated, she did not watch Resident #40 swallow her pills because Resident #40 wanted to keep her pills for a later moment. CMA K said she was aware that Resident #40 needed to be educated, assessed, and able to demonstrate she could safely administer her medications by the charge nurse and MD before medications were left at bedside to self-administer. CMA K stated, taking her pills from her was not an option. CMA K said she understood that she should have stayed with her or took the medications back to the medication cart but Resident #40 wanted her pills. CMA K said this failure could possibly cause an overdose for another resident or put Resident #40 at risk for seizures. During an interview and observation on 7/25/22 at 4:05 p.m., the DON was notified by the surveyor that 14 unidentified medications were left at Resident #40 bedside. The DON went to Resident #40 room and removed the medications. During an interview on 7/27/22 at 4:40 p.m., CMA C said she always stayed with Resident #40 until medications were swallowed. CMA C said Resident #40 needed to be educated, assessed, and able to demonstrate she could safely administer her medications by the charge nurse and MD before medications were left at bedside to self-administer. CMA C said the medication aide that was administering medications was responsible for ensuring medications were not left at bedside. CMA C said this failure put Resident #40 and others at risk for overdose. During an interview on 7/27/22 at 5:22 p.m., LVN A said she always stayed with the residents until medications were swallowed to prevent choking or adverse effect. LVN A said pills should never be left at the bedside for the resident to take at another time. LVN A said Resident #40 needed to be educated, assessed, and able to demonstrate she could safely administer her medications by the charge nurse to allow medications at bedside. LVN A said the MD would be notified of the assessment and an order will be given. LVN A said the before a resident could have medications at bedside a lock box must be obtain. LVN A said the nurse that was administering the medications was responsible for ensuring medications were not left at bedside. LVN A said this failure put others at risk for accidental overdose and did not guarantee Resident #40 would take all her pills. During an interview on 7/27/22 at 6:55 p.m., the DON said Resident #40 was not allowed to have medications at bedside. The DON said Resident #40 should be educated, assessed, and able to demonstrate she could safely administer her medications by the charge nurse and MD to allow medications at bedside. The DON said having medications at bedside put residents at risk for safety, potential overdose and not taking the medication at the correct time. The DON said she was responsible for monitoring to ensure medications were not left at bedside. The DON said the pharmacy consultant comes monthly to do random medication passes. The DON said the facility also has a resource nurse that comes weekly to monitor the passing of medications. The DON stated, CMA K made a bad choice. Record review of the facility's policy titled Medication Administration dated May 2007 indicated . it is the policy of this facility that medications shall be administered as prescribed the by the attending physician . the person administering medications must remain with the resident until medication has been swallowed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to serve food to Resident #18 that met her needs. 2.Record review of the face sheet and consolidated physician orders dated 7/26/2022 indicated Resident #18 was [AGE] years old and was admitted on [DATE] with diagnoses including dementia, generalized muscle weakness, and high blood pressure. There was a physician's order for a regular diet, mechanical soft texture. (A mechanical soft diet is a texture-modified diet that restricts foods that are difficult to chew or swallow. Foods can be pureed, finely chopped, blended, or ground to make them smaller, softer, and easier to chew). Record review of the MDS dated [DATE] indicated Resident #18 understood others and was understood. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 11, indicating Resident #18 was moderately cognitively impaired. The MDS indicated the resident required mechanically altered food. Record review of care plan dated 7/19/2022 indicated Resident #18 had a potential nutritional problem related to dementia and a history of difficulty swallowing. There was an intervention for diet as ordered by physician and to provide and serve diet as ordered. Record review of a weight summary for Resident #18 indicated on 6/10/2022 the resident weighed 137.2. On 7/19/2022 the resident weighed 130.2. During an interview on 7/25/22 at 11:19 a.m., Resident #18 revealed she could not eat her meals because of teeth. She said every day she eats oatmeal for breakfast, mashed potatoes for lunch, and peanut butter and jelly sandwiches for supper. She said the worst things was when the cook mashed the potatoes and left the peels in the potatoes. She said she had reported this to staff but could not remember the names. She said she had told the lady that checked her tray that she cannot eat her food. She said she cannot chew the potato peels and had to pick them out. She said she has dentures but did not like to eat with them. During an observation and interview on 7/25/22 at 1:00 p.m., lunch was delivered to Resident #18. She was served mashed potatoes with peels and a bowl of peached. She said she did not tell the aide the mashed potatoes were not right because the aide did not ask. She said she might eat a little but not much. She said she had some ice cream on her night stand she would eat. During an observation and interview on 7/26/22 at 12:57 p.m. Resident #18 eating in room. On the table in front of her was a bowl of mashed potatoes. There were potato peels in the mashed potatoes. She pushed the bowl away from her, I can't eat this. It is just lumps and peels. The mashed potatoes did appear dry and lumpy. She said she did not tell the aide because they never do anything about it. During an interview on 7/26/22 at 10:12 a.m. CNA G revealed Resident #18 ate mashed potatoes every day with milk. She said Resident #18 could not chew the potato peels in the mashed potatoes. She said she had noticed Resident #18 would spit the potato peels out into a napkin and she only eats a small amount of her mashed potatoes. She said she reports food complaints to the nurses and the dietary supervisor. During an interview on 7/27/22 at 2:36 p.m., LVN D revealed she had checked Resident #18's trays in the past. She said she was unaware of any issues Resident #18 had with her mashed potatoes. During an interview on 7/27/22 at 3:23 p.m., the Dietary Supervisor said she heard complaints by word of mouth from the residents and the aides. She said then she goes to the resident to try to solve the problems. She said she had not recently visited with Resident #18. She said she was unaware that kitchen staff was serving her the potatoes with the peels. She said whoever the nurse on duty would be the one to have checked her tray. She said whoever checked her tray should have told her there was an issue . During an interview on 7/27/22 at 3:30 p.m., the ADON revealed Resident #18's tray should have been checked by a nurse and they should have reported any issues to the dietary manager and an alternative should have been offered. She said the dietary manager should have then talked to the resident to resolve the issue. During an interview on 7/27/22 at 4:12 p.m., the DON revealed with any food complaints an alternate should be offered. She said any staff hearing a food complaint should write a grievance and notify administration. She said she is always on the hall and was unaware of the issue with the mashed potatoes with Resident #18. She said residents not liking their food or being able to eat their food could affect the resident's nutrition. She said, It would make me depressed. During an interview on 7/27/22 at 5:25 p.m., the administrator revealed staff should address food complaints by offering alternatives or going back to the kitchen to report complaints. Review of a facility Menus policy dated 9/2017 indicated, .It is the policy of this facility to assure that menus are developed and prepared to meet nutritional needs of the residents and resident choices including their nutritional .needs . Based on observations, interviews, and record review, the facility failed to follow the therapeutic diet as ordered by the physician for 2 of 24 residents (Resident #7 and Resident #18) reviewed for therapeutic diets. The facility failed to ensure Resident #7 was served a regular pureed diet as ordered by the physician. The facility failed to serve food to Resident #18 that met her needs. These failures could place residents at risk for poor intake, weight loss, unmet nutritional needs, and choking. Findings included: 1.Record review of the order summary report dated 07/27/22 indicated Resident #7 was an [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing foods or liquids) following cerebrovascular disease, Alzheimer's (progressive disease that destroys memory and other important mental functions) and Parkinson's (brain disorder that causes unintended or uncontrollable movements). Record review of the order summary report dated 7/27/22 indicated Resident #7's diet was a regular diet with pureed texture with a start date 3/30/22. Record review of the MDS dated [DATE] indicated Resident #7 understood others, made himself understood. The MDS indicated Resident #7 was moderately cognitive impaired (BIMS score of 10). The MDS indicated he required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and total dependent with bathing. The MDS indicated Resident #7 required a mechanically altered diet. Record review of the care plan dated 7/26/22 indicated Resident #7 was at risk for swallowing difficulties related to dysphagia. The care plan interventions were diet to be followed as prescribed. Record review of Resident #7 meal ticket indicated he required a regular diet with pureed consistency. During dining observation on 7/25/22 at 12:41 p.m., Resident #7 was eating a regular consistency sour cream pound cake. After surveyor intervention the dessert was removed, and Resident #7 was given a bowl of pudding. During an interview on 7/27/22 at 3:26 p.m., the Dietician said she expected dietary staff to follow diet orders. The Dietician said if a purred diet was ordered the residents can only have pureed textured desserts such as pudding, applesauce, ice cream. The Dietician said the failure for providing regular texture instead of pureed texture was a choking hazard. The Dietician stated, it was inappropriate they should follow written orders. During an interview on 7/27/22 at 3:55 p.m., [NAME] F said dietary cooks were responsible for checking the diets with the diet roster and the tray card before serving. [NAME] F said Resident #7 had a pureed diet consistently ordered. [NAME] F said Resident #7 should have been given a pureed dessert instead of the pound cake. [NAME] F said the potential harm for serving regular consistently to Resident #7 was choking. During an interview on 7/27/22 at 4:05 p.m., the Dietary Manager said dietary staff were responsible for checking the diets with the diet roster and the tray card before serving. The Dietary Manager said Resident #7 had a pureed diet consistently ordered. The Dietary Manager said Resident #7 should had not been given a regular texture pound cake. The Dietary Manager said it was her responsibility to monitor the diets by completing spot checks 3-4 times a day. The Dietary Manager said she was unable to say why Resident #7 received a regular texture pound cake on 7/25/22. The Dietary Manager said the potential harm for serving regular consistently to Resident #7 were choking and dying. During an interview on 7/27/22 at 4:40 p.m., CMA C said dietary cooks, nurses and then the staff that serve the tray to Resident #7 was responsible for checking the diet with the diet roster and the tray card before serving to Resident #7. CMA C said diet rosters are provided from the dietary manager. CMA C said Resident #7 had a pureed diet consistently ordered. CMA C said Resident #7 should have been given a pureed dessert instead of the pound cake. CMA C said the potential harm for serving regular consistently to Resident #7 was choking. During an interview on 7/27/22 at 5:22 p.m., LVN A said nurses were responsible for checking the diets with the diet roster and the tray card before serving. LVN A said Resident #7 had a pureed consistency diet ordered. LVN A said Resident #7 should have not been given pound cake for his dessert. LVN A said the potential harm for serving regular consistently to Resident #7 was aspiration and choking. During an interview on 7/27/22 at 6:55 p.m., the DON indicated the nurses were responsible for checking the diets with the diet roster and the tray card before serving, and she expected the residents to receive the diet as ordered. The DON said Resident #7 should had been given a pureed dessert. The DON said the dietary manager was responsible for providing the diet rosters. The DON said ultimately, she was responsible for monitoring mealtimes and supervising but Monday she was not in the dining room. The DON indicated a resident receiving a wrong diet could cause choking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 19 residents reviewed for resident records. (Resident #30) The facility failed to document and monitor resident #30's injury to 5th left toe (toenail separated from skin underneath). This failure could place the resident at risk for not receiving appropriate care due to incomplete/inaccurate information being documented. Findings included: Record review of the physician order report dated 07/27/2022 indicated Resident #30 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses of epilepsy (neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions), essential hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease (blocked airflow making it difficult to breathe) and other lack of coordination. Record review of the MDS dated [DATE] indicated Resident #30 made himself understood and understood others. The MDS indicated Resident #30's cognition was moderately impaired (BIMS score 8). The MDS indicated Resident #30 required extensive assistance with bed mobility, transfer, dressing, and personal hygiene and limited assistance with locomotion. During an observation and interview on 07/27/2022 at 9:23 AM Resident #30 had an intact dressing to his left 5th toe dated 7/26/22. Resident #30 said yesterday he was bleeding and LVN M took him back to his room and cleaned it and applied dressing. Resident #30 said he did not know how he injured himself. During an observation and interview on 07/27/2022 at 9:24 AM LVN A said she did not know why Resident #30 had a dressing to his left 5th toe. LVN A said she was not communicated this information and Resident #30 had no wound care orders for his left 5th toe. LVN A removed the dressing and reported Resident #30 had dried blood around his left 5th toenail and it appeared like Resident #30 bumped his toe and injured his toenail. LVN A said she was going to step out of the room to gather wound care supplies. LVN A said she would notify the doctor and obtain wound care orders. LVN A said nurses were responsible for notifying the doctor of any new wounds for wound care orders and writing new orders. LVN A said not monitoring and providing wound care to Resident #30's injury to the left 5th toe could lead to infection and gangrene and possibly amputation due to the resident being diabetic. During a phone interview on 07/27/2022 at 4:17 p.m., LVN M said yesterday or the day before, he could not remember exactly, Resident #30 hit his left 5th toe on one of the legs of the wheelchair and the left 5th toe was bleeding. He said he placed a dressing on the left 5th toe to stop the bleeding. LVN M said he did not notify the doctor of the injury to Resident #30's left 5th toe and he did not obtain wound care orders for the injury. LVN M said the nurses were responsible for notifying the doctor of injuries and obtaining orders from the doctor and completing incident reports. LVN M said there could be a communication breakdown because he did not complete an incident report or notify the doctor and write orders for wound care. LVN M said Resident #30's injury to his left 5th toe could lead to infection if left untreated. During an interview on 07/27/2022 at 6:20 p.m., the DON said the nurses were responsible for notifying the doctor of any injuries and obtaining orders when injuries occurred. The DON said she expected the nurses to complete incident reports. The DON said risk management monitored incident occurrences and performed chart audits to ensure proper documentation. The DON said not providing wound care due to no orders could lead to infection. Record review of the facility's Wound management policy revised on 05/2007 did not address notifying the physician of new wounds.

Based on observation, interview, and record review the facility failed to ensure residents received their mail promptly for 6 of 14 confidential residents reviewed for personal privacy. The facility failed to ensure residents received their mail on the weekend. This failure could affect residents in the facility who receive mail and place them at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life. Findings included: During a confidential group interview, residents said that the mail was not distributed on Saturdays. The residents said the Receptionist was responsible for distributing mail and she was only employed Monday through Friday. Record review of grievance logs presented did not indicate any grievances had been filed by the residents about mail not being distributed on Saturdays. During an interview on 07/27/2022 at 4:20 p.m., the Receptionist said the mailbox was in front of the building and everybody had access to it. The Receptionist said she was responsible for distributing mail while at work on Monday through Friday, and there was a Receptionist for Saturday and Sunday. The Receptionist added that the weekend Receptionist did not distribute the mail. The weekend Receptionist stacked it on the desk for her to distribute on Mondays. The Receptionist said she was not aware the residents had the right to have their mail distributed on Saturdays. The Receptionist said the residents not receiving their mail could make them feel like they are not getting what they needed in a timely manner. During an interview with the administrator on 07/27/2022 at 5:50 p.m., the administrator said he was aware the residents had the right to receive their mail on Saturdays. He said the Receptionists were responsible for distributing mail and he was under the impression the mail was being distributed by the weekend Receptionist on Saturdays. He said ultimately it was his responsibility to ensure the mail was distributed and, in the future, he would check with the Receptionist on Monday mornings to ensure the mail was distributed on Saturdays. The administrator said it was important for the residents to receive their mail on Saturdays because it might be the only way for them to communicate with their loved ones and they can be negatively emotionally affected. During an interview with the DON on 07/27/2022 at 6:20 p.m., the DON said she was aware of and expected the residents to receive their mail on Saturdays and she was not aware the residents had not been receiving their mail on Saturdays. The DON stated this was important because it was the residents right to have their mail. The DON said this could affect the residents because they could feel like their rights are being violated and make them feel like they do not have a voice and are not independent. Record review of the Residents Rights policy indicated the Resident has the right to privacy in written communication including the right to send and promptly receive mail that is unopened, and to have access to stationary, postage and writing implements at the resident's expense. Record review of HUMAN RESOURCES CODE CHAPTER 102. RIGHTS OF THE ELDERLY (texas.gov) accessed on 7/06/2022 read: Sec. 102.003. RIGHTS OF THE ELDERLY. (a) An elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights. An elderly individual is entitled to privacy while attending to personal needs and a private place for receiving visitors or associating with other individuals unless providing privacy would infringe on the rights of other individuals. This right applies to medical treatment, written communications, telephone conversations, meeting with family, and access to resident councils. An elderly person may send and receive unopened mail, and the person providing services shall ensure that the individual's mail is sent and delivered promptly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 19 residents (Resident #24, Resident #30 and Resident #7) reviewed for care plans and therapeutic diets. The facility failed to ensure Resident #24 mobility bars to aide in easy turning and repositioning while in bed were in place, as ordered by the physician. The facility failed to ensure Resident #30 smoking assessment was completed according to care plan intervention. The facility failed to ensure Resident #7 was served a regular pureed diet as ordered by the physician. These failures could place the residents at risk for harm and not receiving the care and/or services to meet their individual needs. Findings included: 1.Record review of physician orders dated 07/27/2022 indicated Resident #24 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy (loss of muscle leading to muscles shrinking and weakening), cerebral infarction(lack of adequate blood supply to brain cells depriving them of oxygen and vital nutrients causing parts of the brain to die off), hemiplegia(muscle weakness or partial paralysis on one side of the body) and hemiparesis(muscle weakness or partial paralysis on one side of the body) following unspecified cerebrovascular disease affecting the left non-dominant side. The physician order indicated Resident #24 had an order for mobility bars to aide in easy turning and repositioning while in bed every evening with a start date of 11/03/2021. Record review of the MDS dated [DATE] indicated Resident #24 required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and supervision for locomotion and eating. The MDS indicated Resident #24 understood and was able to make himself understood. The MDS indicated Resident #24's cognition was moderately impaired (BIMS score of 8). Record review of the care plan dated 04/29/2021 indicated Resident #24 was at risk for ADL self-care performance deficit related to CVA (cerebrovascular accident) with hemiplegia/hemiparesis and the intervention indicated an enabler bar was to be provided for assistance with ADLS. Record Review for physicians' orders for Resident #24 dated 07/01/2022-07/31/2022 indicated for staff to check for mobility bars to aide in easy turning and repositioning while in bed every evening shift. The treatment administration record was checked off as completed for July 1, 2022 through July 26, 2022. During an observation on 07/25/2022 at 3:43 p.m., Resident #24 was observed lying in bed with no mobility bars installed. During an observation on 07/26/2022 at 9:50 a.m., Resident #24 was observed lying in bed with no mobility bars installed. During an observation and interview on 07/27/2022 5:05 p.m., LVN A observed with surveyor Resident #24 in bed with no mobility bars installed. LVN A said she was not aware Resident #24 had an order for mobility bars and would notify maintenance to get them installed. LVN A said it was the DON and MDS responsibility to ensure orders were implemented. LVN A said not having the mobility bars could affect Resident #24's ability to reposition himself while in bed due to having a paralyzed side. 2. Record review of the physician order dated 07/27/2022 indicated Resident #30 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses of epilepsy (neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions), essential hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease (blocked airflow making it difficult to breathe) and other lack of coordination. Record review of the MDS dated [DATE] indicated Resident #30 made himself understood and understood others. The MDS indicated Resident #30's cognition was moderately impaired (BIMS score 8). The MDS indicated Resident #30 required extensive assistance with bed mobility, transfer, dressing, and personal hygiene and limited assistance with locomotion. Record review of the care plan dated 07/25/2022 indicated Resident #30 had the potential for injury related to smoking. The care plan intervention for Resident #30 indicated to monitor to assess for compliance with facility smoking policy/individual plan. Record review for Resident #30 indicated no smoking assessment was completed. During an interview on 07/27/22 at 5:05 p.m., LVN A said the smoking assessments should be completed on admission by the social worker. LVN A said she was not aware of the care plan intervention for Resident #30. LVN A said without a smoking assessment staff would not know if Resident #30 was safe for smoking. During an interview on 07/27/2022 at 6:20 p.m., the DON said the nurses were responsible for making sure the smoking assessments were completed. The DON said the nurse managers and nurses auditing charts were responsible for ensuring all smoking assessments were completed. The DON said reports were done with the quality-of-care meeting weekly and as needed to monitor for completion of the smoking assessments. The DON said not completing the smoking assessments placed Resident #30 at risk of not smoking safely and he could get harmed. Record review of the facility Smoking Policy dated 4/2017;7/2018 indicated, for those residents who enjoy smoking, wellness staff will perform a smoking evaluation to determine if the resident is able to safely smoke in the designated areas. During an interview with the DON on 07/27/2022 at 6:20 p.m., surveyor requested the policy for following physician's orders, and the policy was not provided prior to exit. 3. Record review of the order summary report dated 07/27/22 indicated Resident #7 was an [AGE] year-old male, readmitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing foods or liquids) following cerebrovascular disease, Alzheimer's (progressive disease that destroys memory and other important mental functions) and Parkinson's (brain disorder that causes unintended or uncontrollable movements). Record review of the order summary report dated 7/27/22 indicated Resident #7's diet was a regular diet with pureed texture with a start date 3/30/22. Record review of the MDS dated [DATE] indicated Resident #7 understood others, made himself understood. The MDS indicated Resident #7 was moderately cognitive impaired (BIMS score of 10). The MDS indicated he required extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and total dependent with bathing. The MDS indicated Resident #7 required a mechanically altered diet. Record review of the care plan dated 7/26/22 indicated Resident #7 was at risk for swallowing difficulties related to dysphagia. The care plan interventions were diet to be followed as prescribed. Record review of Resident #7 meal ticket indicated he required a regular diet with pureed consistency. During dining observation on 7/25/22 at 12:41 p.m., Resident #7 was eating a regular consistency sour cream pound cake. After surveyor intervention the dessert was removed, and Resident #7 was given a bowl of pudding. During an interview on 7/27/22 at 3:26 p.m., the Dietician said she expected dietary staff to follow diet orders. The Dietician said if a purred diet was ordered the residents can only have pureed textured desserts such as pudding, applesauce, ice cream. The Dietician said the failure for providing regular texture instead of pureed texture was a choking hazard. The Dietician stated, it was inappropriate they should follow written orders. During an interview on 7/27/22 at 3:55 p.m., [NAME] F said dietary cooks were responsible for checking the diets with the diet roster and the tray card before serving. [NAME] F said Resident #7 had a pureed diet consistently ordered. [NAME] F said Resident #7 should have been given a pureed dessert instead of the pound cake. [NAME] F said the potential harm for serving regular consistently to Resident #7 was choking. During an interview on 7/27/22 at 4:05 p.m., the Dietary Manager said dietary staff were responsible for checking the diets with the diet roster and the tray card before serving. The Dietary Manager said Resident #7 had a pureed diet consistently ordered. The Dietary Manager said Resident #7 should had not been given a regular texture pound cake. The Dietary Manager said it was her responsibility to monitor the diets by completing spot checks 3-4 times a day. The Dietary Manager said she was unable to say why Resident #7 received a regular texture pound cake on 7/25/22. The Dietary Manager said the potential harm for serving regular consistently to Resident #7 were choking and dying. During an interview on 7/27/22 at 4:40 p.m., CMA C said she was the med aide for Resident #7 on the 6a-2p shift and the CNA for Resident #7 on the 2p-10p shift. CMA C said dietary cooks, nurses and then the staff that serve the tray to Resident #7 was responsible for checking the diet with the diet roster and the tray card before serving to Resident #7. CMA C said diet rosters are provided from the dietary manager. CMA C said she was assigned to Resident #7 CMA C said Resident #7 had a pureed diet consistently ordered. CMA C said Resident #7 should have been given a pureed dessert instead of the pound cake. CMA C said the potential harm for serving regular consistently to Resident #7 was choking. During an interview on 7/27/22 at 5:22 p.m., LVN A said she was Resident #7's 6a-6p charge nurse. LVN A said nurses were responsible for checking the diets with the diet roster and the tray card before serving. LVN A said Resident #7 had a pureed consistency diet ordered. LVN A said Resident #7 should have not been given pound cake for his dessert. LVN A said the potential harm for serving regular consistently to Resident #7 was aspiration and choking. During an interview on 7/27/22 at 6:55 p.m., the DON indicated the nurses were responsible for checking the diets with the diet roster and the tray card before serving, and she expected the residents to receive the diet as ordered. The DON said Resident #7 should had been given a pureed dessert. The DON said the dietary manager was responsible for providing the diet rosters. The DON said ultimately, she was responsible for monitoring mealtimes and supervising but Monday she was not in the dining room. The DON indicated a resident receiving a wrong diet could cause choking. During an interview on 7/27/22 at 8:10 p.m., the Regional Nurse indicated there was no policy related to pureed diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 5 of 19 residents reviewed for ADLs (Resident #14, #37, #41, #43, and #214). The facility did not provide scheduled showers or baths for Residents #14, #37, #41, #43, and #214). The facility did not offer to remove chin hairs from female Residents #41 and #43. This failure could place residents who required assistance from staff for personal hygiene at risk of not receiving care and services to meet their needs, and emotional stress. Findings included: 1. Record review of the face sheet and consolidated physician orders dated 7/27/2022 indicated Resident #14 was [AGE] years old and was admitted on [DATE] with diagnoses including left femur (thigh bone) fracture, chronic pain, and need for assistance with personal care. Record review of the MDS dated [DATE] indicated Resident #14 understood others and was understood. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 14, indicating Resident #14 was cognitively intact. The MDS indicated Resident #14 required limited assistance with personal hygiene and was totally dependent on staff for bathing. Record review of care plan dated 5/12/2022 indicated Resident #14 an ADL self-care performance deficit related to a right hip fracture. With interventions for staff to physical assist with ADLs as needed. Record review of a Documentation Survey Report for bathing indicated Resident #14 did not receive a shower on July 6, 2022, July 7, 2022, July 8, 2022, July 9, 2022, July 10, 2022, July 11, 2022, July 12, 2022, and July 13, 2022. This indicated the resident did not receive a shower for 8 straight days with the residents only refusal on July 7, 2022. The report indicated Resident #14 did not receive a shower on July 15, 2022, July 16, 2022, July 17, 2022 and July 18, 2022. This indicated the resident did not receive for 4 straight days. During an interview on 7/25/22 at 10:40 a.m., Resident #14 revealed she was scheduled for showers on Tuesday, Thursdays, Saturdays. She said she did not always get her scheduled showers. 2. Record review of the face sheet and consolidated physician orders dated 7/27/2022 indicated Resident #37 was [AGE] years old and was admitted on [DATE] with diagnoses including depression, anxiety, and need for assistance with personal care. Record review of the MDS dated [DATE] indicated Resident #37 understood others and was understood. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 7, indicating Resident #37 was severely cognitively impaired. The MDS indicated Resident #37 required limited assistance with personal hygiene and physical help in part of bathing activity. Record review of a care plan dated 6/26/2022 indicated Resident #37 had an ADL self-performance deficit. Resident #37 needed assistance with the help of 2 people for transfers. Bathing was not addressed in the care plan. Record review of a Documentation Survey Report for bathing indicated Resident #37 did not receive a shower on July 15, 2022, July 16, 2022, July 17, 2022, and July 18,2022. During an interview on 7/25/22 at 3:05 p.m., Resident #37 revealed she did not always receive her scheduled showers and said she could not shower without help. She said she was scheduled to have showers on Tuesdays, Thursdays, and Saturday. 3. Record review of the face sheet and consolidated physician orders dated 7/27/2022 indicated Resident #41 was [AGE] years old and was admitted on [DATE] with diagnoses including diabetes, generalized muscle weakness, and high blood pressure. Record review of the MDS dated [DATE] indicated Resident #41 understood others and was understood. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 7, indicating Resident #41 was severely cognitively impaired. The MDS indicated Resident #41 required limited assistance with personal hygiene and supervision with bathing. Record review of care plan dated 7/26/2022 indicated Resident #41 required assistance with ADL care. Resident #41 had an ADL self-performance deficit. The care plan indicated Resident #41 was totally dependent on staff to provide a bath as necessary. Record review of a Documentation Survey Report for bathing indicated Resident #41 did not receive a shower on July 2, 2022, July 3, 2022, July 4, 2022, July 5, 2022, July 7, 2022, July 8, 2022, July 9, 2022, July 10, 2022, July 11, 2022, July 12, 2022, July 14, 2022, July 15, 2022, July 16, 2022, July 17, 2022, July 18th, 2022, July 19, 2022, July 21, 2022, July 23, 2022, July 24, 2022, July 25, 2022, July 26, 2022, and July 27, 2022. No resident refusals were charted . During an observation and interview on 7/27/22 at 11:44 a.m., Resident #41 had greasy hair and many white chin hairs approximately 1 centimeter long. She said she had not received her showers for the week. She said she washed her hair when she showered. She said she could not pluck the chin hairs herself and needed help. She said she did not like having chin hairs. She said not receiving her showers made her feel dirty. She said her hair was greasy and that it made her feel unclean. She said she was supposed to receive her showers on Monday, Wednesday, and Friday. 4. Record review of the face sheet and consolidated physician orders dated 7/26/2022 indicated Resident #43 was [AGE] years old and was admitted on [DATE] with diagnoses including dementia, generalized muscle weakness, and need for assistance with personal care. Record review of the MDS dated [DATE] indicated Resident #43 understood others and understood. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 12, indicating Resident #43 was moderately cognitively impaired. The MDS indicated Resident #29 required limited assistance with personal hygiene and physical help in part of bathing activity. The care plan dated 7/25/2022 indicated Resident #43 required assistance with ADL care. The care plan indicated Resident #43 needed assistance with transfers. The care plan did not indicate bathing needs. Record review of a Documentation Survey Report for bathing indicated Resident #43 did not receive a shower on July 15, 2022, July 16, 2022, July 17, 2022, and July 18th, 2022. During an observation and interview on 7/25/22 at 3:08 p.m., Resident #43 had many long white chin hairs. The hairs were scatter across her chin and were approximately 1 centimeter in length. She had a disheveled appearance. She said she was supposed to get baths on Monday, Wednesday, and Friday. During an observation and interview on 7/27/22 at 5:21 p.m., Resident #43 revealed she did not like having chin hairs. She said she could not pluck her chin hairs because she did not have any tweezers. She said staff had never offered to shave her chin hairs. She said it made her feel grungy to not have a shower. She said having chin hairs was embarrassing. 5. Record review of the face sheet and consolidated physician orders dated 7/27/2022 indicated Resident #214 was [AGE] years old and was admitted on [DATE] with diagnoses including anxiety disorder, stroke, and seizures. Record review of the MDS dated [DATE] indicated Resident #214 usually understood others and was sometimes understood. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 3, indicating Resident #214 was severely cognitively impaired. The MDS indicated Resident #214 required extensive assistance with personal hygiene and total dependence for bathing. The care plan dated 7/19/2022 indicated Resident #214 had an ADL self-care performance deficit. There was an intervention for staff to assist with bathing. Record review of a Documentation Survey Report for bathing indicated Resident #43 did not receive a shower on July 18, 2022, July 19, 2022, and July 20, 2022. During an interview on 7/25/22 at 10:56 a.m., Resident #214 said he had not received scheduled baths. During an interview on 7/27/22 at 8:35 a.m., Anonymous Employee H revealed she wished to remain anonymous. She said she did hear complaints from residents saying they did not receive their scheduled showers or baths. She said she heard a ton of complaints. She said she had reported these complaints to the DON. She said residents going 4 and 5 days without a bath or a shower was par for the course. During an interview on 7/27/22 at 9:26 a.m., CNA B revealed she said she had known residents to refuse showers. She said she rarely heardp complaints from residents about not receiving their scheduled showers or baths. During an interview on 7/27/22 at 10:12 a.m., CNA G revealed she had known of residents not getting their scheduled showers. She said Resident #214 missed baths because he was not listed on the daily shower list. She said a copy is kept at the nurse's station. She said the nurses updated the list. She said Resident #214 had complained to her about not getting his scheduled baths. She said she was not sure why the resident was left off of the shower list and other residents could have been left off of the list . She said there had been problems with the evening shift not helping with the showers and baths. She said they were supposed to help but did not. She said the morning shift could not do all of the showers and the 2-10 shift needed to do the ones assigned to them. During an interview on 7/27/22 at 2:36 p.m., LVN D revealed she was aware that residents had missed scheduled baths and showers. She said when that happened they rearrange the schedule to get them a bathed or showered. She said the CNAs should have documented when the residents refuse. She said residents should never go 4 and 5 days without a bath or shower. She said residents not having a shower or, unshaved chin hairs, greasy hair is a dignity problem . During an interview on 7/27/22 at 3:05 p.m., LVN A said revealed she was aware of residents not getting baths because they had refused. She said all refusals should have been charted. She said there had been a problem with new admits because the agency nurses were not assigning the new residents to a shower day and the residents were not added to the shower sheet because of this. She said LVN D and herself updated this list when they were on duty. She said residents not getting bathed could make them feel like they smell and could cause skin infections. She said chin hairs for women were supposed to be shaved when residents receive showers. She said resident could feel ashamed and embarrassed because of unshaved chin hairs. During an interview on 7/27/22 at 3:30 p.m., the ADON revealed she had not heard residents complain of not getting showers or baths. She said the aides had told her residents refuse at times. She said refusals should have been charted on the ADL chart. She said it was the DON's job and her job to oversee the staff and make sure residents were getting their showers or baths. She said any refusal should be reported to the nurse. She said the nurse should report it to herself or the DON. She said they would then go talk to the resident. She was unaware of residents not being placed on the shower sheets. She said chin hairs should be shaved when the resident was bathed or showered. She said residents have the right to be clean and have showers or baths. During an interview on 7/27/22 at 4:12 p.m., the DON revealed a shower list is created by the nursing staff on the weekends and as needed. She said online charting program did not trigger bath charting. She said baths were considered an as needed task in the charting program. She said there were also daily shower sheets. She said she expected scheduled showers and baths to be given to the residents. She said females with chin hairs should be groomed. She said not having a bath or females having chin hairs is a dignity issue for sure. During an interview on 7/27/22 at 5:25 p.m., the administrator said residents should have received showers or baths as scheduled. He said residents did have a choice. He said resident need to have autonomy and choice. He said you have to have a schedule. He said he would never expect residents to go without a shower or bath unless they refuse. He said he would expect for any refusal to be charted. He said the older generation could be embarrassed by chin hairs. He said staff should want to offer the residents help with chin hairs and would expect the issues to be addressed. On 7/27/2022 at 4:12 p.m., the daily shower sheets were requested from the DON. The shower sheets were not received prior to exit. Review of a grievance dated 7/7/2022 indicated a family member of a previous resident had reported the resident has not had a shower. The grievance indicated a summary of findings/conclusion, shower scheduled for tonight; met with the aide . Review of a facility Bath, Shower policy dated 05/2007 indicated, .It is the policy of this facility to promote cleanliness, stimulate circulation, and assist in relaxation .document all appropriate information in medical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 6 of 19 residents reviewed for palatable food. (Residents #4, #11, #18, #20, #37, and #210) The facility failed to provide palatable food served at an appetizing temperature or taste to Residents #4, #11, #18, #29, #37 and #210 who complained the food was served cold and did not taste good. 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 included: 1. Record review of the face sheet and consolidated physician orders dated 7/26/2022 indicated Resident #4 was [AGE] years old and was admitted on [DATE] with diagnoses including chronic heart failure, end stage renal disease (kidney disease), and diabetes. Record review of the MDS dated [DATE] indicated Resident #4 understood others and was understood. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 12, indicating Resident #4 was moderately cognitively impaired. The MDS indicated the resident was on a therapeutic diet. Record review of a care plan last revised on 7/19/2022 indicated Resident #4 had a nutritional problem or was at risk for a nutritional problem. There was an intervention for a diet as ordered by the physician. 2. Record review of consolidated physician orders dated 7/27/2022 indicated Resident #11 was [AGE] years old and admitted on [DATE] with mild protein-calorie malnutrition, major depressive disorder, and anxiety. Record review of the MDS dated [DATE] for Resident #11 did not indicate speech clarity or BMS score. The MDS indicated Resident #11 required mechanically altered diet. Record review of a care plan dated 7/22/22 indicated Resident #11 had nutritional problems or was at risk for nutritional problems. There were interventions to provide and serve diet as ordered and to provide assistance with meals as needed. 3. Record review of the face sheet and consolidated physician orders dated 7/26/2022 indicated Resident #18 was [AGE] years old and was admitted on [DATE] with diagnoses including dementia, generalized muscle weakness, and high blood pressure. There was a physician's order for a regular diet, mechanical soft texture. (A mechanical soft diet is a texture-modified diet that restricts foods that are difficult to chew or swallow. Foods can be pureed, finely chopped, blended, or ground to make them smaller, softer and easier to chew). Record review of the MDS dated [DATE] indicated Resident #18 understood others and was understood. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 11, indicating Resident #18 was moderately cognitively impaired. The MDS indicated the resident required mechanically altered food. Record review of care plan dated 7/19/2022 indicated Resident #18 had a potential nutritional problem related to dementia and a history of difficulty swallowing. There was an intervention for diet as ordered by physician and to provide and serve diet as ordered. Record review of a weight summary for Resident #18 indicated on 6/10/2022 the resident weighed 137.2. On 7/19/2022 the resident weighed 130.2. 4. Record review of a face sheet and consolidated physician orders dated 7/27/2022 indicated Resident #20 was [AGE] years old and admitted on [DATE] with diagnoses diabetes, high blood pressure and muscle weakness. Record review of the MDS dated [DATE] indicated Resident #20 was understood and understood others. A BIMS (Brief Interview for Mental Status) score of 15 indicated Resident #20 was cognitively intact. There were no nutritional needs addressed in the MDS. Record review of a care plan dated 7/26/2022 indicated Resident #20 had nutritional problem or a potential nutritional problem. With an intervention to honor resident rights to make personal dietary choices. 5. Record review of a face sheet consolidated physician orders dated 7/27/2022 indicated Resident #37 was [AGE] years old and admitted on [DATE] with diagnoses of coronary artery disease (disease of the blood vessels to the heart), anxiety, and depression. Record review of the MDS dated [DATE] indicated Resident #37 was understood and understood others. A BIMS (Brief Interview for Mental Status) score of 7 indicated Resident #37 was severely cognitively impaired. The MDS indicated Resident #37 was on a therapeutic diet. Record review of a care plan dated 6/26/2022 indicated Resident #37 had a nutritional problem or a potential nutritional problem. There were no interventions concerning her diet. 6. Record review of a face sheet and consolidated physician orders dated 7/27/2022 indicated Resident #210 was [AGE] years old and admitted on [DATE] with diagnoses including stroke, kidney diseases, and gastro-esophageal reflux disease. Record review of the MDS dated [DATE] indicated Resident #210 was understood and understood others. A BIMS (Brief Interview for Mental Status) score of 13 indicated Resident #210 was cognitively intact. There were no nutritional needs addressed in the MDS. Record review of a care plan dated 7/26/2022 indicated Resident #210 had impaired physical mobility and a self-care deficit. The care plan indicated Resident #210 had a nutritional problem or a potential nutritional problem. There was an intervention to honor resident rights to make dietary choices. Record review of grievances indicated a grievance on 6/10/2022 by a former resident with a complaint of food is cold every meal. There was a grievance from the same resident on 6/23/2022 indicated the resident had voiced concerns that her breakfast was not edible. An offer was made for the resident to eat in the dining room and to move the residents room to the other end of the hall During an interview on 7/25/22 at 10:49 a.m. Resident #4 revealed the food on the weekends was not good. He said the food was cold and did not taste good. During an interview on 7/25/22 at 11:19 a.m., Resident #18 revealed she could not eat her meals because of her teeth. She said every day she eats oatmeal for breakfast, mashed potatoes for lunch, and peanut butter and jelly sandwiches for supper. She said the worst things was when the cook mashed the potatoes and left the peels in the potatoes. She said she had reported this to staff but could not remember the names. She said she had told the lady that checked her tray that she cannot eat her food. She said she cannot chew the potato peels and had to pick them out. She said she has dentures but did not like to eat with them. During an observation and interview on 7/25/22 at 1:00 p.m., lunch was delivered to Resident #18. She was served mashed potatoes with peels and a bowl of peached. She said she did not tell the aide the mashed potatoes were not right because the aide did not ask. She said she might eat a little but not much. She said she had some ice cream on her night stand she would eat. During an interview on 7/25/22 at 3:05 p.m., Resident #37 revealed the facility served a lot of squash. She said for lunch she was served Herbed Squash and it tasted terrible. She said sometimes the food was cold. During an interview on 7/25/22 at 3:28 p.m., Resident #20 revealed the food was terrible and was always cold. During an interview on7/26/22 at 7:40 am., Resident #210 said the food was terrible. She said the meat never tasted good. During an interview on 7/26/22 at 10:12 a.m., Resident #11 revealed there were problems with the cafeteria. She said the cornbread served on 7/26/2022 was burned and she could not even cut the burned part off. She said she did not eat the cornbread because it was burned. She said sometimes the food was just overcooked. She said she often bought her own soup and carried it to the cafeteria for it to be heated for her. She said the soup is often cold and she had to send it back to be re-heated. She said her soup had been served to her at time after kitchen staff dumped it in a bowl and did not heat it up. During an observation and interview on 7/26/22 at 12:57 p.m., Resident #18 eating in room. On the table in front of her was a bowl of mashed potatoes. There were potato peels in the mashed potatoes. She pushed the bowl away from her, I can't eat this. It is just lumping and peels. The mashed potatoes did appear dry and lumpy. She said she did not tell the aide because they never do anything about it. During an observation and interview on 7/26/22 at 13:27 p.m., a lunch tray was sampled by the Dietary Supervisor and four surveyors. The sample tray consisted of macaroni and cheese, roast beef, carrots, a biscuit, and a cookie. The macaroni and cheese was bland and cold. It tasted like macaroni with no cheese sauce. The roast beef was slightly warm. The biscuit was soggy on the bottom from sitting on the other foods. The carrots were slightly warm. The cookie was overcooked and hard around the edges. The dietary supervisor said the food was warm but not hot enough. She said the macaroni was bland. She said the biscuit was soggy from sitting on the roast beef. During an interview on 7/27/22 at 8:35 a.m., Anonymous Employee H revealed they had heard food complaints. The employee said the complaints were that the food was cold, overcooked, and had no taste. The employee said they had reported this to the DON. The employee said they had witnessed kitchen staff dumping Resident #11's soup in a bowl and not heating it up. During an interview on 7/27/22 at 9:26 a.m. CNA B revealed she had heard a lot of food complaints. She said the residents tell her the food is cold, overcooked, and taste nasty. She said she reports all food complaints to the charge nurse. During an interview on 7/27/22 at 10:12 a.m. CNA G revealed Resident #18 ate mashed potatoes every day with milk. She said Resident #18 could not chew the potato peels in the mashed potatoes. She said she had noticed Resident #18 would spit the potato peels out into a napkin and she only eat a small amount of her mashed potatoes. She said she reports food complaints to the nurses and the dietary supervisor. She said she has heard a lot of food complaints. She said residents tell her the food is cold and they do not get enough food. She said she has told the nurses all of the time and has reported the issue to the Dietary Supervisor. During an interview on 7/27/22 at 2:36 p.m., LVN D revealed she had checked Resident #18's trays in the past. She said she was unaware of any issues Resident #18 had with her mashed potatoes. She said she has heard food complaints from the resident. She said she had been told the food does not taste good, the food is cold, and the meat is tough. She said sometimes Resident #11's soup is served cold and at times just not the way she wants it. She said the food is reheated in the microwave. During an interview on 07/27/22 at 3:05 p.m., LVN A revealed she has always heard food complaints such as I don't like that and there was no variety. She said occasionally she had heard that the food was cold. She said Residents should not be served food that they cannot chew. During an interview on 7/27/22 at 3:23 p.m., the Dietary Supervisor said she heard complaints by word of mouth from the residents and the aides. She said then she goes to the resident to try to solve the problems. She said she had not recently visited with Resident #18. She said she was unaware that kitchen staff was serving her the potatoes with the peels. She said whoever the nurse on duty would be the one to have checked her tray. She said whoever checked her tray should have told her there was an issue. She said she had heard food was not seasoned good, the food was too crunchy or hard, and occasionally that the food was cold. She said Resident #11 wants her soup too hot. She said the soup was cooked in the microwave until it was boiling. She said she was unaware of a staff member dumping the soup right out of the can and into the bowl without it being heated up. She said residents not eating their food could affect a resident's attitude and make them think the kitchen staff did not care about them. During an interview on 7/27/22 at 3:30 p.m., the ADON revealed Resident #18's tray should have been checked by a nurse and they should have reported any issues to the dietary manager and an alternative should have been offered. She said the dietary manager should have then talked to the resident to resolve the issue. She said she had heard of different issues with the food. She said she had heard complaints of the food not being hot enough. During an interview on 7/27/22 at 4:12 p.m., the DON revealed with any food complaints an alternate should be offered. She said any staff that heard a food complaint should write a grievance and notify administration. She said she was always on the hall and was unaware of the issue with the mashed potatoes with Resident #18. She said Resident #11 ate soup around the clock because she had dental issues. She said was unaware her soup was being served cold. She said residents not liking their food or being able to eat their food could affect the resident's nutrition. She said, It would make me depressed. During an interview on 7/27/22 at 5:25 p.m., the Administrator revealed staff should address food complaints by offering alternatives or going back to the kitchen to report complaints. He said he had not heard food complaints. He said administration makes rounds daily to ask residents if they need anything and how things are going. He feels the food service process is taking too long serving food to the residents and plans to make changes. He said the food should be served hot. He said it is the CNAs job to be checking the food as it is served and if it were cold it could be heated up. During an interview on 7/27/22 at 8:10 p.m., the Regional Nurse indicated there was no policy related to palatable food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 staff (CNA G) and 1 of 8 resident (Resident #4) reviewed for infection control. The facility failed to ensure CNA G who worked on the presumptive COVID-19 isolation hall wore PPE appropriately. The facility failed to isolated Resident #4 away from other residents. These failures could place residents, staff, and visitors at risk for exposure to COVID-19/infectious diseases. Findings included: Record review of the face sheet dated 7/26/2022 indicated Resident #4 was [AGE] years old and was admitted on [DATE] with diagnoses including chronic heart failure, end stage renal disease (kidney disease), and diabetes. Record review of the consolidate physician orders for Resident #4 and was dated 7/26/2022 indicated an order for contact/droplet precautions for 14 days upon admission to the facility every shift for 14 days with a start day of 7/18/2022 and an end date of 8/1/2022. Record review of the MDS dated [DATE] indicated Resident #4 understood others and was understood. The MDS indicated a BIMS (Brief Interview for Mental Status) score of 12, indicating Resident #4 was moderately cognitively impaired. The MDS indicated Resident #4 required supervision with locomotion on and off of the unit. Record review of a care plan last revised on 7/19/2022 indicated Resident #4 was at risk for signs and symptoms of COVID-19. There were interventions to educate staff, resident and visitors of COVID-19, of signs and symptoms and precautions and to encourage resident to use a mask to cover nose and mouth when staff were present. Record review of a list of COVID-19 positive staff and residents provided upon entrance to the facility on 7/25/2022 indicated since 7/5/2022 there were 5 COVID-19 positive staff members and 13 positive residents. The last resident tested positive on 7/17/2022 and the last staff member tested positive on 7/24/2022. Record review of an COVID Reminders In-service for all staff dated 7/21/2022 indicated, .mask or respirator .secure ties or elastic bands at middle of head and neck, fit flexible band to nose bridge .fit snug to face and below chin .fit-check respirator . During an observation on 7/25/22 at 10:46 a.m. CNA G was sitting at a desk on the presumptive COVID-19 isolation hall charting on a computer with her N95 mask below her nose. There was a resident sitting next to her less than two feet away. The resident was not wearing a mask. CNA G coughed once while her mask was down. During this observation there was no attempt made by CNA G to pull the mask over her nose. During an observation on 7/25/22 at 10:49 a.m., Resident #4 came down the hallway in his wheelchair with no mask on from a common area with no mask on. Resident #4 went past CNA G and the resident sitting next to her. There was no attempt made by CNA G to encourage either resident to wear a mask. There were two white signs hanging on the door of the room. One read, Please see nurse before entering. The other read, Respiratory/Droplet Isolation, Required PPE: Gloves, Gown, N95-Mask and Goggles/Faceshield. There was a pink sign on the door that read, STOP: See Nurse, Resident is on New admission Isolation until A Bed 7/28/2022, B Bed 7/29/2022. During an interview on 7/25/22 at 10:57 a.m., CNA G revealed the roommate of Resident #4 was on isolation for being a new admit. She said all new admits were placed on that hall for isolation. During an observation on 7/25/22 at 11:00 a.m., CNA G was assisting the resident sitting next to her back to the resident's room. CNA G's N95 mask was below her nose. During an observation on 7/25/22 at 4:06 p.m., Resident #4 left his room with no mask on. Resident #4 left the isolation hall and entered a common area of the facility. During an observation on 7/26/22 at 7:34 a.m. CNA G was walking down the presumptive COVID-19 hall with her N95 mask below her nose. During an observation on 7/26/22 at 10:17 a.m., Resident #4 was sitting in the common area while staff read to the residents. There was no attempt made by staff to redirect Resident #4 back to his room or to encourage him to wear a mask. During an observation on 7/26/22 at 10:37 a.m., CNA G was providing direct care to a resident with her N95 mask down below her nose. During an observation on 7/26/22 at 10:43 a.m., CNA G was performing a Hoyer lift transfer of a resident with the DON. CNA G's N95 mask was not sealed across the bridge of her nose. During an interview on 7/26/22 at 11:06 a.m., CNA G said she had problems keeping her mask up over her nose. She said the mask would slide down her nose. She said she did try to keep the mask up over her nose. She said she had not been fit tested for an N95. She said she had been in-serviced on how to properly wear an N95 and she did know that it was supposed to stay above her nose. During an observation on 7/26/22 at 11:30 a.m., Resident #4 was present at an exercise activity for all resident with no mask. There was greater than 20 residents present at the activity. Resident #4 wheeled across the room in close proximity of other residents. At times coming within one foot of other residents. There was no attempt made by staff to redirect Resident #4 back to his room or to encourage him to wear a mask. During an observation on 7/27/22 at 8:31 a.m., Resident #4 was sitting out in the common area with no mask on. There were 3-4 other residents present in the area. Several staff members walked through the common area. There was no attempt made by staff to redirect Resident #4 back to his room or to encourage him to wear a mask. During an interview on 7/27/22 at 8:35 a.m., Anonymous Employee H revealed Resident #4 had been out of his isolation room without a mask on many times. The employee said Resident #4 did not attend activities but did come through areas where activities were going on with non-isolated residents present. During an interview on 7/27/22 at 9:26 a.m., CNA B revealed all staff were supposed to be wearing N95 mask. She said she had received training on how to properly wear the mask and it was supposed to stay above the nose at all times. She said she did work on the presumptive positive COVID-19 hall. She said all residents on isolation were supposed to stay in their rooms. She said she has encouraged Resident #4 to stay in his room and to wear a mask when he did have to leave his room. She said she had reported the resident not staying in his room to the DON. During an interview on 07/27/22 at 10:12 a.m., CNA G revealed residents on isolation were supposed to stay in their room. She said she did know now that Resident #4 was supposed to be on isolation. She said at first she did not know because he had been here before. She said she had witnessed him eating in the dining room with other residents while he was supposed to be on isolation. During an interview on 7/27/22 at 2:25 p.m., Resident #4 revealed had three Covid-19 vaccines and was part of a Covid-19 study. He said he was not aware he was on isolation and did not know he was supposed to stay in his room. He said staff had not told him he was on isolation, that he should wear a mask while out of his room, or for him to stay in his room. During an interview on 7/27/22 at 2:36 p.m., LVN D revealed said she had worked on the presumptive positive COVID-19 hall. She said Resident #4 was on isolation because he came back from the hospital. She said he should have been staying in his room and wearing a mask when he does have to come out of the room. She said if he were COVID-19 positive he could pass COVID-19 to the other residents. She said she thought residents were tested twice a week. She said she had witnessed Resident #4 out of his room around other residents with no mask while he was on isolation. During an interview on 7/27/22 at 3:05 p.m., LVN A said residents on isolation should not be out of their rooms. She said those on isolation for presumptive COVID-19 could pass COVID-19 on to other residents. During an interview on 7/27/22 at 3:30 p.m. the ADON revealed all staff were required to wear an N95 or KN95 mask because of the positives in the building. She said the straps should be in the proper place on the head and the mask should cover the nose and mouth. She said there should be a seal over the bridge of the nose. She said there have been in-services on how to properly wear PPE (personal protective equipment) but she is unsure if there have been any in-services about fitting of mask. She said they do encourage quarantined residents to stay in their rooms and wear a mask when they have to leave the room. She said Resident #4 had been told he was on isolation when he returned from the hospital. She said he was a long-term resident and was usually on Hall 200. She said he had to go to dialysis and appointments. She said staff should have encouraged him to wear a mask. She said him being outside of his room without a mask could expose other residents to COVID-19. She said the facility was currently on outbreak status. She said the last resident to test positive was on July 17, 2022. During an interview on 7/27/22 at 4:12 p.m., the DON revealed all staff should have been wearing an N95 or KN95 because of the outbreak status. She said she had to tell CNA G to pull up her mask. She said CNA G's mask fit her loose and it would slide down her nose. She said she had even asked her to change her mask numerous times. She said staff not wearing a mask properly could cause residents to be exposed to Covid-19. She said Resident #4 was on isolation. She said Resident #4 was very stubborn and non-compliant. She said he had been provided with mask and had been educated on wearing them. She said it could be a big deal with him exposing other residents to COVID-19 and with infection control. During an interview on 7/27/22 at 5:25 p.m., The administrator revealed the only time a mask should have been down was for staff to take a quick drink at the nurse's station or in the break room. He said the mask should be always worn over the nose and mouth while out in a public area. He said he expected residents on isolation to stay in their room. He said there were difficult residents that could not be kept in their room. He expected staff to have encouraged them to stay in their room and wear a mask when they did leave their room. He said staff not encouraging a resident on isolation to return to their room or wear a mask, This is absolutely not ok. He said Resident #4 was an unknown exposure from being in the hospital. He said if he did pop positive you could have a potential spread of Covid 19. Review of a facility Infection Control and Prevention Program, subject: Transmission Based Precautions and Isolation policy dated 9/29/2017 indicated, It is the policy .to prevent the spread of communicable diseases and conditions .it is therefore appropriate to use the least restrictive approach possible that adequately protects the resident and others .mask and eye protectors: must be worn if blood or other body fluids may be splashed or sprayed into the mucous membranes of the eyes, nose, and/or mouth .Room Placement: will depend on the epidemiology of the specific microorganisms, the ability of the resident to assist in confining and containing the microorganisms and temporal relationship of the known infected or colonized residents to newly identified cases .Residents with respiratory symptoms .should be encouraged to wear a mask if they insist on leaving their room . Review of a Facemask Do's and Don'ts for Healthcare personnel, https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html, dated June 2, 2020, indicated, .don't wear your facemask under your nose or mouth . Review of a CDC (Centers of Disease Control and Prevention) article titled Proper N95 Respirator Use for Respiratory Protection Preparedness accessed on last updated on 8/4/2020 at https://blogs.cdc.gov/niosh-science-blog/2020/03/16/n95-preparedness/ indicated .OSHA requires healthcare workers who are expected to perform patient activities with those suspected or confirmed to be infected with COVID-19 to wear respiratory protection, such as an N95 respirator. N95 respirator refers to an N95 filtering facepiece respirator (FFR) that seals to the face and uses a filter to remove at least 95% of airborne particles from the user's breathing air. It is important to note that surgical masks, sometimes referred to as facemasks, are different than respirators and are not designed nor approved to provide protection against airborne particles. Surgical masks are designed to provide barrier protection against droplets, however they are not regulated for particulate filtration efficiency and they do not form an adequate seal to the wearer's face to be relied upon for respiratory protection. Without an adequate seal, air and small particles leak around the edges of the respirator and into the wearer's breathing zone . Review of Clinical Questions about COVID-19: Questions and Answers, https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html, last updated June 8, 2022, indicated, .Currently, those at greatest risk of infection are persons who have had prolonged, unprotected close contact (i.e., within 6 feet for 15 minutes or longer) with a patient with confirmed SARS-CoV-2 infection, regardless of whether the patient has symptoms. Persons frequently in congregate settings (e.g., homeless shelters, assisted living facilities, college or university dormitories) are at increased risk of acquiring infection because of the increased likelihood of close contact. Those who live in or have recently been to areas with sustained transmission may also be at higher risk of infection. All persons can reduce the risk to themselves and others by wearing a mask, practicing physical distancing, washing their hands often, and taking other prevention measures .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: Resident #26's sunny side eggs were prepared with pasteurized eggs. food items were dated, labeled, and sealed appropriately. hair restraints were worn by dietary staff. expired food item was discarded. the toaster and microwave clean and free of food debris. ice machine filter clean and free from debris the cooking grease in the deep fryer was kept clean. the deep fryer was free of grease build up. This failure could place residents at risk for foodborne illness. Findings included: During an observation in the refrigerator and freezer on 7/25/22 starting at 10:49 a.m. revealed 1 squeeze bottle of Welch's Concord Grape Jelly undated; 1 bag of carrot raisin salad undated; 1 unopened large bag of salad garden mix with a brown substance noted on the lettuces throughout the bag dated 7/20/22; 1 metal container with 2 boiled eggs with no date or label; 1 box of frozen green beans undated; and 1 frozen box of peach cobbler buffet style undated. During an observation in the dry storage room on 7/25/22 starting at 10:49 a.m. revealed 1 bag of vanilla wafers unlabeled and undated; 6 boxes of iodized salt undated; 9 boxes of grits undated; 2 containers of Quaker oats undated; 3 containers of sweet and sour sauce undated; and 3 squeeze bottles of brown substance identified by the Dietary Manager as syrup unlabeled and undated. During an observation, interview, and record review on 7/25/22 starting at 10:49 a.m., revealed a box of 99 unpasteurized eggs. The Dietary Manager reviewed the 7/13/22 invoice with surveyor and stated, I thought the eggs were pasteurized. She said Resident #26 was the only resident at this time receiving sunny side eggs. The Dietary Manager said she was unaware of the eggs been unpasteurized until surveyor intervention. The Dietary Manager said she will be throwing the eggs out and will notify her staff. During an observation in the kitchen on 7/25/22 at 11:00 a.m., revealed the toaster with food particles, yellow buildup inside the microwave, grease buildup around the deep fryer, and dark brown grease noted inside the deep fryer. The ice machine filter was covered with a thick grey fuzzy substance. During an observation on 7/25/22 at 11:07 a.m., Dietary Aide L was preparing desserts for the lunch meal. Dietary Aide L was wearing a turquoise and grey baseball cap without a hair restraint. During an interview won 7/25/22 at 2:55 p.m. the facility's food distributor's customer service department indicated the eggs were purchased on 7/13/22 were not pasteurized. During an observation on 7/25/22 at 5:10 p.m., the Dietary Manager was in the dry storage room without a hair restraint. Record review of a dining services and sanitation audit dated 7/21/22 completed by the Dietician indicated open/use by date and label products was not up to standards during her visit. The audit indicated items in the dry storage room items were not dated, labeled, covered, or rotated. The Dietician commented on the audit the microwave needs to be replaced. Record review of a face sheet dated 7/27/22 indicated Resident #26 was a [AGE] year-old male, readmitted on [DATE] with diagnosis including essential hypertension (force of the blood against the artery walls is too high), dementia without behavioral disturbance (loss of memory, language, problem solving, and other thinking abilities were severe enough to interfere with daily life) and hyperlipidemia (blood has too many lipids (or fats). During an interview and record review on 7/26/22 at 2:10 p.m., Resident #26 indicated he had not experienced any affects in the last few weeks from the eggs. Record review of the infection and control tracking and trending revealed there had not been any affects from the unpasteurized eggs. During an interview on 7/27/22 at 3:26 p.m., the Dietician stated her first visit to the facility was about a week ago. She stated she did notice while in the facility food was not labeled or dated. The Dietician stated she expected all food to be labeled with the date received. She stated, The harm that can occur from food not being labeled and dated was the quality of food can be effected as well as potential contaminates and serving spoiled food. She stated during her visit she did not notice staff not wearing hairnets, but she did expect all staff to wear hairnets while in the kitchen. She stated the potential harm for not wearing hairnet while in kitchen was physical debris getting into food. The Dietician was not aware the ice machine filter was dirty. She stated she did check the inside and outside of the ice machine, but the filter was usually checked and changed by maintenance. The Dietician stated she did notice grease fryer had grease build-up. She states she expected the grease fryer to be cleaned and oil changed weekly. Also, states the color of the grease should be light in color. She stated this failure could affect the taste and quality of the product/food. The Dietician stated she was unaware unpasteurized eggs were in the facility. The Dietician stated she expected eggs to be from source serves pasteurized eggs. The Dietician stated if unpasteurized eggs are served it can cause food-borne illness. Dietician stated, best practice was a 3-day shelf life. If quality of product was poor (brown looking) it should be disposed of. She stated the failure of serving poor quality food can affect patient intake. The Dietician said a copy of the audit was given to the dietary manager prior to exiting. During an interview on 7/27/22 at 3:55 p.m., [NAME] F stated all food products should be labeled and dated within around 1 hour of shipment. [NAME] F said foods should be discarded by their 3-day shelf life. She stated the potential harm for serving food past the shelf life was you don't know when to discard or safe-to-eat. [NAME] F said all staff was responsible for ensuring this was done. She said all staff should wear a hairnet while in the kitchen. She said the potential harm could be hair in food and safety for residents. [NAME] F said ice filters should be cleaned 1 time per week by a dietary staff. She said this could cause bacteria growth was harmful to residents. [NAME] F said fryer grease should be changed after the third use. She said grease buildup on sides of fryer should be cleaned two or three times per week. She said this potential harm could cause sickness or food-borne illness. [NAME] F said she was unaware the eggs were unpasteurized. [NAME] F said she did not usually cook with the eggs due to her coming in the evening. [NAME] F stated you identify pasteurized vs unpasteurized by the little P on the eggs. She stated cooking with unpasteurized eggs can cause food-borne illness. [NAME] F said all staff was responsible for ensuring this was done. During an interview on 7/27/22 at 4:05 p.m., the Dietary Manager said she had worked at the facility for 6-8 weeks. She said cleanliness was important in the kitchen, so you are not spreading germs or contaminating anything. She said she was responsible for making sure the kitchen was cleaned appropriately. The dietary manager said hair nets should be on when they walk in the door, so no hair contaminates the food. The dietary manager said all food should be labeled with date received and the date it was opened. She said when freight is put up, whoever touched the item needs to label and date the item as to when it was opened. She said if it is taken out of the original box then it should be labeled what it is, the date received, and when they opened it. She said it should be dated so we know the food is not old and know how long it had been opened. She said food should be discarded after 3-day shelf life. The Dietary Manager said maintenance was responsible for ice filter changes. She said the fryer needed to be cleaned 1 time per week and the grease needed to be changed 1 time per week. The Dietary Manager said these failures could cause food born illness. She said the microwave and toaster was cleaned after surveyor intervention. She said she did daily sweeps during the day and may point out things that needed to be done or she did those things. She stated this failed because of lack of memory. During an interview on 7/27/22 at 7:30 p.m., the Administrator said he expected all food to be labeled and dated. He said he expected the kitchen to be clean and staff preventing cross contamination. The Administrator said he had only been at this facility for two weeks. Record review a facility food storage policy dated 8/2007 did not address labeling and dating food products. During an interview on 07/27/2022 at 6:55 p.m. a policy for general kitchen sanitation was requested from the DON but was not provided upon exit.