HANSFORD COUNTY HOSPITAL DISTRICT DBA LAKERIDGE NU

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #1, Resident #2 and #3) reviewed for infection control.1. CNA A failed to change gloves when going from dirty to clean when providing incontinence care for Residents #1, #2, and #3. These failures could place residents at risk for cross contamination and infection. The findings include: Resident #1 Record review of the admission record for Resident #1, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (a group of permanent movement disorders that affect brain-controlled muscle functions), schizoaffective disorder, bipolar type (mental health disorder) and anemia (not enough red blood cells to carry oxygen throughout the body). Record review of the quarterly MDS assessment for Resident #1, dated 08/27/25 revealed Resident #1 was always incontinent of bladder and bowels. Record review of the current care plan for Resident #1, last reviewed on 06/27/25, revealed there was a focus area: Bladder/Bowel Incontinence: I have bowel and bladder incontinence. During an observation on 09/05/25 at 11:30 AM, CNA A provided incontinence care and catheter care for Resident #1 with the help of CNA B. CNA A and CNA B washed their hands with soap and water and put on a clean pair of gloves. CNA A then unfastened the brief for Resident #1 and began cleaning his groin area with wipes. Resident #1 was turned on his side and CNA A removed the old brief. CNA A then wiped Resident #1's buttocks and placed a clean brief under Resident #1. CNA A secured the new brief and pulled up Resident #1's pants with the help of CNA B. CNA A then removed her gloves and used hand sanitizer to clean her hands. CNA A did not change her gloves and perform hand hygiene before going from dirty to clean during the procedure. Resident #2 Record review of the admission record for Resident #2, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: atherosclerotic heart disease (thickening or hardening of the arteries) dysphagia (difficulty swallowing), and aphasia (a language disorder that makes it difficult to communicate). Record review of the quarterly MDS assessment for Resident #2, dated 08/17/25, revealed Resident #2 was always incontinent of bladder and bowels. Record review of the current care plan for Resident #2, last reviewed on 09/04/25, revealed there was a focus area: [Resident #2] has bladder incontinence r/t history of UTI (Urinary Tract Infection). During an observation on 09/05/25 at 11:00 AM, CNA A provided incontinence care for Resident #2 with the help of CNA B. CNA A and CNA B washed their hands with soap and water and put on clean gloves. CNA A then unfastened Resident #2's brief and cleansed his groin with wipes. Resident #2 was turned on his side and CNA A wiped his buttocks with wipes. CNA A then removed the dirty brief and placed a clean brief under Resident #2 without changing her gloves. CNA A then secured Resident #2's brief and pulled his pants up. CNA A then transferred Resident #2 to his wheelchair and removed her gloves. CNA A then used hand sanitizer to cleanse her hands. CNA A did not change her gloves and perform hand hygiene before going from dirty to clean during the procedure. Resident #3 Record review of the admission record for Resident #3, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (a group of permanent movement disorders that affect brain-controlled muscle functions), strabismus (crossed eyes or squint), and mild intellectual disabilities. Record review of the comprehensive MDS assessment for Resident #3, dated 07/30/25, revealed Resident #3 was frequently incontinent of bladder and always incontinent of bowels. Record review of the current care plan for Resident #3, last reviewed on 09/04/25, revealed there was a focus area: [Resident #3] has bowel and bladder incontinence. During an observation on 09/05/25 at 11:45 AM, CNA A provided incontinence care for Resident #3 with the help of CNA B. CNA A and CNA B washed their hands with soap and water and put on clean gloves. CNA A pulled down Resident #3's shorts and then unfastened Resident #3's brief. CNA A then cleansed Resident #3's groin with wipes. CNA A then removed Resident #3's old brief and then wiped his buttocks with wipes. CNA A placed a clean brief under Resident #3. CNA A secured Resident #3's brief and pulled up Resident #3's shorts. CNA A then transferred Resident #3 to his wheelchair. CNA A then removed her gloves and used hand sanitizer to cleanse her hands. CNA A did not change her gloves and perform hand hygiene before going from dirty to clean during the procedure. During an interview on 09/05/25 at 11:53 AM, CNA A stated she had received training regarding changing her gloves and performing hand hygiene when going from dirty to clean during a procedure. CNA A stated she could not remember the last time she was trained for incontinence care and infection control. CNA A stated she did not change her gloves and perform hand hygiene when going from dirty to clean because she did not think about it. CNA A stated the residents had an increased risk for UTI's and germs. During an interview on 09/05/25 at 11:54 AM, the DON stated she expected the staff to change their gloves and perform hand hygiene when going from dirty to clean when providing care to a resident. The DON stated she did not remember when the last training was for incontinence care/infection control and stated the staff were scheduled to be trained that month regarding infection control. The DON stated CNA A usually did transport for the facility but would get pulled to the floor if a CNA called in. The DON stated a potential negative outcome to the residents was possible infections or UTI's. During an interview on 09/05/25 at 2:35 PM, the Admin stated she expected the staff to change their gloves when going from dirty to clean when providing care. The Admin stated CNA A probably was not paying attention or was nervous and that was why she forgot to change her gloves and perform hand hygiene when going from dirty to clean. The Admin stated CNA A was usually the van driver for the facility, but she was pulled to the floor because someone call in that day. The Admin stated CNA A was trained to change her gloves when going from dirty to clean. The Admin stated the residents had a potential negative outcome for spreading infection. Record review of the facility policy titled, Policies and Practices - Infection Control, with a revised date of October 2018 reflected the following: Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #1, Resident #2 and #3) reviewed for infection control.1. CNA A failed to change gloves when going from dirty to clean when providing incontinence care for Residents #1, #2, and #3. These failures could place residents at risk for cross contamination and infection. The findings include: Resident #1 Record review of the admission record for Resident #1, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (a group of permanent movement disorders that affect brain-controlled muscle functions), schizoaffective disorder, bipolar type (mental health disorder) and anemia (not enough red blood cells to carry oxygen throughout the body). Record review of the quarterly MDS assessment for Resident #1, dated 08/27/25 revealed Resident #1 was always incontinent of bladder and bowels. Record review of the current care plan for Resident #1, last reviewed on 06/27/25, revealed there was a focus area: Bladder/Bowel Incontinence: I have bowel and bladder incontinence. During an observation on 09/05/25 at 11:30 AM, CNA A provided incontinence care and catheter care for Resident #1 with the help of CNA B. CNA A and CNA B washed their hands with soap and water and put on a clean pair of gloves. CNA A then unfastened the brief for Resident #1 and began cleaning his groin area with wipes. Resident #1 was turned on his side and CNA A removed the old brief. CNA A then wiped Resident #1's buttocks and placed a clean brief under Resident #1. CNA A secured the new brief and pulled up Resident #1's pants with the help of CNA B. CNA A then removed her gloves and used hand sanitizer to clean her hands. CNA A did not change her gloves and perform hand hygiene before going from dirty to clean during the procedure. Resident #2 Record review of the admission record for Resident #2, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: atherosclerotic heart disease (thickening or hardening of the arteries) dysphagia (difficulty swallowing), and aphasia (a language disorder that makes it difficult to communicate). Record review of the quarterly MDS assessment for Resident #2, dated 08/17/25, revealed Resident #2 was always incontinent of bladder and bowels. Record review of the current care plan for Resident #2, last reviewed on 09/04/25, revealed there was a focus area: [Resident #2] has bladder incontinence r/t history of UTI (Urinary Tract Infection). During an observation on 09/05/25 at 11:00 AM, CNA A provided incontinence care for Resident #2 with the help of CNA B. CNA A and CNA B washed their hands with soap and water and put on clean gloves. CNA A then unfastened Resident #2's brief and cleansed his groin with wipes. Resident #2 was turned on his side and CNA A wiped his buttocks with wipes. CNA A then removed the dirty brief and placed a clean brief under Resident #2 without changing her gloves. CNA A then secured Resident #2's brief and pulled his pants up. CNA A then transferred Resident #2 to his wheelchair and removed her gloves. CNA A then used hand sanitizer to cleanse her hands. CNA A did not change her gloves and perform hand hygiene before going from dirty to clean during the procedure. Resident #3 Record review of the admission record for Resident #3, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (a group of permanent movement disorders that affect brain-controlled muscle functions), strabismus (crossed eyes or squint), and mild intellectual disabilities. Record review of the comprehensive MDS assessment for Resident #3, dated 07/30/25, revealed Resident #3 was frequently incontinent of bladder and always incontinent of bowels. Record review of the current care plan for Resident #3, last reviewed on 09/04/25, revealed there was a focus area: [Resident #3] has bowel and bladder incontinence. During an observation on 09/05/25 at 11:45 AM, CNA A provided incontinence care for Resident #3 with the help of CNA B. CNA A and CNA B washed their hands with soap and water and put on clean gloves. CNA A pulled down Resident #3's shorts and then unfastened Resident #3's brief. CNA A then cleansed Resident #3's groin with wipes. CNA A then removed Resident #3's old brief and then wiped his buttocks with wipes. CNA A placed a clean brief under Resident #3. CNA A secured Resident #3's brief and pulled up Resident #3's shorts. CNA A then transferred Resident #3 to his wheelchair. CNA A then removed her gloves and used hand sanitizer to cleanse her hands. CNA A did not change her gloves and perform hand hygiene before going from dirty to clean during the procedure. During an interview on 09/05/25 at 11:53 AM, CNA A stated she had received training regarding changing her gloves and performing hand hygiene when going from dirty to clean during a procedure. CNA A stated she could not remember the last time she was trained for incontinence care and infection control. CNA A stated she did not change her gloves and perform hand hygiene when going from dirty to clean because she did not think about it. CNA A stated the residents had an increased risk for UTI's and germs. During an interview on 09/05/25 at 11:54 AM, the DON stated she expected the staff to change their gloves and perform hand hygiene when going from dirty to clean when providing care to a resident. The DON stated she did not remember when the last training was for incontinence care/infection control and stated the staff were scheduled to be trained that month regarding infection control. The DON stated CNA A usually did transport for the facility but would get pulled to the floor if a CNA called in. The DON stated a potential negative outcome to the residents was possible infections or UTI's. During an interview on 09/05/25 at 2:35 PM, the Admin stated she expected the staff to change their gloves when going from dirty to clean when providing care. The Admin stated CNA A probably was not paying attention or was nervous and that was why she forgot to change her gloves and perform hand hygiene when going from dirty to clean. The Admin stated CNA A was usually the van driver for the facility, but she was pulled to the floor because someone call in that day. The Admin stated CNA A was trained to change her gloves when going from dirty to clean. The Admin stated the residents had a potential negative outcome for spreading infection. Record review of the facility policy titled, Policies and Practices - Infection Control, with a revised date of October 2018 reflected the following: Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Abuse Coordinator for 3 of 6 residents (Resident #1, #2, and #3) reviewed for abuse. <BR/>A. <BR/>The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding Resident #1 being fed forcibly by CNA A on an unknown date. <BR/>B. <BR/>The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding Resident #2 being transferred in a rough manner (chucked in the bed) by CNA A on an unknown date. <BR/>C. <BR/>The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding Resident #3 being changed improperly by CNA B on an unknown date. <BR/>These failures could place residents as risk for abuse and neglect. <BR/>Findings included:<BR/>Resident #1 <BR/>Record Review of Resident #1's face sheet, dated 1/28/25, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss) and anxiety (increased worry). <BR/>Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 00, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 did not exhibit physical behavior (hitting, kicking, pushing, scratching, grabbing, and abusing) during the review period [E0200]. Section GG revealed Resident #1 was dependent on staff for all her eating needs [GG0130]. Section K revealed that Resident #1 had the following swallowing disorder: coughing or choking during meals [K0100.].<BR/>Record review of Resident #1's progress notes dated from 10/27/24- 1/28/25 did not reveal any information regarding choking or allegation of abuse between the dates of 1/01/25-1/28/25.<BR/>Record review of Resident #1's care plan, dated 1/21/25, revealed a focused area, initiated on 12/13/23, Resident #1 had an ADL self-care performance deficit r/t dementia. The goal initiated on 12/13/23, was Resident #1 would maintain current level of function through the review date review date (02/06/24-01/21/25). The interventions initiated 12/13/23 included while eating Resident #1 would be fed for all meals.<BR/>During an interview on 1/28/25 at 2:50 PM, Resident #1 was unable to answer any questions about the staff's feeding technique. She lay in bed and was nonverbal at the time of the attempted interview.<BR/>Resident #2 <BR/>Record Review of Resident #2's face sheet, dated 1/28/25, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss), pain in unspecified joint and anxiety (increased worry). <BR/>Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 03, indicating the resident was severely cognitively impaired. Section GG revealed Resident #2 requires partial or moderate assistance when it comes to chair/bed to chair transfer.<BR/>Record review of Resident #2's progress notes dated from 10/27/24- 1/28/25 did not reveal any information regarding improper transfer or allegation of abuse between the dates of 1/01/25-1/28/25.<BR/>Record review of Resident #2's care plan, dated 6/14/24, revealed a focused area, initiated on 6/17/24, Resident #2 had an ADL self-care performance deficit r/t left hip and sacrum fracture. The goal initiated on 6/17/24, was Resident #2 would maintain current level of function through the review date review date (08/15/24-06/20/25). The interventions initiated 6/17/24 included Resident #2 required extensive assistance by 1 staff to move between surfaces. <BR/>During an interview on 1/28/25 at 4:15 PM, Resident #2 stated she could not remember if staff had been rough with her. When asked about transfers, she said she could not remember anything. <BR/>Resident #3<BR/>Record Review of Resident #3's face sheet, dated 1/28/25, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with a diagnosis of Alzheimer's (memory loss) and anxiety (increased worry). <BR/>Record Review of Resident #3's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 03, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 did exhibit verbal behavior (threatening, screaming and cursing at others) during the review period [E0200]. Section GG revealed that Resident #3 requires substantial/maximal assistance regarding toileting hygiene [GG0130]. Section H revealed Resident #3 was always incontinent of bowel and urinary [H0300-0400].<BR/>Record review of Resident #3's progress notes dated from 10/27/24- 1/28/25 did not reveal any information regarding improper perineal care or allegation of abuse between the dates of 1/01/25-1/28/25.<BR/>Record review of Resident #3's care plan, dated 3/08/24, revealed a focused area, initiated on 3/18/24, Resident #3 had bladder incontinence r/t Alzheimer's. The goal initiated on 3/18/24, was Resident #3 was at risk for septicemia (life threatening bacterial disease) will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through review date (4/30/24-06/20/25). The interventions initiated 3/18/24 did not include instruction to staff on what to do regarding incontinence care. <BR/>Record review of Resident #3's care plan, dated 3/08/24, revealed a focused area, initiated on 3/18/24, Resident #3 had an ADL Self Care performance deficit r/t Alzheimer's. The goal initiated on 3/18/24, was Resident #3 was to maintain current level of function in eating through the review date (4/30/24-06/20/25). The interventions initiated 3/18/24 stated Resident #3 was totally dependent on staff for toilet use.<BR/>Record review of Resident #3's care plan, dated 3/08/24, revealed a focused area, initiated on 3/18/24, Resident #3 was resistive to care and would refuse to be changed r/t Alzheimer's. The goal initiated on 3/18/24, was Resident #3 would cooperate with care through review date (4/30/24-06/20/25). The interventions initiated 3/18/24 did not include if Resident #3 resisted with ADLs, negotiate a time so that the resident can participate in the decision making process.<BR/>During an interview on 1/28/25 at 4:00 PM, Resident #3 did not provide any pertinent information related to the deficient practice. <BR/>During an interview on 1/28/25 at 12:14 PM, Student C stated that she reported allegations of abuse when she was completing her clinical at the NF. She said she was not in a place where she could talk but could give the information later to the investigator. She said she did write a statement and reported the allegations of abuse to the ADON and the ADM that she had witnessed abuse and neglect at the facility. <BR/>During an interview on 1/28/25 at 1:15 PM, CNA A stated she was unsure of the exact day and time but that Student C had alleged that she was doing something wrong. The CNA stated she did not do anything wrong. She stated that she was asked to write a statement and was addressed about the allegations immediately. She said she focused on providing care for her residents and would not abuse them.<BR/>During an interview on 1/28/25 at 2:00 PM, the DON stated that she was unsure of the date and time but that Student C did not make a report of abuse to her. She said the report was made to the ADON. She said she was not clear on all the allegations, but it was her understanding that CNA A force-fed someone and threw someone on their bed. She said it was her understanding that an investigation was done, the facility cameras were watched, and none of the findings were valid. She stated she was unsure of which resident was force-fed but that she believed the resident who was thrown in bed was Resident #2.<BR/>During an interview on 1/28/25 at 2:20 PM, the ADON stated she was unsure of the date and time, but Student C came to her at least three weeks ago with another employee (CNA D). She stated that she was told by CNA D that Student C needed to speak with her. The ADON stated that she was told by Student C that she (Student C) had an abuse case that she wanted to report. The ADON stated that the DON was off on that day, and as a result, she went to the ADM. She stated she did not want to take a statement regarding abuse by herself. She stated that in the presence of the ADM, CNA Student C stated that CNA A fed a resident with a spoon with too much food, making the resident choke. The ADON stated that Student C reported that CNA B performed perineal care incorrectly. The ADON stated that she could not fully remember what Student C alleged. She stated they had Student C write a statement, which was submitted to the ADM. The ADON stated it was her understanding that the information gathered was submitted to their corporate. She stated that it was told to her that what was told to her (the ADON) and what was on the statement were different. She stated they educated staff on what to do if residents are choking and how to conduct perineal care. She stated that they asked nurses if they had witnessed anything and that no one had reported anything. The ADON stated that after she, the DON, and the ADM got statements and consulted with corporate, it was concluded that Student C was a new CNA and everything was a first for Student C in the nursing home environment. The ADON stated she had been trained on the facility's abuse policy. She stated that failure to report allegations of abuse to HHSC could result in the nursing facility being shut down. She said abuse could continue if it is not reported correctly. She stated that the purpose of reporting allegations of abuse to HHSC was to ensure that residents are treated fairly and keep them free from abuse and that all allegations of abuse are investigated on a higher level. She stated she was unaware that the allegations had not been reported to HHSC. She stated she was unaware that the incident with Student C was supposed to be reported to HHSC. She stated that their system to monitor and ensure that the abuse policy was being followed was that all allegations of abuse should be reported to the abuse coordinator, the ADM. The ADON stated that in-services and education on expectations are conducted. She stated they are trained and train the staff to report anything that seems unjust and anything they would not want to their family members. She said the ADM and the DON will conduct the investigation and report the appropriate information to HHSC. She stated that she expected all allegations of abuse to be reported to the abuse coordinator (ADM), the abuse policy followed, and all staff educated accordingly. The ADON stated that the ADM and DON were responsible for reporting allegations of abuse to HHSC. She said she was unsure of the reason the allegations of abuse reported by Student C were not to HHSC.<BR/>During an interview on 1/28/25 at 3:00 PM, the ADM stated he was unsure of the specific date and time, but Student C reported that she had concerns about how staff at the NF were taking care of the residents. He stated he had her write a statement. He stated that during their interview, Student C reported that a staff (CNA B) was rough with a resident, and the resident was screaming out. He said that he was told by Student C that another staff member (CNA A) had chucked another resident into bed. He said Student C stated that a staff (CNA A) overfed a resident and caused her to choke. The ADM said he took Student C's statement and sent it to his corporate staff. He stated he was instructed to conduct a 1:1 with both staff members, assess all residents, in-service all staff on customer care, and conduct safe surveys with residents. The ADM stated that Student C did not mention the term abuse or neglect. The ADM stated that he interpreted the student's statement that she had concerns but was not alleging abuse. He stated that he felt the student was bringing to his attention that the staff were rushing. He stated he would hope that his staff, when reporting serious incidents, would be specific and use the actual word abuse and neglect. She stated that she did not disclose the resident's names when Student C reported the incident. He stated that in the process of their investigation, they concluded that it was Resident #1 regarding the feeding incident, Resident #2 who was allegedly chucked on the bed, and Resident #3 involved in the perineal care. The ADM stated that because Student C did not provide names, he could not be 100 percent sure those were the residents involved. The ADM stated he did not report the allegations to HHSC because he did not perceive them as allegations of abuse but thought it was a concern in all three instances where staff may have been rushing and needed additional education. He stated that the purpose of reporting allegations to HHSC was to prevent abuse and to ensure that the resident's rights were being taken care of. The ADM stated that the potential negative outcome of not reporting all allegations of abuse to HHSC was that residents could endure abuse. He stated he was familiar with the facility's abuse policy and had been trained on the policy. He stated he was aware that he did not report the concerns to HHSC. He said their system for monitoring the implementation of the facility's abuse policy was to consult with corporate staff to see if they have enough evidence to report the allegation. He stated he had been trained to report all allegations of abuse to HHSC, and he expected all allegations of abuse. He stated he was responsible for reporting allegations of abuse to HHSC. <BR/>During an interview on 1/28/25 at 3:30 PM, CNA D stated that she could not remember the date or the time, but a few weeks before her interview with the investigator, Student C came to her and stated she had observed abuse and neglect in the facility. She stated that she stopped Student C before she could report anything to her and explained to her that she could not take that type of report. She stated she took her to the Administrator's office. She stated they knocked, and he did not answer. CNA D stated she took Student C to the ADON. She stated that after that, she did not know what had happened with the abuse reporting process. <BR/>During an interview on 1/28/25 at 3:40 PM, the DON stated that she had been trained on the facility's abuse policy and was familiar with it. She said she had been trained that all allegations of abuse had to be reported to HHSC. She said the purpose of reporting to HHSC was to protect residents from abuse while the investigations were being conducted. She said the potential negative outcome for the resident is that abuse can continue if not appropriately addressed. She said she was aware that the allegations from Student C were not reported to HHSC, but it was not reported because there were no findings that substantiated what Student C reported. The DON said she expected all allegations of abuse to be reported to HHSC. She said that she and the ADM were responsible for reporting allegations of HHSC.<BR/>During an interview on 1/29/25 at 10:06 AM, CNA B stated she did not remember the exact date and time but had been asked to change Resident #3 with the assistance of student aides. She said that after she changed Resident #3, management asked her to write a statement because it was alleged that she was rough with Resident #3. CNA B told the students that Resident #3 was sensitive. She said that while changing Resident #3, she forgot that Resident #3 needed cream and had intended to tell the night shift to put cream on her. CNA B stated that one of the students (name unknown to her) went and retrieved the cream. She said, Thank you, and put the cream on her. She said she was unaware of any issues or concerns from the student aides at the time of the incident. She said she was given a warning about the incident.<BR/>During an interview on 1/29/25 at 10:12 AM, the Regional Clinical director stated she received an email from the ADM (the email date was not disclosed during the interview). She stated that the email from the ADM stated that he (the ADM) had a grievance from one of the CNA students (she did not disclose which CNA student by name). She said she read Student C's statement that was attached to the email and advised the ADM to investigate, in-service, and conduct safe surveys. She stated that after reading Student C's statement, she considered what she reported to be a concern, not an allegation of abuse. She stated that this instruction was given because there was no merit to the concerns that the CNA student disclosed. The Regional Clinical Director stated that the ADM never stated that there was an allegation of abuse. The Regional Clinical Director stated that if there is a complaint of abuse, it is customary for them to investigate and immediately notify HHSC. She stated she was unaware if the term abuse was used when the concerns were made. She stated that the ADM had been trained on the abuse policy and is the abuse coordinator. She stated she felt comfortable with the ADM interpreting if there was an allegation of abuse. She stated that the ADM received the basic abuse training that all staff receive, but she was unaware of any additional training he may have received as the abuse coordinator. The Regional Clinical director stated she read Student C's statement and considered it a grievance. She stated that it was a strange situation because she is unsure if something is going on in the facility where the staff may be against CNA A. She stated that the ADM was responsible for reporting to HHSC. She said the purpose of reporting all allegations to HHSC was so they (HHSC) could come out and ensure that the facility followed the correct protocol to prevent abuse. She stated the reason the allegations of abuse were not reported was because they were considered a grievance and not an allegation of abuse. <BR/>During an interview on 1/29/25 at 11:17 AM, Student C stated that 1/10/25 she graduated from CNA school. She stated that her experience at the NF was challenging. She stated that on the previous Tuesday (01/7/25) before graduation, she observed CNA B perform perineal care on Resident #3. She stated she observed her partially clean and not put cream on her buttocks. She stated that CNA B would not put the cream on Resident #3, so she retrieved the cream. She stated that CNA B thanked her, and when she went to put the cream on Resident #3, it appeared that CNA B forcibly put the cream in Resident #3 buttocks, and when she removed her hand, there was feces on CNA B's gloves, indicating that Resident #3 was not clean. Student C said CNA B did not attempt to reclean Resident #3. She stated that the next day (1/08/25), while she was feeding Resident #1, CNA A took over feeding Resident #1. Student C stated that she observed CNA A provide at least two large spoonful of mashed potatoes and other unknown sauces and feed them to Resident #1. Student C stated that when CNA A attempted to give her another heaping spoonful of food, Resident #1 appeared to start choking and spit the food out on her clothing protector. Student C stated she provided Resident #1 with a drink, which seemed to help her. She stated that CNA A was feeding Resident #1 all the while eating her own lunch in between providing Resident #1 bites of food. She stated that CNA A threw Resident #2 in the bed the same day. She stated she felt bad for the residents at the NF. She stated that Resident #2 told CNA A she was moving too fast and was crying. Student C stated she felt bad for all the residents at the NF because of the treatment she saw. She stated she went to CNA D, who told her she would have to report what she observed and showed her where to go. She stated she went to the ADON office on her first day. She stated that she made herself clear that she wanted to report abuse. She said the ADON told her she would have to get the ADM as she could not take a statement of that nature herself. She stated that when the ADON retrieved the ADM, they passed CNA A and told her, After this, we will need to talk. She stated that CNA A attempted to walk with the ADON and ADM, but the ADON stopped her. Student C said this made her feel uncomfortable as this would make it obvious that she was the one making the report of abuse. She stated they went to the office, and she reported what she had experienced, including the alleged allegations of abuse with Resident #1 ,#2, and #3. She stated that in the presence of the ADM and ADON, she made herself clear that she was alleging that Resident #1, #2, and #3 had been abused. She stated that she was asked to write a statement. She stated she was placed in the room next to the ADM office and could hear him sucking his teeth and breathing hard as if he was irritated. She stated that this treatment caused her not to focus on her statement as much. She stated that staff were coming in and out, and the ADM would come and ask her if she was done frequently. She stated that she did not include names or the words abuse or neglect because she was instructed by the ADM to only write what she observed. She stated that the tone of the environment set by the ADON and ADM made her rush and forget that she had another incident to report about CNA A. She said that CNA A had made an inappropriate comment to an unknown resident while showering him but did not want to say anything further because she already felt she had caused enough trouble. She stated that while reporting what she observed with Resident #1, #2, and #3, she (Student C) had become emotional and started crying. She stated that no one followed up with her about what she reported. She said she did not consider what she reported a grievance. She said she had received training on ANE during certified nurses aide training from the school but only attended the NF for hands on training with the residents. <BR/>Record review of the email, dated 1/29/25, forwarded by the Regional Clinical Director revealed the following:<BR/>Student C's witness statement was attached.<BR/>The ADM emailed Student C's witness statement to Regional Clinical Director and reported that a student had complaints about staff care.<BR/>Record review of Student C's handwritten statement, dated 1/9/25, revealed the following:<BR/>December 7, 2025<BR/>I witness CNA B not cleaning the patient (Resident #3) in room private area right. She also did not use diaper rash medicine and when I brought it to her and told her to use it she placed it on her hand and forcefully shoved her hand in the lady's legs. The lady was in so much pain she yelled.<BR/>January 8, 2025<BR/>I witnessed CNA A put a over amount of food into the mouth of a patient (Resident #1) who couldn't move and was rushing feeding her. The lady choked so I gave her kool-laid.<BR/>January 9, 2025<BR/>I witnessed CNA A chuck Resident #2 on the bed. CNA A was in a hurry due to trying to leave early.<BR/>Record review of CNA A's handwritten statement, dated 1/08/25, revealed the following:<BR/>I, CNA A, was feeding residents and it was said I over feed, but I truly feel that I over did it, but I will be careful and safe. <BR/>Record review of CNA A's handwritten statement, dated 1/09/25, revealed the following:<BR/>I, CNA A, had 4 students with me to put Resident #2 to bed as asked by my nurse. As I stood her up I smelled her, so I got her brief and wipes and changed her while she was standing when I assisted her to bed.<BR/>There were no provider investigation reports available for review that involved Resident #1, #2 or #3 as of 1/28/25. <BR/>Record review of CNA B's handwritten statement, dated 1/07/25, revealed the following:<BR/>Tuesday January 7th the students asked me for help with Resident #3, so I came to help. I let them know as I was helping that she's (Resident #3) sensitive so when you move her even just a little it hurts her. She (Resident #3) was a little red. It was the last round. I didn't have cream so I was gonna let night shift know she was red so they could put some on her but one of the student aids went and got some cream so I did put dome on her after she was changed.<BR/>Record review of the facility's investigation report, dated 1/11/25, revealed the following:<BR/>The investigation from the student was completed and the conclusion did not show any abuse or neglect. The staff need to be in-serviced on taking their time and more personal care when caring for residents. Safe surveys were completed by the Licensed Social Worker on other residents down the hall and no complaint made at this time.<BR/>The staff (CNA B) that was in question about her perineal care technique: had stated to the student before they went in that the resident will scream out when you touch her in any manner. <BR/>The staff (CNA A) that put Resident #2 to bed, stated she did not chuck as stated or do any type of transfer that would be considered abuse at that time. It may have seemed rough to the student.<BR/>The staff (CNA A) that was feeding the resident (Resident #1) stated she was giving her large spoons, but that was normal for the resident (Resident #1) and she did not choke; and if so the nurse would have intervened.<BR/>Record review of LVN E's handwritten statement, dated 1/09/25, revealed the following:<BR/>Head to toe skin assessment performed on Resident #2.<BR/>One old bruise noted to back of right arm, measuring 1 cm by 1.5 cm , and greenish in color.<BR/>Residents skin is warm/dry to touch. Skin turgor elastic (ability to stretch and return to normal).<BR/>No abnormalities noted, no other skin breakdown noted.<BR/>No rashes/lesions noted to skin.<BR/>Record review of facility's inservice overview, dated 1/10/25, revealed that staff were inserviced on the following:<BR/>Customer service: Respect resident's rights, respect their privacy and show compassion with care<BR/>Direct care Staff: Take your time with personal care, be gentle and use caution with care during transferring, assisting with meals and bathing.<BR/>Record review of a total of 6 safe surveys, dated 1/10/25, revealed the following:<BR/>No resident reported feeling unsafe, abused or handled roughly.<BR/>Record review of facility employee training, dated 1/10/25, revealed the following:<BR/> CNA B was trained on perineal care technique.<BR/>Record review of facility employee training, dated 1/10/25, revealed the following:<BR/> CNA A was trained on transfer technique and assisting residents with feeding.<BR/>Record review of the facility policy, Filing Grievances, revised December 2024, revealed:<BR/>Policy Statement<BR/>Our facility will assist residents, their representatives (sponsors), other interested family members, or resident advocates in filing grievances or complaints when such requests are made.<BR/>Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form.<BR/>The resident, or person filing the grievance and/or complaint in behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the administrator, or his or her designee, within 3 working days of the filing of the grievance or complaint with the facility. A written summary of the report will also be provided to the resident, and a copy will be filed in the business office.<BR/>Record review of the facility grievance log dated from November 2024-January 2025 did not include a concern involving Resident #1, #2 or Resident #3.<BR/>Record review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation, revised April 2021, revealed:<BR/>Policy Statement <BR/>All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations). <BR/> Policy Interpretation and Implementation <BR/>If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.<BR/>The administrator or the individual making the allegation immediately reports his or her suspicion to tl1e following persons or agencies:<BR/>The state licensing/certification agency responsible for surveying/licensing the facility;<BR/>Immediately is defined as:<BR/>within two hours of an allegation involving abuse or result in serious bodily injury; or<BR/>within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.<BR/>Reporting Results of Investigations<BR/>The administrator, or his/her designee, provide the appropriate agencies or individuals listed above witl1 a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.<BR/>.

Based on observation, interview and record review, the facility failed to provide a private space for the resident's monthly Resident Council meetings for 13 of 13 anonymous residents who attended Resident Council meetings. (Resident Council 12/04/2024).<BR/>The facility failed to provide a private place for residents to be able to hold Resident Council Meetings monthly. <BR/>This failure could result in issues affecting the residents' feeling that their grievances are not being acted upon and could place all residents who attend the Resident Council meetings at risk for feelings of powerlessness and decreased self-worth.<BR/>The Findings included:<BR/>During the confidential Resident Council interview on 12/04/2024 at 9:45 AM. the thirteen residents in attendance stated they had no privacy during their meetings. The meeting space was arranged by the Activity Director and the meeting space was held in the front lobby. The front lobby had the front door, the Administrator's office, and the BOM's office. Even though there was a sign on the wall outside of the front door informing staff the Resident Council was meeting staff and visitors continued to enter the front door, Administrator's, and BOM's office. The residents stated that normally the resident council meeting is held in the dining room where all staff come and go through the duration of the meeting. The residents in the meeting stated it was communal area for staff to interrupt them during their monthly Resident Council meetings and they did not feel the meetings were private. The stated they would prefer the meetings to be private and only staff they invited be allowed to hear what they discussed. A total of seven observations were made of facility staff and visitors entering and exiting the front door, Administrator's office, the BOM's office, and coming in the front area from the facility during the confidential Resident Council interview on 12/04/2024.<BR/>Observation of Resident Council Meeting on 12/4/2024 at 9:45 AM. The Activity Director had set up the meeting in the front lobby by the front door for 13 Residents to attend. Observed staff walking in and out during the meeting. Observed that the front lobby was next to the Administrator's office and the BOM's office. <BR/>During an interview with the Activity Director on 12/06/2024 at 10:31 AM. The Activity Director stated she is responsible for setting up the resident council meetings and the place in which they are held. The Activity Director stated that the policy stated that the resident council meetings should be provided with privacy with no staff being able to interrupt the meetings. She stated that many of the residents had voiced their concern with staff members walking in and out of the meetings. She stated that the residents voiced their concern of the staff hearing what they were talking about and retaliating against them for it. The Activity Director stated that her biggest concern since she took the position is the privacy not being provided during resident council meetings. She stated that she had mentioned her concerns with the Administrator, and he had stated that she would need to get with the physical therapy team to see if that room could be used for the meetings. She stated that she was not sure why the meetings had not been moved to a private area for the residents. She had stated that she brought the privacy concern up to the Administrator twice and it had not been taken care of. The Activity Director stated that this had not been accommodated for the residents. She stated that the negative potential outcome of the residents not being provided privacy during resident council meetings is that the residents may get upset and feel that the staff will retaliate against them. <BR/>During an interview with the Administrator on 12/09/2024 at 11:00 AM. The Administrator stated that the facility only has the physical therapy room that would accommodate the privacy for the meetings. The Administrator stated that the Activity Director had been told to get with physical therapy to see if the Resident Council meetings could be held in there. The Administrator stated that the negative outcome of not being able to provide privacy for the Resident Council meetings would cause the residents to not freely voice their concerns and to feel that their rights had been taken away. <BR/>Record review of facility provided policy on 12/12/2024, titled, Resident Council, date revised in February 2021, stated: <BR/>Policy Statement: The facility supports resident rights to organize and participate in the resident council. <BR/>The purpose of the resident council is to provide a forum for:<BR/>a. residents, families, and resident representative to have input in the operation of the facility.<BR/>b. discussion of concerns and suggestions for improvement.<BR/>c. consensus building and communication between residents and facility staff, and<BR/>d. disseminating information and gathering feedback from interested residents. <BR/>2. All residents are eligible to participate in the resident council. The facility staff encourages residents who are willing to participate. Staff, visitors, or other guests may attend resident council meetings if invited by the respective resident group. <BR/>3. The resident council group is provided with space, privacy, and support to conduct meetings. <BR/>5. Council meetings are scheduled monthly or more frequently if requested by residents. The date, time, and location of the meetings are noted in the activities calendar. <BR/>6. A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the items of concern.

Based on interviews, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 1 of 1 resident (Resident #51). <BR/>The facility failed to ensure 1 of 1 resident were provided a copy of the grievance that Resident #51 had filed, upon request, Resident #51 had the right to obtain a written decision related to their grievance. <BR/>This failure could place the residents at risk of unresolved grievances, decreased quality of life, and feeling of hopelessness. <BR/>Findings included:<BR/>Resident #51:<BR/>Resident #51:<BR/>Record review of Resident #51 face sheet revealed an admission date of 04/08/2024 with a BIMS (Brief Interview for Mental Status) of thirteen, meaning that Resident #51's cognition is intact. Resident #51 had a diagnosis that included: acute respiratory failure (cannot maintain normal levels of oxygen and carbon dioxide in the blood), pain in the left wrist, morbid obesity, major depression disorder, dysthymic disorder (mild but long term form of depression), heredity & idiopathic neuropathy (sensory and motor nerves of the peripheral nervous system are affected and no underlying etiology is found), high blood pressure, gout (form of arthritis that causes severe pain, swelling, redness and tenderness in the joints), osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down), muscle weakness, rotator cuff tear or rupture (a tear in the tissues connecting muscle to bone (tendons) around the shoulder joints), mass and lump in lower limb, edema (swelling). <BR/>During an interview with Resident #51 on 12/05/2024 at 2:12 PM. Resident #51 stated that he had asked the Social Worker for a copy of the grievance that he had filed, and she stated that the Administrator told her to not give him a copy. Resident #51 was frustrated and stated, I would like to know what they are doing with the grievance that I filed. This grievance was an individual grievance filed by the resident. <BR/>During an interview with the Social Worker on 12/09/2024 at 10:29 AM. The Social Worker stated that when Resident #51 had asked her for a copy of his grievances, she had asked the Administrator. She stated the Administrator stated the resident does not get a copy, so she told the resident that they do not give a copy. The Social Worker stated that she was not sure what the policy stated about giving a copy of grievances to the resident. The Social Worker read the policy in front of Surveyor. Social Worker stated that the policy stated that a copy should be provided to the resident. There was no resolution listed to the grievance. The Social Worker stated that the negative potential outcome of not providing a copy of the grievances would be that it may make the resident upset and it is impeding on resident rights. <BR/>During an interview with the Administrator on 12/09/2024 at 11:00 AM. The Administrator stated that he does not know what the policy stated about providing a copy, but he is sure that he does not have to provide one. The Administrator read the policy in front of Surveyor. The Administrator stated that he did not realize that he had to provide a copy of the grievances, but he did see in the policy where he was supposed to provide a copy of the grievances. The Administrator stated that he had never had to give a copy of the grievances to a resident. The Administrator stated that the policy stated that he should provide a copy of the grievances to the resident. The Administrator stated that the negative potential outcome of not providing a copy of the grievance to a resident could make the resident feel as though the grievances are not being taken care of or addressed. The Administrator stated that it is a Resident Rights issue. The Administrator stated that it is the responsibility of the Administrator or the Social Worker to provide a copy of the grievances to the resident.<BR/>Record review of facility provided policy on 12/5/2024, titled, Filing Grievances/Complaints, date revised in December 2004, stated: <BR/>Policy Statement: Our facility will assist residents, their representatives (sponsors), other interested family members, or resident advocates in filing grievances or complaints when such requests are made. <BR/>1. Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form. <BR/>3. Grievances and or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complaint on behalf of the resident. <BR/>4. The Administrator has been delegated as the Grievance Official for the facility. <BR/>5. Upon receipt of a written grievance and/or complaint, the social worker will investigate the allegations and submit a written report of such findings to the administrator within three working days of receiving the grievance and/or complaint. <BR/>6. The Administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. <BR/>7. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the administrator, or his or her designee, within three working days of the filing of the grievance or complaint with the facility. A written summary of the report will also be provided to the resident, and a copy will be filed in the business office.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent elopement for 1 of 7 residents who wandered (Resident #60). The facility further failed to ensure that the resident environment remained as free of accident hazards on 2 of 2 Halls (Hall1/Central and Hall2), in that:<BR/>1). The facility failed to adequately supervise Resident #60 to prevent him from eloping from the facility on 8/18/22 and 9/03/22. <BR/>The facility failed to develop and implement interventions to prevent elopement after multiple verbalizations by Resident #60 of wanting to leave the facility which resulted in him eloping.<BR/>2) The facility failed to store chemicals in a safe manner and were left accessible to residents in common areas on 2 of 2 Halls (Hall 1/Central and Hall 2).<BR/>An immediate jeopardy (IJ) was identified on 9/28/22 at 5:25 PM. While the IJ was removed, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy and a scope of pattern.<BR/>These failures related to adequate supervision could place residents at risk for wandering into unsafe environments outside of the facility and sustaining serious injury, harm, impairment or death. Failures related to chemical storage could place residents at risk for chemical injuries. <BR/>The findings include:<BR/>1) Resident #60<BR/>Record review of the face sheet and Order Summary Report for male Resident #60 dated 9/15/22 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnosis of Hypothyroidism, Unspecified, Major Depressive Disorder, Recurrent, Unspecified, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Muscle Weakness (Generalized), Cognitive Communication Deficit, Unsteadiness on Feet, Major Depressive Disorder, Recurrent Severe Without Psychotic Features, and Anxiety Disorder Due to Known Physiological Condition.<BR/>Record review of the admission MDS assessment for Resident #60 dated 8/19/22 revealed that the resident had a BIMS score of 4 , indicating he was cognitively impaired. Further record review of the MDS revealed the resident had a behavior of rejecting care. This behavior occurred every one to three days. The resident was also documented as wandering and this behavior occurred daily. It was further documented that the residents wandering did not place the resident at significant risk of getting to a potentially dangerous place, such as stairs, outside of the facility.<BR/>Record review of the current undated care plan for Resident #60 revealed that there was a Focus titled, The resident is an elopement risk r/t dementia. ***Patient has a (electronic monitoring device) *** *(Electronic monitoring device) checks 3 times each shift. *Staff will round to lay eyes on patient every 1 to 2 hours and as needed. Patient eloped on 08/18/2022* WAS FOUND SAFE AND RETURNED TO BUILDING Date Initiated: 08/10/2022 Revision on: 08/19/2022. The documented Goal for this Focus was documented as follows, The resident's safety will be maintained through the review date. Date Initiated: 08/10/2022 Revision on: 09/07/2022. Target Date: 11/30/2022. o The resident will not leave facility unattended through the review date. Date Initiated: 08/10/2022 Revision on: 09/07/2022 Target Date: 11/30/2022. The Approach for this Focus was documented as, o Assess for fall risk. Date Initiated: 08/10/2022 o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Date Initiated: 08/10/2022 .<BR/>Record review of the Elopement Risk Assessment for Resident #60 conducted on 8/09/22 by LVN D revealed that the resident made statements and or threats to leave the facility and made frequent request to go home. It also documented that the resident had confused expressions related to tasks to complete. It further documented that the resident verbalized anger and frustration related to his placement. The document stated that the resident had restless behavior such as wandering. Additional information listed on the form revealed that the resident did not recognize stoplights and signs, did not know precautions when crossing streets and did not know the location of his current residence. It was further documented that the resident does not recognize all needs but some. Related to physical capacity it documented that the resident ambulates independently or with device. Cognitive skills for daily decision-making were listed as modified independence - some difficulty in new situation only.<BR/>Record review of the Progress Notes (8/10/22 thru 9/03/22) for Resident #60 revealed:<BR/>-On 8/18/22 at 4:45 PM the resident could not be found in the facility. He was found and returned to the facility at 6:37 PM. The nurse on duty was LVN C (agency). The police were called, and facility staff searched for the resident in the facility and surrounding areas. Family and department heads were informed. On his return it was determined he had no injury and an electronic monitoring device was placed on the resident on his return. <BR/>-On 8/28/22 the resident removed his electronic monitoring device and staff placed another one on his ankle. <BR/>-On 8/30/22 the resident's wife discovered his electronic monitoring device amongst the resident's possessions and staff placed another one on the resident's right wrist. <BR/>-On 9/3/22 at 9:15 AM Resident #60 could not be found in the facility again. He was found by family at 11:43 AM and returned to the facility at 12:00 PM. The LVN on duty was LVN D (agency). The police were called, and facility staff searched for the resident in the facility and surrounding areas. Family and department heads were informed. The resident had no injuries. <BR/>-On 9/03/22, 12:00 PM - Upon entrance to facility, door alarm sounded d/t resident being noted to have electronic monitoring device on wrist. How resident got out of facility with electronic monitoring device on is TBD ADON requested Q 30 min checks for a couple areas then hrly (hourly) until further notice . The resident was discharged from the facility on 9/03/22. <BR/>Record review of the Incident-by-Incident Type list for the facility dated 9/13/22 revealed that there was one resident listed as having an elopement incident. The date range for the list was 3/13/22 to 9/13/22. Resident #60 was not listed on this document as eloping from the facility.<BR/>Record review of the MAR/TAR for Resident #60 for August 2022 revealed that the facility started ordered electronic monitoring device checks on 8/11/22 on the night shift. The electronic monitoring device was checked Q shift. On 8/17/22 there was no documentation that the electronic monitoring device was checked on the dayshift. On 8/18/22 it was documented that the resident had his electronic monitoring device on during the day and night shift. On 8/19/22 at 4:00 PM the residents electronic monitoring device monitoring order changed from Q shift to Q4 hours. Further documentation on the TAR revealed that on 8/25/22 there was no documentation that the electronic monitoring device had been checked at (4:00 AM). The resident's electronic monitoring device was documented as being off him on the following dates and times:<BR/>8/28/22 at (8:00 PM)<BR/>8/30/22 at (4:00 PM and 8:00PM)<BR/>8/31/22 at (12:00 AM and 8:00 AM)<BR/>On 8/31/22 there was no documentation of the electronic monitoring device being checked at (4:00 AM). <BR/>Record review of the September 2022 MAR/TAR for Resident #60 revealed an order for electronic monitoring device checks Q4 hours. There was no documentation on 9/1/22 at (4:00 PM) that the electronic monitoring device was checked. Further record review of this MAR/TAR for Resident #60 revealed that the electronic monitoring device documentation for his right ankle and left wrist on 9/2/22 ( 8:00 AM and 12:00 PM) was documented as Other and to see the nurses notes for an explanation. The resident was documented as having the electronic monitoring device on starting 9/02/22 at (4:00 PM) through (12:00 PM) on 9/3/22. The electronic monitoring device checks on 9/03/22 revealed that the resident had his electronic monitoring device on for the 8:00 AM and 12:00 PM checks. <BR/>Record review of the Progress Notes for Resident #60 revealed no documentation as to why there was no on or off electronic monitoring device documentation on 9/2/22 at (8:00 AM) and (12:00 PM).<BR/>On 9/16/22 at 10:11 AM, an interview and record review was conducted with LVN C (agency) regarding Resident #60's wandering and eloping from the facility. He stated the resident was a wanderer but could converse and state his needs. He added that he would hang around at the exit door near room [ROOM NUMBER]. He was definitely a wanderer. Regarding the day the resident eloped, he stated, on 8/18/22 it was a normal day. Dinner was served. LVN C was in the dining room helping out. Staff report to him at approximately 4:45 PM that they could not find the resident. LVN C searched every room, outside and surrounding areas including businesses. He also called local hospital ERs. Family and law enforcement were called, and the resident was located by police at 82nd street and returned at approximately 6:50 PM. Upon the resident's return, he was assessed, and an electronic monitoring device was placed on him. He further stated the resident had a history of asking for scissors to cut off his electronic monitoring device. The LVN stated he was on duty the next day and monitored him closely. He added he double checked him every hour or two for his whereabouts. There were no other interventions to prevent him from eloping. The LVN stated he was told by staff the resident would remove his electronic monitoring device and ask for scissors to cut it off. He added that the resident never asked him for scissors. LVN C was then asked about their procedures related to electronic monitoring devices. He stated he visually checked the electronic monitoring devices and documented it in the MAR. He added that if a resident wanders to the front of the facility, the electronic monitoring device alarms. He added staff used harder zip type ties to keep the electronic monitoring device on once they knew he could take it off. LVN C then checked the electronic incident documentation system to see if an incident report had been developed for the elopements on 8/18/22 and 9/03/22 and found none. LVN C also stated that he contacted the Administrator, DON and ADON about the 8/18/22 elopement but did not contact the physician. He added that it was not OK not to inform the physician. Regarding the missing incident reports, he stated if there is no documentation it is not done. He further stated he was not sure if the facility had an elopement protocol and did not know what the facility elopement protocol was. He stated, I'm just agency. He also added that there was no documentation of his monitoring of the resident every one or two hours. He stated that his monitoring documentation was only in the nurses' notes .<BR/>On 9/16/22 at 11:14 AM, an interview was conducted with the DON. Regarding Resident #60 she stated he was tall, had dementia, confusion, was a wanderer and was admitted from a secure facility . Regarding wandering intervention for the resident, she stated after the first elopement they increased electronic monitoring device checks and checked the room daily. Staff checked every shift and more often. The second time he eloped, staff implemented checks every 2 hours. She added, the last time he eloped, he still had his electronic monitoring device on. Staff did not know if someone let him out. She was unsure how far he was from the facility the first time he eloped. The second time he eloped he was found outside a new restaurant on 82nd street. Regarding their elopement protocol, she stated nurses are to check each room. Some staff checked the parameters. Within an hour we called the police. Regarding any orientation provided to agency nurses prior to assuming duties in the facility, she stated, staff conduct a quick one. Staff familiarize them with the charting system. Contact information is given to them for the DON and ADON. Regarding residents, agency staff know what to do. They are informed of resident tendencies. <BR/>On 9/16/22 at 11:29 AM, an interview was conducted with the Administrator. Regarding elopement protocols, she stated, if residents are not found they look in-house. The administrator is informed, and the administrator informs staff by group text and the department heads look for the resident. She stated the second elopement was handled this same way. Regarding Resident #60 she stated, he was a dementia resident admitted from a secure nursing home. He did not do any wandering there. He was here two weeks and then was found outside. He was gone about 45 minutes . He was not exit seeking. She added that after meals his dementia tells him to go to work. Staff knew to monitor him after meals. He thought he was trying to get to work when he was found at a restaurant on 82nd and Quaker Avenue (Approximately 0.6 miles from the facility). He was found quickly. She believed, the first time he was found on 76th and Salem Avenue (approximately 0.3 miles from the facility). She further stated, both times he was gone an hour or less . The second time was on a Saturday. <BR/>On 9/16/22 at 11:54 AM, an interview was conducted with the Maintenance Supervisor regarding the electronic monitoring device system. He stated there are two doors with the electronic monitoring device system; the front and the dining room that are exits are alarmed. He added he checks the doors weekly on Mondays. During the generator test it deactivates the electronic monitoring device system and the test lasts 30 minutes . He further stated to test the electronic monitoring devices, he uses an electronic monitoring device and goes to the door to check if it alarms. He also stated that he has a resident, with a monitoring device, go by the door and see if it locks. Regarding Resident #60, he stated the resident got out two times. The first time, staff say he cut off the electronic monitoring device. The second time only thing he could think of was the resident went out with a visitor. He added he did not know if anyone heard the electronic monitoring device alarm go off, but staff should have. <BR/>Record review of the facility documentation on Door Alarm checks revealed that weekly checks were made. Between 8/01/22 and 9/12/22 all door alarms were documented as passing and had no issues (8/01/22, 8/08/22, 8/15/22, 8/23/22, 8/29/22, 9/05/22 and 9/12/22).<BR/>On 9/16/22 at 12:45 PM, an interview was conducted with the ADON regarding Resident #60's elopement. Regarding why the incidents happened, she stated, some family may have let him out. He may have been gone out before staff saw him. It's hit and miss who's around the exit door. LVN D told her she did not hear an alarm. Agency staff was at station one. She added that the first elopement he said he was going to work. It was something all staff knew. These were suggestions of what he was thinking. She stated they ensured residents do not elope outside of the facility by conducting hourly checks , frequent checks. She added if staff hear the alarm, they go straight to the door. She further stated there were no documentation of the (hourly) checks. She added, staff make sure they make rounds. She stated, everyone is responsible to ensure that residents do not elope from the facility. She added, she expected that staff are in the building working and others are out searching for any eloped residents. She stated that if residents were not appropriately monitored and eloped, others could elope from the facility. She also stated that there was no paper documentation of the monitoring that they conducted on Resident #60. <BR/>On 9/16/22 at 2:40 PM, an interview was conducted with the Administrator. Regarding Resident #60 elopements she stated, the staff did not think he would leave prior to the first elopement . She added that staff were supposed to monitor the resident after dinner . She also stated that someone may have let him out. She stated caregivers, charge nurse, nursing and administrator were responsible for ensuring that residents do not elope from the facility. She added she expected staff to provide a better monitoring system to prevent elopements. She further stated she made it clear to staff and they should have taken Resident #60 to his room after his meals. She was asked how an elopement could affect residents. She responded by stating that the facility makes sure residents are in a safe environment, experiencing no harm.<BR/>On 9/16/22 at 3:06 PM, an interview was conducted with agency LVN E (agency). She stated she worked in the facility approximately three times a month. She stated that she was not oriented by the facility regarding missing residents and the elopement protocol prior to working in the facility. She stated that she had been oriented at other facilities. She stated if residents elope from the facility they could be in danger, run over, or multiple things happen to them.<BR/>On 9/19/22 at 7:50 PM an interview was conducted with LVN D (agency at the time of elopement). She stated Resident #60, was a roamer and walked all day and night. He was super confused. Sometimes he would layer his clothes wearing seven or eight shirts at a time. All day he would say he was going somewhere. She stated she was not told specifically to take the resident back to his room after meals, but felt it was a given fact. Regarding the 9/03/22 elopement, she stated, it was an hour and a half after breakfast . She had been looking for him for him for something and then discovered he was missing. She added staff started checking and he was not found. Staff did not hear an alarm; no one did. She stated, if the door is held, it should have alarmed. She added that she did not know what exit he may have gotten out of. She stated she did not develop an incident report but documented the incident in the nurse's notes. She stated the incident occurred on her second day at work and she called the family, ADON and DON. She added that family brought the resident back and she assessed him. She was asked what could result from an elopement of a resident. She stated if residents were to elope from the facility they could be hit by a car and be led to do things they should not do. She added that the resident talked well and presented himself well if you were not aware he had dementia . She stated that she had not call the doctor about the incident. She stated when she started working in the facility, nothing special was told to her about Resident #60, but she was made aware that he removed his electronic monitoring device. She added that she placed it back on him a couple of times and that he would pull real hard and could pull it off.<BR/>During an interview conducted on 09/29/2022 at 9:42 AM with the Administrator , she said she did not recall if they had reviewed camera footage once she was notified the facility had been searched, they started searching outside. She said she was out of town during Resident #60's second elopement. She said it was her understanding that both elopements were through the front door of the facility. She was not sure if an alarm went off, she was told Resident #60 was out on the porch outside of the facility, seen by another visitor, then later found at a restaurant. She said the first time Resident #60 eloped; he was found about a block from his house, which she said was in the area of the facility, talking to the neighbors who called the police while they were at the facility with the Administrator. She further stated the electronic monitoring device alarm on the door goes off until the keypad code is entered by staff.<BR/>Observation made on 09/28/2022 at 8:16 AM showed a camera to be in the lobby facing the entrance to the facility.<BR/>Observation made on 09/28/2022 at 8:45 AM showed a camera facing the first nurses' desk nearest the entrance to the facility (Hall1).<BR/>Observation on 09/28/2022 at 8:47 AM showed a camera facing the facility's dining hall and back door entrance.<BR/>Observation made on 09/28/2022 at 8:48 AM showed a camera facing the break room. <BR/>Observation made on 09/28/2022 at 8:50 AM showed a camera facing the south side door at the end of the east hall (Hall 2).<BR/>Observation made on 09/28/2022 at 8:35 AM showed a camera to be facing the north side door at the end of the east hall (Hall 2).<BR/>During an interview conducted on 09/28/2022 at 8:59 AM with the Administrator, she said all the cameras were working. She said the monitors were in the central supply room in the beauty shop. <BR/>During an observation and interview on 9/28/22 at 9:58 AM with the Maintenance Supervisor, he was asked if it would be possible to check camera footage from specific dates. He was not sure if the cameras saved footage. Observation of the central supply closet inside the beauty salon room with the Maintenance Supervisor revealed a monitor could be seen with several viewing panels for all cameras showing no footage being taken currently on any camera as indicated by a blank black screen. Using the search feature found on the monitor, the Maintenance Supervisor typed in the dates in question (08/18/2022, 09/03/2022) and no footage was found. Observation of the cameras in the Dietary Manager's office showed live footage from only the temperature-scanning camera located in the lobby could be seen. He was unable to show footage of the dates in question (08/18/2022, 09/03/2022).<BR/>During an interview conducted on 09/28/2022 at 9:28 AM with the DON. When asked about the cameras and whether they had ever reviewed camera footage after Resident #60's elopements. She said she did not know how to access them and has never reviewed camera footage. <BR/>During an interview conducted on 09/28/2022 at 10:33 AM, the Maintenance Supervisor stated he had spoken with the facility's IT (Information Technology) department and was told the cameras send footage to the Administrator's computer with storage only for the last 30 days. He said the Administrator did not know that though, and he was going to her office next to see if it was set up on her computer. Based on the time frames of stored footage, he was asked to provide footage from 09/03/2022 for the hours leading up to Resident #60's noted absence from the facility at 9:15 AM. <BR/>During an interview conducted on 09/28/2022 at 11:36 AM with the Administrator, she said they had made progress on finding camera footage from 09/03/2022 and said: they are looking at it right now. <BR/>During an interview conducted on 09/28/2022 at 11:37 AM, the ADON was asked if they had found the footage from 09/03/2022 pertaining to Resident #60 and the elopement from 09/03/2022. She said they were still looking.<BR/>Observation made on 09/28/2022 at 11:37 AM showed staff members in the Business Office Manager's office looking at camera footage on the computer. <BR/>During an interview conducted on 09/29/2022 at 10:39 AM with the Business Office Manager concerning footage that she and the ADON had reviewed the previous day, she said they were not able to see any footage of the resident exiting the building. She said they had reviewed footage from all the cameras in the facility yesterday, and that not all doors exiting the facility had a camera facing them that adequately captured the view of the door. <BR/>On 9/28/22 at 9:10 AM, an interview was conducted LVN A. Regarding Resident #60 she stated, she remembered him. Staff were told to basically watch him and keep an eye on him; Every 30 minutes. She had to check his wander guard four times a day because he would take it off. His roommate was Resident #40. Their room was near the nurse's station. Regarding Resident #60's electronic monitoring device removal, she stated she did not know what he cut it off with. She never witnessed the removal. Staff placed a type of zip tie on it to keep it on. The band looked like it was cut when she saw it. She thought he may have got a butter knife to cut it off. She stated she never checked the resident for a knife and she only kind of looked around his room for an item that could have been used to cut it off. She added, he could get aggressive. She stated Resident #60 mostly watched TV. It seemed lunchtime he might get up. Regarding training about elopements and wandering residents she stated, she had not had any since being in the facility, which was approximately 2 months. She stated she learned from other facilities to keep an eye on them. The other places (facilities) staff saw them and where they were. Regarding any documentation of the 30-minute checks that she conducted on wandering residents, she stated she recently started documenting the checks and added that her weak point in nursing was documentation. She further stated, she could not recall staff asking her to document the one- or two-hour checks on Resident #60's whereabouts. Regarding any interventions told to her after the 8/18/22 elopement, she stated, she was told to make sure to keep an eye on him; her and the CNAs. He was always dressed and ready to go. He mainly stayed in his room. She further stated she never had anything to write on the nurse communication sheets about Resident #60. She stated the nurse communication sheets were placed in the box and then given to the ADON.<BR/>Record review of the Nurse Communication Sheets for 8/18/22 and 9/03/22 - 9/04/22 revealed no documentation related to Resident #60.<BR/>On 9/28/22 at 9:45 AM LVN A was interviewed and stated, sometimes Resident #60 ate in his room and she tried to be in the dining room to feed her residents during meals. She added, because he was an elopement risk, she kept her eyes on him. She further stated that no one had told her that Resident #60 needed to be taken to his room after meals.<BR/>On 9/28/22 at 9:53 AM an interview was conducted with CNA I. She stated staff did one-hour checks on Resident #60 and documented it on their POC (CNA electronic resident documentation kiosk). Staff just checked that he had not wandered off and that his electronic monitoring device was on. He was known to take it off. She stated she never figured out how he got it off. He would tear it off. He was strong. Regarding the 8/18/22 elopement, she stated she was the one that noticed he was gone. Staff searched inside and outside. Staff would see him wandering. He walked with Resident #40. She noticed she had not seen him at her hourly check . It was at supper, and she had not seen him. After he returned, staff was instructed to conduct 30-minute checks. They changed where his wander guard was applied. She added, there was no documentation of the 30-minute checks, it was just every day and it continued. She stated, she received training regarding wandering residents and elopement weeks or months ago. She further stated staff were told Resident #60 should go back to his room after meals by LVN A.<BR/>On 9/28/22 at 10:40 AM, an interview was conducted with the DON. Regarding interventions implemented after the elopement on 8/18/22, she stated, electronic monitoring devices were checked frequently, and redirection using activities. The nurse was to report abnormal behaviors. The nurse also made rounds. Staff were rounding different hours for the electronic monitoring devices. On 8/19/22 they checked the wander guard three times and then later every four hours. Regarding interventions for the resident removing his electronic monitoring device, she stated, place a new one on and provide education to the resident which was not very effective. Staff changed the positions of the electronic monitoring device. Staff made sure the electronic monitoring devices was comfortable. The main intervention was rounding every four hours. She stated that she would check him when she saw him. The Resident spent a lot of time in common areas. Regarding how he got the electronic monitoring devices off, she stated there was nothing in his room to remove it. Staff thought he was just pulling it off. The resident made comments about scissors. Staff checked everywhere they could for something he used to take the electronic monitoring devices off. The DON stated she thought it was irritating to him and he pulled it off. Regarding if staff had been instructed to take the resident to his room after meals, she stated, she instructed staff to conduct more rounding. She further stated she did not instruct staff to take Resident #60 back to his room after meals. Regarding in-services or training provided for wandering residents and elopements, she stated, staff were provided verbal education. She added more attention was given to station two since Resident #60 resided there. She stated she talked to LVN D, who was the charge nurse. LVN A and agency staff. She added she started the verbal education when the electronic monitoring device was placed on him. Regarding the screening process to determine if referred residents were appropriate for admission, she stated, they reviewed the referrals with a whole team. If there were unresolved issues with the referral, the DON was responsible for addressing the issues. She stated that she did not see Resident #60 prior to admission. She added that the referrals for admission for Resident #60 were received by the Administrator. The DON stated she ensured the nurses were competent in their skills in caring for residents that wandered by the DON and ADON talking to them. She added staff do rounds and check on the residents. Regarding what type of plan was in place for wanderers, she stated, the facility has electronic monitoring devices and an electronic monitoring device system. It locks the door. Staff check doors weekly. Staff try to provide activities for wanderers. Regarding any type of in-services provided on wanderers and elopement since admitting residents with those issues, she stated, staff were provided a lot of verbal instruction. The most recent documented in-service was 6/16/22. She stated, she did not think the facility was secure enough for Resident #60. She added that the facility was secure to a certain extent. <BR/>On 9/28/22 at 11:24 AM an interview was conducted with the DON regarding why there was no incident report done for Resident #60's two elopements. She stated, no incident report was done since staff found him within two hours. She stated she was told that by the Administrator.<BR/>During an interview conducted on 9/28/2022 at 1:47 PM with the DON , she was asked if notification to Resident #60's physician regarding his elopement had been made. She said that notification to the resident's physician would be documented in a progress note in the EMR (Electronic Medication Record). She said she would verify with the ADON as well and ask if there is anywhere else that would be documented. This documentation was never provided. <BR/>During an observation and interview on 9/28/22 at 11:28 AM, CNA I demonstrated where the resident monitoring documentation was located in the POC system for CNAs. The dates range checked was 8/19/22 through 9/03/22. There was no documentation in this system of hourly monitoring checks. At this time CNA I stated, she guessed their instructions to monitor were just verbal. Staff were verbally told to do it. She confirmed that there was no documentation on any of those days that one hour or 30 minutes or any resident checks were conducted for Resident #60. The only documentation that she found was on 9/02/22. There was a note that stated, walk with supervision. <BR/>On 9/28/22 at 11:45 AM an interview was conducted with the Administrator. Regarding monitoring documentation, she stated, staff would not be documenting unless he was one-on-one supervision or mandated. She stated, It was just known, especially after meals, that he wandered. There was nothing written. Regarding any viewing of the cameras footage for Resident #60's elopements. She stated, they cannot find anything on camera so far. Regarding in-services offered on wanderers and elopement, she [TRUNCATED]

**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 needed respiratory care, were provided such care, consistent with professional standards of practice for 3 (Resident #50, Resident #68, Resident #35) of 7 residents reviewed for respiratory care.<BR/>The facility failed to follow their policy for proper storage of oxygen tubing for Resident #50, Resident #68, and Resident #35.<BR/>This failure could place residents at risk for respiratory compromise and infection. <BR/>Findings included:<BR/>Resident #50<BR/>Review of Resident #50's face sheet revealed a [AGE] year-old female with an original admission date of 06/16/23 with the following diagnoses: Atherosclerotic Heart Disease (disease of the heart's major vessels), Cognitive Communication Deficit (inability to effectively communicate needs), Chronic Obstructive Pulmonary Disease (airflow blockage and breathing-related problems), Type II Diabetes Mellitus (abnormally elevated blood sugar levels), Heart Failure (heart condition), Kidney Failure (condition causing kidneys to not function properly ), Gastroesophageal Reflux Disease (digestive condition), and Hypertension (high blood pressure). <BR/>Record review of Resident #50's significant change MDS dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. Section O - Special Treatments, Procedures and Programs revealed Resident #50 used oxygen therapy while a resident.<BR/>Record review of Resident #50's comprehensive care plan, dated 10/15/24, revealed resident #50 may use oxygen therapy related to Chronic Obstructive Pulmonary Disease. <BR/>Record review of Resident #50's current Physician Orders dated 12/09/24 revealed an order for oxygen to be administered at 2-3 liters per minute per nasal cannula (tube in nostrils) every shift as needed. <BR/>During an observation and interview on 12/03/24 at 9:01 AM, Resident #50 was resting in bed. The resident's oxygen cannula and tubing were observed laying on the floor. The resident's oxygen concentrator was on at 3 liters per minute. No bag for storage of oxygen tubing was observed. Resident #50 stated staff usually change the tubing and humidifier, but she did not recall staff placing a bag to store the oxygen tubing in while it was not in use. Resident #50 stated, that is probably why it ends up on the floor. <BR/>During an observation on 12/06/24 at 10:47 AM, there was no bag for oxygen tubing storage observed in the room of Resident #50. <BR/>Resident #68<BR/>Record review of Resident #68's face sheet revealed a [AGE] year-old male with an admission date of 05/14/24 with the following diagnoses: Dementia (loss of thinking, memory, and reasoning skills), Atrial Fibrillation (irregular heart rate which causes poor blood flow), Type II Diabetes Mellitus (abnormally elevated blood sugar levels), Depression, Malignant Neoplasm of lung (lung cancer), and Hypertension (high blood pressure).<BR/>Record review of Resident #68's significant change MDS dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. Section O - Special Treatments, Procedures and Programs revealed Resident #68 used oxygen therapy while a resident.<BR/>Record review of Resident #68's current Physician Orders dated 12/09/24 revealed an order for oxygen to be administered at 2 liters per minute as needed for shortness of breath. <BR/>During an observation on 12/03/24 at 9:07AM, Resident #68 was out of the facility. The resident's oxygen cannula was observed laying across the bed with the tubing laying on the floor. No bag for storage of oxygen tubing was observed.<BR/>During an observation and interview on 12/03/24 at 11:26 AM, Resident #68 was observed sitting on the side of his bed with oxygen on at 2 liters per minute via nasal cannula. The resident stated, to his knowledge, there was not a bag for storage of his oxygen tubing when it was not in use. The resident stated, I usually just put it wherever when I take it off. I don't know where it's supposed to go. <BR/>Resident #35<BR/>Review of Resident #35's face sheet revealed a [AGE] year-old male with an original admission date of 07/15/15 with the following diagnoses: Chronic Kidney Disease (long-standing disease of the kidneys, leading to kidney failure) Atherosclerotic Heart Disease (disease of the heart's major vessels), Cognitive Communication Deficit (inability to effectively communicate needs), Chronic Obstructive Pulmonary Disease (airflow blockage and breathing-related problems), Type II Diabetes Mellitus (abnormally elevated blood sugar levels), Heart Failure (heart condition), Absence of kidney, Gastroesophageal Reflux Disease (digestive condition), and Dependence on Supplemental Oxygen. <BR/>Record review of Resident #35's quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. Section O - Special Treatments, Procedures and Programs revealed Resident #50 used oxygen therapy while a resident.<BR/>Record review of #35's current Physician Orders dated 12/09/24 revealed an order for oxygen to be administered at 2-3 liters per minute as needed for Chronic Obstructive Pulmonary Disease. <BR/>During an observation and interview on 12/03/24 at 9:01 AM, Resident #35 was in bed watching tv with oxygen on at 3 liters per minute via nasal cannula. Resident #35 had a motorized wheelchair with a portable oxygen tank attached. The cannula and tubing from the portable oxygen tank were observed laying on the floor. The resident stated he does not have a bag to place his oxygen tubing in. He stated staff usually change the tubing and humidifier bottle on Sunday nights, but they do not always bring a bag for the tubing to be stored in. No storage bag was observed on concentrator or portable oxygen tank. Resident #35 stated he does not have anywhere to put his oxygen tubing when he gets up. The resident stated, I usually just throw it over the bed or hang it on the back of the wheelchair but a lot of times it ends up on the floor. <BR/>During an observation on 12/06/24 at 10:35 AM, Resident #35 was observed resting in bed with oxygen on at 3 liters per minute via nasal cannula. No bag was observed for oxygen tubing storage on concentrator or portable oxygen tank. Oxygen tubing from portable tank on the resident's wheelchair was observed touching the floor. <BR/>During an interview on 12/06/24 at 10:36 AM with LVN A, she stated oxygen tubing should be kept in plastic bags when not in use and should be changed out with the tubing and humidifier bottles every Sunday on the night shift. She stated she was not sure why there would not be bags available in resident rooms who were on oxygen. She stated oxygen tubing should not be on the floor or be placed anywhere that it could become contaminated. She stated a potential negative outcome for failure to properly store oxygen tubing was infection. <BR/>During an interview on 12/06/24 at 10:41 AM with CNA A, she stated the night shift was responsible to make sure bags were placed in the rooms of residents who were on oxygen. She stated she was assigned to the hall for Resident # 50, Resident #68 and Resident #35. She stated she had just returned from her days off and today was her first day back at work. She stated she had not checked the oxygen storage bags today because she had not had time yet. She stated bags should be checked daily and changed every Sunday night. She stated it was the responsibility of all staff to make sure bags were available for storage of oxygen tubing. She stated oxygen tubing should never be on the floor or anywhere that it could pick up germs. She stated she had been trained by the facility on proper oxygen tubing storage. She stated a potential negative outcome of failure to properly store oxygen tubing was infection. <BR/>During an interview on 12/09/24 at 11:16 AM with the ADM, he stated he was not aware that residents requiring oxygen did not have storage bags for oxygen tubing. He stated the facility's policy was that oxygen tubing was stored in bags when not in use. He stated storage bags for oxygen should be checked daily and changed out weekly. He stated nursing staff was responsible for placing oxygen tubing storage bags in rooms where oxygen was being administered. He stated staff had been trained on proper storage of oxygen tubing by nursing administration. He stated his expectation of staff for proper oxygen tubing storage was that the tubing would be stored in a plastic bag when oxygen was not in use. The ADM stated a potential negative outcome for failure to properly store oxygen tubing would be infection control issues.<BR/>During an interview on 12/09/24 at 11:27 AM with the DON, she stated she was not aware that residents requiring oxygen did not have storage bags for oxygen tubing. She stated she did not know what the facility policy stated regarding oxygen storage bags. She stated nurses and CNA's were responsible for placing oxygen tubing storage bags in rooms where oxygen was being administered. She stated her expectation of staff for proper oxygen tubing storage was to make sure tubing is stored properly and assure that tubing was not on the floor. She stated a potential negative outcome for failure to properly store oxygen tubing would be the risk of infection to residents.<BR/>Record review of the facility-provided policy titled, Departmental (Respiratory Therapy- Prevention of Infection, Revised November, 2011 revealed:<BR/>Purpose<BR/>The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff.<BR/>Steps in the Procedure<BR/> Infection Control Considerations Related to Oxygen Administration<BR/> .<BR/> 8. Keep the oxygen cannulae and tubing used PRN in a plastic bag when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments on for 2 medication cart (South-hall Medication Cart and North-hall Medication Cart)) of 2 carts reviewed for storage and 1 treatment cart (Station 2) of 2 treatment carts. <BR/>The facility failed to ensure two narcotic boxes for 1 medication cart was always locked. <BR/>The facility failed to ensure that medications were properly labeled and stored properly. <BR/>The facility failed to ensure treatment cart medications were stored in a secure locked manner, while unattended, for 1 of 2 treatment carts (Station 2).<BR/>This failure could place residents at risk of having access to unauthorized narcotic medications and/or lead to possible harm, drug overdose, or drug diversions. <BR/>Findings included: <BR/>On 11/06/2023 at 4:07 pm, an observation and interview was done for medication cart check and medication pass for the south cart on south hall with LVN E. During the observation the narcotic box located inside of the medication cart was left unlocked with heavy duty tape on the outside to help open the door of the narcotic box. LVN E continued to leave the narcotic box unlocked while closing the medication cart. When asked about leaving the narcotic box unlocked LVN E stated that she just leaves it open because it makes it easier when she goes to give her medications. When LVN E was told that she could not leave the narcotic box unlocked, LVN E closed the box and then opened it again and closed the medication cart. LVN E continued to leave the narcotic box unlocked for the duration of the medication pass and gently closing the door to the narcotic box making sure to not completely close the narcotic box. <BR/>On 11/6/23 at 5:27 PM a treatment cart was observed on Station 2 near the nurse station. The cart was unlocked and unattended near room [ROOM NUMBER]. <BR/>On 11/6/23 at 5:28 PM an observation and interview were conducted with LVN A, charge nurse on Station 2. She stated she thought she locked the treatment cart. She further stated that inside of the treatment cart were insulin pens and the medications given to Resident #21 via G-tube. Observation of the cart interior revealed containers of resident ointments, insulin pens and medications for Resident #21 (pills). <BR/>On 11/6/23 at 5:32 PM an interview was conducted with LVN A. LVN A stated the nurse and medication aide were responsible for ensuring the medications were stored in a secure manner. She added that the treatment cart should have been locked. Regarding what could result from medications not being secured properly, she stated residents could get into the treatment cart and medications and it could be dangerous for them.<BR/>On 11/07/2023 at 8:36 am an observation of medication pass and medication cart check for north hall was conducted with MA. During the medication cart check, it was observed that two loose pills were in the area of the medication punch cards. The two medications were identified as lisinopril and Amlodipine 10 mg, located in the second drawer of the medication cart. It was observed that the MA's medication cart stored some fragrances along with the medications that was identified as Scentsy fresh 16 fl. Oz (apple cinnamon), and sure scents (Hawaiian scent) automatic refill 4.5 oz. During medication cart check it was observed that the north cart had expired medications listed as: calcium carbonate expired on 08/2023 (500 mg), albuterol sulfate for Resident #24, there was no label on the inhaler but there was a label on the box, but the box was open with the potential of the inhaler not secured. Symbicort 80/45 mcg was observed for Resident #32 with no label on the medication and not secured in the box. Observed Ventolin HFA 90 mcg for Resident #49 with no pharmacy label. Observed nasal decongestant OTC designated for Resident #43 with no pharmacy label. Observed Fluctuant 200/25 mcg for Resident #49 with no pharmacy label. <BR/>On 11/07/2023 at 8:59 am an Interview was conducted with MA. MA stated that she does not know why there was loose pills on the cart and that she may have responsibility for the cart now, but it was also a shared cart. MA stated that when she assumes responsibility, she does check her cart but did not notice the two loose pills in her medication cart when she previously checked it. MA stated that the pink loose pill was definitely a lisinopril because she always gives this mediation, and it looked familiar to her. MA stated that the medication that was stored with an open box such as inhalers should be labeled on the medication and the box because if the medication was to fall out of the designated box, then they would not know whose medication and where their medication was located. MA stated that the negative potential outcome for having loose pills or no label on medications could be accidentally giving the wrong patient the wrong medication. MA stated that the negative potential outcome for giving a resident an expired medication would be the loss of potency and the resident would not be getting the medication that was required for them to have and possibly causing their health to decline. MA stated that she has been trained on medications labeling. MA stated that the training is randomly through in-services and are approximately held monthly. MA stated that the scents that were found on the cart during medication cart check was not hers but another MA that worked at the facility. MA stated they usually do not keep fragrances on the carts. MA stated that the negative potential outcome was that a resident could possibly ingest a chemical that they do not need to ingest and possibly affecting their health. MA stated that it goes back to the 5 rights of medications: the right patient, the right drug, the right time, the right dose, and the right route. <BR/>On 11/07/2023 at 9:17 am an observation was completed of LVN E during medication pass. LVN E demonstrated to Surveyors that the narcotic box was left unlocked and there was heavy duty tape on the medication to help her to be able to lift the box door to the unlocked narcotics. LVN E demonstrated to the Surveyors that she had the key on her keychain that was kept in her pocket. LVN E demonstrated to Surveyors that the key fit the narcotic box and was able to successfully open the narcotic box. During the entire medication pass, LVN E left the narcotic box unlocked even after she had been asked about why she had left the narcotic box unlocked on several occasions. LVN E continued with the medication pass and gently lowering the lid to the narcotic box down so that she did not lock the box. LVN E demonstrated to the Surveyors that the box would lock and open with the key when she was asked by Surveyors to lock the box and then to open the box with the key. <BR/>On 11/07/2023 at 9:17 am an Interview was conducted with LVN E. LVN E stated that she was aware that there was tape on the narcotic box and that the narcotic box was open and not locked. LVN E stated that the reason that there was tape on the narcotic box was because it was hard to open the box every time, she needed to get a narcotic out of the box. LVN E stated that the protocol for narcotic box on the medication cart was that the narcotics should be double locked. LVN E stated that if a medication cart was to be left unlocked then a resident could accidentally get a narcotic. LVN E stated that the reason she just leaves the narcotic box open was because it was too heavy to open and makes it difficult, but she was aware that she was supposed to have it locked at all times. LVN E stated that she was just doing it to save time to get to her medications quicker. <BR/>Interview with the Administrator on 11/07/2023 at 10:40 am., the Administrator stated that the policy states that the medication cart should be double locked, and the narcotics were to be locked in a separate compartment within the locked medication cart. The Administrator stated that his expectations for all employees that have assumed responsibility for the medication cart was to have the medication cart locked at all times when not getting medications out of the medication cart. The Administrator stated that in-services has been completed for narcotics but not on locked carts with narcotics. The Administrator stated that the negative potential outcome for not locking narcotics within the medication cart was that a resident could potentially get hurt by overdosing and, It could be really bad, and it should be locked. The Administrator stated that in-services for medication administration has been completed by the DON. The Administrator stated that the carts should not have loose pills and that the day that the State came into the building he advised the staff to check the carts to make sure they were in good shape. The Administrator stated that for the labeling that all medication should be labeled correctly and anytime there was an unlabeled medication or a medication that was not labeled correctly, not to take it, and send it back to the pharmacy. The Administrator stated that the policy states that the medication must be labeled. The Administrator stated that his expectations was for an open boxed inhaler should be labeled on the medication and the box because if the medication came out of the box and the medication was not labeled then the wrong resident could be getting the wrong medication. The Administrator stated that this goes back to the 5 rights of medication. The Administrator stated that the 5 rights of medication were: the right patient, the right drug, the right time, the right dose, and the right route.<BR/>On 11/8/23 at 11:07 AM an interview was conducted with the DON related to the unlocked unattended treatment cart. She stated staff were instructed to lock their carts when not with it. Regarding why the situation occurred, she stated more than likely the person was in a hurry and forgot to lock it. Regarding what she expected of staff, she stated staff should always lock the cart. Regarding whom was responsible for ensuring medications were secured on the carts, she stated the nurse on duty, DON and ADON. She added that spot checks of carts were conducted. Regarding what could result from medications not being secured on the medication or treatment carts, she stated residents could get into the carts and eat creams and take pills. DON stated that staff has been in-serviced on medications through in-services and she will make sure to complete another in-service. <BR/>Record Review of facility provided policy, labeled, Storage of Medication, date revised in November 2020, revealed:<BR/>Policy heading:<BR/>The facility stores all drugs and biologicals in a safe, secure, and orderly manner.<BR/>Policy Interpretation:<BR/>1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. <BR/>2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. <BR/>3. The nursing staff is responsible for maintaining medications storage and preparation areas in a clean, safe, and sanitary manner. <BR/>4. Drug containers that have missing, incomplete, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy destroyed. <BR/>5. Hazardous drugs are clearly marked and stored separately from other medications. <BR/>6. Compartments (including, cut not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left attended. <BR/>8. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medications is separate from access to non-controlled medications. A). Controlled medications that are part of a single unit dose distribution system may be stored with non-controlled medications when the supply is minimal, and shortages are readily detectable. <BR/>Record Review of facility provided policy, labeled, Administering Oral Medications, date revised on October 2010, revealed:<BR/>Purpose:<BR/>The purpose of this procedure is to provide guidelines for the safe administration of oral medications.<BR/>General Guidelines:<BR/>Follow the medication administration guidelines in the policy entitled Administering Medications. <BR/>Steps in the procedure:<BR/>7. Check the expiration date on the medication. Return any expired medications to the pharmacy. <BR/>10. Confirm the identity of the resident <BR/>11. Explain the procedure to the resident <BR/>Record Review of facility provided policy, labeled, Controlled Substances, date revised in April 2019, revealed:<BR/>Policy Statement:<BR/>The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. <BR/>Policy Interpretation and Implementation<BR/>6. Keys to controlled substance containers are kept on a single key ring separate from any other keys. <BR/>Record Review of facility provided In-Services, labeled, Medication, dated on 03/27/2023 revealed under Summary of Subject Matter: 10 rights of Medication Administration. 12 employees signed and attended. <BR/>Record Review of facility provided In-Services, labeled, Random Cart Checks, dated on 06/ 05/2023 stated under Summary of Subject Matter: Random checks for narcotics and disposals of medication must be done daily. Shows 7 employees signed and attended. <BR/>Record Review of facility provided In-Services, labeled, Weekly cart audits must be performing along with narcotic counts with medication and nurses, dated on 06/07/2023 revealed that 6 employees signed and attended. <BR/>Record review of the facility policy, titled Storage of Medications, revised November 2020 revealed the following documentation, Policy Heading. The facility stores, all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation. <BR/>1.Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. <BR/>6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. <BR/>Record Review of CMS Appendix PP State Operations Manual Medication Access and Storage last revised 02/03/2023, revealed A facility is required to secure all medications in a locked storage area and to limit access to authorized personnel .During a medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area/cart.

Based on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability.<BR/>1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Puree) at 1 of 1 meal observed (12/03/24 lunch). <BR/>These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. <BR/>The findings included:<BR/>During confidential individual interviews 5 of 14 residents voiced concerns related to food palatability. The residents stated the food did not taste good and the residents did not like eating the facility food. One resident stated she wasn't sure if the cooks knew how to follow a recipe. One resident stated the food was very bland with no taste.<BR/>On 12/03/24 at 10:50 AM the Dietary Manager was informed of a request for a test tray for the noon meal.<BR/>Observation on 12/03/24 at 1:07 PM the test trays arrived at the conference room and sampling began at 1:09 PM with the following results:<BR/>Regular Meal - Regular Texture<BR/>Enchiladas - no issues<BR/>Spanish [NAME] - very bland, no taste<BR/>Beans - thick/dry<BR/>Churro - no issues<BR/>Regular Meal - Mechanical Soft Texture<BR/>Enchiladas - no issues<BR/>Spanish [NAME] - bland, no taste<BR/>Beans - thick/dry<BR/>Regular Meal - Puree<BR/>Enchiladas - no issues<BR/>Spanish rice - bland, no taste, unappetizing look/lack of color<BR/>Beans - no issues<BR/>Interview on 12/03/24 at 1:20 PM, the DM was asked to try the test tray and stated the Spanish rice was a little dry and doesn't really have a flavor and the beans could have been more moist. The DM stated the rice comes in a pre-seasoned pack that she pours out of the bag and lets it cook in the oven. The DM stated she did not add any seasonings to the rice and residents have not complained to her before. The DM stated the beans also come in a bag and all she did was put them in a pot with water and let them cook. <BR/>Interview on 12/09/24 at 9:34 AM, the DM stated some of the food items come in a pack with seasonings already and she is afraid to over-season the food. The DM stated salt and pepper packets are provided to the residents for extra seasonings if they want. The DM stated she tests food that comes out of the kitchen every now and then. The DM stated she was unaware of any complaints from the residents. The DM stated she has been trained on food palatability. The DM stated she did not know any negative outcomes to the residents because the residents always have alternate choices to choose from if they did not like the meal. <BR/>Interview on 12/09/24 at 11:36 AM, the ADM stated the DM and the cooks are responsible for food palatability concerns. The ADM stated the dietary staff have been trained on food palatability and stated sometimes it may be a preference problem. The ADM stated all residents prefer different kinds of foods. The ADM stated the residents have a risk of weight-loss and not eating if the food did not taste good to them. <BR/>Record review of the facility policy and procedure titled, Menu planning, with a revised date of 06/01/19, reflected the following: <BR/>The facility believes that nutrition is an important part of maintaining the well-being and health of its residents and is committed to providing a menu that is well-balanced, nutritious, and meets the preferences of the resident population

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>1)The facility failed to ensure the kitchen was free of insect infestations (roaches),<BR/>2) The facility failed to ensure food and non-food contact surfaces were clean, and<BR/>3) The facility failed to ensure foods and food contact equipment were protected from possible contamination during processing, storage and service. <BR/>These failures could place residents at risk for food contamination and foodborne illness. <BR/>The findings include:<BR/>~ The following observations were made during a kitchen tour that began on 9/13/22 at 9:19 AM and concluded at 10:36 AM:<BR/>The spout had a buildup of residue and dirt on the drink dispensing machine drink gun.<BR/>Observation of 1 of 2 ovens, right side, revealed that there were too numerous to count adult, nymph (pre adult), and adult roaches with egg cases crawling in the oven. There was also a heavy accumulation of roach specs/feces.<BR/>On 9/13/22 at 9:33 AM the Dietary Manager stated regarding the roaches that the pest control operator sprayed for roaches last week. She added that the section of the oven, with roaches, was not used. She stated that the roach population had worsened recently, and she reported it to the administrator. Then the pest control came. <BR/>The plastic food bin exteriors were gummy and soiled.<BR/>The small plastic scoop storage cabinets had a buildup of dirt on the exterior and had a gummy feel.<BR/>There was one roach crawling on the floor when a large pot was moved on the floor under the convection oven.<BR/>There was a buildup of gummy grease on the convection oven top and sides.<BR/>There was a dead roach on the cart where the toaster oven was stored next to the steam table.<BR/>There was a heavy accumulation of roach specs (feces) on the piping behind the steam table.<BR/>There was an area of wallboard that was buckled at the steam table. The interior of the gap revealed there was a heavy accumulation of roach specs.<BR/>The drink gun/drink dispensing area table had buckling paint and a sticky buildup.<BR/>The pump type drink carafes had a gummy exterior.<BR/>There was a heavy accumulation of roach specs on the encased electrical outlet next to the three-compartment sink.<BR/>There were five dead roaches observed stuck to the wall behind the fire extinguisher sign near the three-compartment sink.<BR/>Inside the Dietary Manager's office in the kitchen, there was a box of thickened water next two containers of Avistat-D spray disinfectant labeled, . If swallowed: call a poison control center or doctor immediately. Caution. Causes moderate eye irritation. There were also boxes of Nepro supplement and 5 large cans of coffee stored on the same shelf.<BR/>On 9/13/22 at 10:06 AM Dietary Manager stated the cans of coffee were used for residents.<BR/>These five large cans of coffee were also on the shelf next to Champion Oven Cleaner labeled, Danger: contains sodium hydroxide. Avoid contact with skin. Injurious if sprayed in eyes. There was a box of teabags on top of this box of oven cleaner. Also on the shelf was Handy Klenz Lime Descaler which was labeled, Danger. Causes serious eye damage. Causes severe skin burns and eye damage. May be corrosive to metals There were bottles of steak sauce, coffee filters, hot sauces and oven bags next to the chemicals. <BR/>There were chemicals on the top shelf above the cans of coffee and other foods which included Pro Power Heavy Duty Oven and Grill Cleaner, labeled, Danger: causes severe skin burns and serious eye damage. There was a can of Enforcer Flea Spray stored on the same shelf.<BR/>An adult roach was crawling on the floor of the water heater closet inside the Dietary Manager's office. T his closet had holes in the ceiling and around the pipes entering the ceiling and wall.<BR/>Observation of a cart at the front of the kitchen revealed that the cart had Champion Oven Cleaner stored next to apple juice and a backpack on the same shelf. The oven cleaner was also stored above boxes of coffee filters that were on a lower shelf.<BR/>The refrigerator and freezer storage area, adjacent to the assist dining room, had an icemaker in which the interior flashing needed cleaning. <BR/>There were two of two unshielded ceiling fluorescent lights in the refrigerator and freezer storage area.<BR/>Observation on 9/13/22 at 10:35 AM the Dietary Manager stated previously roaches come out continuously and were worse at one time. She added that the roaches were wherever you turned your head.<BR/>~ The following observations were made during a kitchen tour that began on 9/13/22 at 11:35 AM and concluded at 12:45 PM:<BR/>The exterior of the large mixer had an accumulation of hardened splattered food.<BR/>Dietary staff A was observed preparing pur&eacute;es. Prior to putting the food in the processor, the surveyor asked to see the interior and blade of the processor. The blade had a sudsy film and was wet and the interior of the processor was wet. She then placed scoops of pot roast and milk into the processor and pureed it. She then placed it in a pan to be placed on the steam table.<BR/>On 9/13/22 at 11:48 AM Dietary staff A was observed washing the processor parts in the dishwasher.<BR/>On 9/13/22 at 11:50 AM the dishwasher cycle ended, and the processor parts were wet (blade and interior of the processor pot).<BR/>On 9/13/22 at 11:51 AM Dietary staff A placed scoops of carrots into the processor and pur&eacute;ed it while the interior and parts were still wet.<BR/>Record review and observation of the Auto Chlor System Super 8 chlorine sanitizer, used in the dishwasher, revealed the following, .Sanitizing Food Contact Surfaces. 5. Drain and allow equipment or utensils to air dry.<BR/>There were two sets of soiled keys stored on the prep table.<BR/>On 9/13/22 at 12:14 PM an adult roach was observed crawling on the floor near the steam table during meal service.<BR/>The following observations were made during a kitchen tour that began on 9/13/22 at 4:35 PM and concluded at 5:56 PM:<BR/>There were 2 bottles of blue colored personal drinks stored on the lower shelf of the prep table next to pans.<BR/>On 9/15/22 at 3:05 PM, an interview was conducted with a Dietary Manager. Regarding the roaches she stated they were pretty much there in the facility. Regarding not allowing the processor to air dry she stated Dietary staff A, felt under pressure. Regarding cleaning of equipment, she stated staff were responsible and they clean as they go. She added that she knew chemicals had to be stored away from food but did not know coffee was an issue. She added that staff conduct deep cleaning on Sundays which included cleaning the fryers and soaking the cups for coffee stains. She stated that she ensured staff follow proper food service procedures and protocols by going by the cleaning schedule and monitoring staff. She further stated that she expected Dietary staff A to let the processor air dry as she normally does. She stated that the problems found in the dietary department could result in residents getting chemicals in their food and residents becoming ill. She stated that staff and the dietary manager were responsible for ensuring staff follow all appropriate food service policies and procedures.<BR/>On 9/15/22 at 4:01 PM, an interview was conducted with the Administrator . Regarding dietary sanitation issues, she stated that residents could be affected by toxics in the food. She added that she expected dietary staff to ensure toxics were stored properly. She further stated she expected the Dietary Manager to check staff and ensure that they do what they are supposed to. She stated she did not know what to do about the roaches. She added the German cockroaches were only treated every six months. She further stated she would take the oven out and fumigate it. She stated the increase in roaches could cause infection control issues.<BR/>Record review of the facility policy titled Sanitization, Revised October 2008 revealed the following documentation, Policy Statement. The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation. 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. 3. All equipment, food contact surfaces and utensils shall be washed to remove or clean completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 10. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. 11. For fixed equipment or utensils that do not fit in the dishwashing machine, washing shell consist of the following steps: a. Equipment will be disassembled as necessary to allow access of detergent/solution to all parts; b. Removable components will be scraped to remove food particle accumulation and washed according to manual or dishwashing procedures. 12. Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. 16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 17. The food services manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.<BR/>Record review of the facility policy titled Food Receiving and Storage, Revised October 2017, revealed the following documentation, Policy Statement. Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation. 15. Pesticides and other toxic substances and drugs will not be stored in the kitchen area or in store rooms for food or food preparation equipment and utensils. 16. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 4 of 4 refrigerators reviewed for food safety (room [ROOM NUMBER], 122, 133, 142). <BR/>The refrigerator located in room [ROOM NUMBER] did not have an up-to-date temperature log nor did it have a thermometer inside of the refrigerator. The refrigerator contained undated perishable food items.<BR/>The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer inside of the refrigerator. The refrigerator contained undated perishable food items.<BR/>The refrigerator located in room [ROOM NUMBER] did not have an up-to-date temperature log nor did it have a thermometer inside of the refrigerator. The refrigerator contained undated perishable food items.<BR/>The refrigerator located in room [ROOM NUMBER] did not have an up-to-date temperature log nor did it have a thermometer inside of the refrigerator. The refrigerator contained undated perishable food items.<BR/>These failures could place residents at risk for food borne illnesses.<BR/>Findings included:<BR/>Observation on 12/03/24 at 9:53 AM of personal refrigerator in room [ROOM NUMBER] revealed a temperature log, dated December 2024, with no temperatures recorded. Personal food items were noted in the refrigerator to include a creamy spinach dip and small squares of cheese. No thermometer was noted inside.<BR/>Observation on 12/03/24 at 9:56 AM of the personal refrigerator in room [ROOM NUMBER] revealed no temperature log. An open bottle of iced tea with a label that read refrigerate after opening was observed in the refrigerator. No thermometer was located inside.<BR/>Observation on 12/03/24 at 10:02 AM of the personal refrigerator in room [ROOM NUMBER] revealed a temperature log, dated November 2024, with no temperatures recorded. No December temperature log was observed. Personal food items were noted in the refrigerator to include potato salad, pimiento cheese, an open bottle of soda, an open container of cranberry juice, 3 containers of Jello and an open jar of pickles. No thermometer was noted inside. <BR/>Observation on 12/03/24 at 10:09 AM of the personal refrigerator in room [ROOM NUMBER] revealed a temperature log, dated December 2024, with no temperatures recorded. No food items were noted in refrigerator at the time of observation. No thermometer was noted inside. <BR/>Observation on 12/03/24 at 12:41 PM of the personal refrigerator in room [ROOM NUMBER] revealed a temperature log, dated December 2024, with no temperatures recorded. A partially eaten burrito wrapped in foil was observed inside. No thermometer was noted inside.<BR/>Observation on 12/05/24 at 8:31 AM of the personal refrigerator in room [ROOM NUMBER] revealed a temperature log, dated November 2024, with no temperatures recorded. Personal food items noted in initial observation remained in the refrigerator to include potato salad, pimiento cheese, an open bottle of soda, an open container of cranberry juice, 3 containers of Jello and an open jar of pickles. No thermometer was noted inside.<BR/>In an interview on 12/09/24 at 11:16 AM, the ADM stated he was not aware that personal refrigerator temperatures were not being monitored. He stated the maintenance supervisor was responsible for monitoring personal refrigerator temperatures, but he was no longer employed by the facility as of one week ago. The ADM stated personal refrigerator temperatures should be checked and logged daily. He stated, going forward, nursing would be responsible for checking food in personal refrigerators and monitoring daily temperatures. He stated his expectation of staff was to monitor personal refrigerators and report any concerns. The ADM stated a potential negative outcome for failure to monitor temperatures in personal refrigerators was that residents could become ill. <BR/>In an interview on 12/09/24 at 11:27 AM, the DON stated she was not aware that personal refrigerator temperatures were not being monitored. She stated she was not sure what the policy was for monitoring personal refrigerators. The DON stated she would get with the ADM to establish whose responsibility it was to monitor personal refrigerators, but she assumed it was the responsibility of housekeeping. She stated personal refrigerator temperatures should be checked daily and followed up on. The DON stated a potential negative outcome for failure to properly monitor personal refrigerator temperatures was that the residents could get bacteria in the GI tract and it could be a health issue. <BR/>Record review of the facility-provided policy titled, Food Receiving and Storage, Revised November 2022 revealed:<BR/>Policy Statement<BR/>Foods shall be received and stored in a manner that complies with safe food handling practices.<BR/>Policy Interpretation and Implementation <BR/> .<BR/>7. Residents may consume foods from sources not procured by the facility (e.g., food brought from family or visitors). <BR/> .<BR/>Foods and Snacks Kept on Nursing Units or in Resident rooms<BR/>1. All food items to be kept at or below 41 degrees F are placed in the refrigerator located at the nurses' station and labeled with a use by date. <BR/> .<BR/>3. Refrigerators must have working thermometers and are monitored for temperature according to state-specific guidelines. Temperatures must be monitored. <BR/>4. Beverages are dated when opened and discarded after twenty-four (24) hours. <BR/>5. Other opened containers are dated and sealed or covered during storage.<BR/>6. Partially eaten food is not kept in the refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area in 5 of 11 resident rooms (104, 107, 116, 119 and 120) on Station 2 (East wing).<BR/>1)The facility failed to ensure that 5 of 11 resident rooms had operable call systems at the bedroom and toilet. <BR/> These failures could place residents at risk of not receiving assistance when needed. <BR/>The findings include:<BR/>On 11/6/23 at 11:18 AM an interview was conducted with Maintenance Supervisor. He stated sometimes the facility had problems with the call system. Repairmen have told the facility in the past that parts for the system cannot be obtained because they stopped making them. <BR/>On 11/6/23 at 3:25 PM an interview was conducted with LVN A. She stated that some of the call lights do not illuminate at the Station 2 nurses station call board. <BR/>On 11/6/23 at 3:26 PM an interview was conducted with CNA A regarding the call system indication board at the Station 2 nurses station. She stated, not all of the call board lights illuminate.<BR/>Observation on 11/6/23 at 3:31 PM in room [ROOM NUMBER], revealed Resident #21 was in the B bed. The resident had an activation pad type call system, and when pressed would not stay on. The call system shut off as soon as pressure was not placed on the pad. <BR/>Observation on 11/6/23 at 3:16 PM revealed when a call was registered from room [ROOM NUMBER] from either A or B bed or the bath there was no light illuminated at the nurse station call board. There was an audible sound, and the dome light was functioning. <BR/>Observation on 11/7/23 at 8:23 AM revealed there was a call registered from room [ROOM NUMBER] and there was no light illuminated for 107 at the nurse station. The dome light illuminated and there was an audible sound.<BR/>On 11/7/23 at 8:25 AM an interview was conducted with the Maintenance Supervisor regarding the call system. He stated, some light up and some don't. It's been like that since January (2023) when he was hired. He added he replaced the bulbs at the nurse station call board and they did not illuminate; he replaced six or seven of them. He stated those rooms that did not illuminate at the nurse call board were rooms 100, 102, 107, 110, and 116. He added there were three or four other ones that also did not illuminate. He stated the Call System Vendor was located out of town and it would take a while for them to come to the facility. He further stated the Call System Vendor had recommended the call system be replaced, then sent in a quote to have it repaired approximately 4 or 5 months ago. He stated the company was given a list of rooms and restrooms that needed repair. He stated, he checked the system one time a month, when it comes up on TELS online maintenance scheduling and documentation system. He added he goes checked each room. Regarding whom was responsible for ensuring that the call system worked, he stated that he was. He stated, the facility would move residents to rooms that had working call systems and would call the Call System Vendor to repair it. He added residents may not get the help they needed due to the partially functioning call system.<BR/>On 11/7/23 at 9:30 AM an interview was conducted with the Maintenance Supervisor. Regarding why part of the call system was not functioning correctly, he stated, he could not get parts for the system. He added he was not familiar with the nurse call panel system. He stated he had called the Call System Vendor to repair it. He further stated he was not provided training on this call system. <BR/>Observation on 11/7/23 at 10:44 AM revealed a call was registered from room [ROOM NUMBER]. The dome light was illuminated at the room, and the sound emitted when a call was placed. There was no light at the nurses station call board indicating room [ROOM NUMBER]. <BR/>During an interview with LVN A on 11/7/23 at 10:44 AM, she stated staff had been complaining about the call system not fully functioning since day one. No specific date was provided. <BR/>Observation on 11/7/23 at 11:35 AM in room [ROOM NUMBER], the call light was tested and there was no light illuminated at the nurse's station call board for room [ROOM NUMBER]. This was when a call was initiated from the bedroom or bath. A sound was emitted, and dome light illuminated. <BR/>On 11/7/23 at 4:51 PM an observation and interview was made of Resident #21 in room [ROOM NUMBER]. LVN A pressed the resident's call pad, and it would not stay on. LVN A revealed she was not aware of this call pad not fully functioning. <BR/>Observation on 11/8/23 at 8:44 AM revealed the call pad in room [ROOM NUMBER] still would not stay on once pressed.<BR/>On 11/8/23 at 11:28 AM an interview was conducted with the Administrator regarding issues found in the facility. Regarding why the call system was not fully functioning on Station 2, he stated the facility had worked on it and the call system was old. He added the system had been worked on a lot. Regarding what he expected staff to have done, he stated double check the call system and see that it was working. Regarding whom was responsible for ensuring that the call system worked properly, he stated that it was the Maintenance Supervisor. Regarding what could result from the call system not being fully functional, he stated residents may not be taken care of.<BR/>Record review of the invoice from the Call Repair Vendor revealed and invoice dated 6/27/23 which documented, Notes. Repaired nurse call on southside of facility.<BR/>Record review of the facility policy, titled Call System, Resident, revised September 2022, revealed the following documentation, Policy Heading. Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy Interpretation, and Implementation. <BR/>1. Each resident is provided with a means to call staff directly for assistance from her his/her bed, from toileting/bathing facilities, and from the floor. <BR/>3. The resident call system remains functional at all times. <BR/>4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan. <BR/>5. The resident call system is routinely maintained and tested by the maintenance department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 6 resident rooms (room [ROOM NUMBER]) located on 1 of 2 facility corridors (East Hall):<BR/>1)Roaches were observed crawling on the walls and floor in 1 of 6 resident rooms (room [ROOM NUMBER]) located on 1 of 2 facility corridors (East Hall), and<BR/>2) The pest control program was further compromised due to the facility having harborage areas that were not repaired, clean and/or orderly (hand sink cabinetry and adjacent wall area, clutter).<BR/>These failures could place residents at risk for infections.<BR/>The findings include:<BR/>During confidential resident interviews, 4 of 6 residents stated they had observed roach activity in the facility. One resident stated, I've seen them in the bathroom, closet and bed area. I've seen new hatchlings. He further stated housekeeping in his room varies and could go three or four days without housekeeping coming to his room. He stated, They don't clean under the bed. Another resident stated, They (Pest Control Vendor) sprayed not too long ago. He stated he last saw a roach in the facility approximately a month ago. One other resident stated, I have seen a few. The last I've seen was the first of the month in the room crawling on the floor. Another resident stated he had last seen roaches approximately four months ago and that was when his roommate had food in the room.<BR/>Observation on 6/11/24 at 3:22 PM in room [ROOM NUMBER] (occupied) there was an adult roach crawling on the wall under the hand sink in an area that had a gap near the wall water inlet. The area had a heavy accumulation of specs/roach feces . There were gaps in the hand sink cabinetry where there was specs built up. One small pre-adult/nymph roach fell from the underside of the hand sink cabinet onto the floor and crawled away. There was another large adult roach crawling in one of the gaps between the hand sink cabinetry frame. The roaches were also observed by the Maintenance Supervisor. The room had cluttered areas, and there were 3 extra mattresses stacked on the vacant A bed. The privacy curtains were drawn around the vacant bed and the room was dark.<BR/>On 6/11/24 at 3:30 PM an interview was conducted with the Maintenance Supervisor. He stated that the facility had been sprayed twice in the last month. He added the Pest Control Vendor came last month (May 2024) for roaches. He stated there were bedbugs in room [ROOM NUMBER] and the Pest Control Vendor found no others in the facility; that was approximately two or three weeks ago. He stated, roaches could get out of control, and the facility could get infested. He further stated roaches could get on residents if not controlled. He stated food and poor cleaning could have caused the current increase in roach activity. He stated housekeeping's responsibilities were to keep the facility clean and maintenance was responsible for obtaining pest control .<BR/>On 6/11/24 at 3:37 PM an interview was conducted with LVN A for the East corridor. She stated she had not seen a roach recently, but they used to be really bad. She added some residents kept food in their rooms and she used to see roaches at the nurse's station. She further stated that she reported roach activity to the Maintenance Supervisor, and she had last seen roaches approximately two months ago.<BR/>On 6/11/24 at 3:55 PM an interview was conducted with MA A. She stated the facility had a roach problem a while back. No dates were given as to how far back.<BR/>On 6/11/24 at 4:22 PM an interview was conducted with the Maintenance Supervisor regarding a monitoring system for pest/roach activity in the facility. He stated he looked around the facility and if he saw any, he would call the Pest Control Vendor. He stated he also received staff reports about roaches. He added that if he saw food in a room, he would check it for roaches. He stated he checked for roaches about one time a week.<BR/>On 6/11/24 at 5:10 PM an interview was conducted with the Maintenance Supervisor. He stated the facility had been working on the roach problem on Hall 2 (east corridor) a while. He added, They (roaches) keep coming back .<BR/>On 6/11/24 at 5:38 PM an interview was conducted with Administrator. He stated the facility treated rooms 110, 111 and 112. He added he thought the roach problem stemmed from (room [ROOM NUMBER] ). He further stated residents brought food to their rooms and at times the occupant of room [ROOM NUMBER] was resistant to staff pest control interventions (turning on lights, moving items). He stated when pest issues were reported, they were acted on. He added the food must be removed (resident areas). He also stated there was a book to report issues like pests located at the nurse's stations. He stated the Maintenance Supervisor and Administrator were responsible for ensuring that pests were controlled in the facility. He stated roaches were nasty and could place residents at risk for infections.<BR/>Record review of the Pest Control Vendor Service Form dated 11/7/23 revealed the facility was sprayed one time for Oriental roaches, American roaches, brown banded roaches, spiders, black/brown widow spiders and brown recluse spray spiders. The sites treated were water points and crack and crevice. Further documentation written on the service form revealed that they sprayed the entire East side of the facility. <BR/>Record review of the Pest Control Vendor Service Form dated 1/4/24 and 2/5/24 revealed that the facility was treated at a frequency of monthly and the target pests were Oriental roaches, American roaches, brown banded roaches, and spiders. The sites treated included crack and crevice.<BR/>Record review of the Pest Control Vendor Service Form dated 2/20/24 revealed that the facility was treated on that date for German roaches. The sites treated were water points, crack and crevice and wall joint.<BR/>Record review of the Pest Control Vendor invoices dated 2/20/24 revealed the following documentation, Description of Work. Treated interior cracks and crevices water and entry points and bathroom, German roaches are progressive and can take multiple treatments to gain full control .<BR/>Record review of the three Pest Control Vendor invoices dated 2/21/24 revealed the following documentation, .Description of Work. Treated interior cracks and crevices water and entry points and bathroom. German roaches are progressive and can take multiple treatments to gain full control . The Pest Control Vendor invoice number 266777617 dated 2/21/24 further revealed, . Description of Work. Treated the hallways in the 100s floor, technician did not see any live German roaches at this time. There was a lot of food open, and mini fridges, which are good spots for them to nest, these types of roaches can be brought in by employees and visitors .<BR/>Record review of the Pest Control Vendor Service Form dated 3/14/24 revealed that the facility was treated at a frequency of monthly and was treated that day for ants, roaches, roaches, brown banded roaches, and spiders. The sites treated water points, perimeter, and crack and crevice.<BR/>Record review of the Pest Control Vendor Service Form dated 4/30/24 revealed that the facility was treated that day for termites.<BR/>Review of the Pest Control Vendor Service Form dated 5/10/24 revealed that the facility was treated that day for bedbugs. <BR/>Record review of the Pest Control Vendor invoice dated 5/10/24 revealed, . Description of Work. Technician sprayed the hallways, hallway to past the double doors on the east side of the building. Technician also sprayed inside of 110 per request. Technician also noticed the roaches were German roaches and left an estimate .<BR/>Record review of the Pest Control Vendor Estimate documentation revealed the following, .5/10/24 Estimate details. German roach treatment. <BR/>Record review of the facility policy, titled Maintenance Services, Revised December 2004, Pest Control, revealed the following documentation, Policy Statement. Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation. <BR/>1. The facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. <BR/>2. Pest control services are provided by (Pest Control Vendor), 1/2/23. <BR/>6. Maintenance services assist, when appropriate and necessary, and providing pest control services .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 7 of 22 residents (Residents #2, #7, #22, #25, #33, #37, and #57) reviewed for resident rights.<BR/>The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Residents #2, #7, #22, #25, #33, #37, and #57 prior to administering melatonin (sleep aide).<BR/>This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the benefits and risks of the medications prescribed.<BR/>Findings included:<BR/>Resident #2 <BR/>Record review of Resident #2's admission record, dated 11/06/23, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include unspecified dementia (loss of cognitive functioning), insomnia (difficulty sleeping) and major depressive disorder (mood disorder). <BR/>Record review of comprehensive MDS assessment dated , 09/10/23, revealed Resident #2 was usually understood. The MDS revealed Resident #2 had a BIMS score of 03 which indicated the resident's cognition was severely impaired. <BR/>Record review of a care plan dated 09/11/23 for Resident #2 revealed a Focus - I have insomnia; Goal - I will sleep 6-8 hours per night through the review period; Interventions - Administer medication as ordered by MD.<BR/>Record review of Resident #2's order summary report dated 11/06/23 revealed the following orders: Melatonin Oral Capsule 5mg Give 5mg by mouth at bedtime related to insomnia, dated 09/25/23. <BR/>Record review of Resident #2's electronic medical record revealed no consent for melatonin.<BR/>During a phone interview on 11/08/23 at 8:17 AM, Family member A stated she does not recall if the facility went over risks and side effects regarding the medication melatonin for Resident #2. <BR/>Resident #7<BR/>Record review of Resident #7's admission record, dated 10/24/23, revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture), insomnia (sleep disorder), and muscle weakness. <BR/>Record review of comprehensive MDS assessment dated [DATE] revealed Resident #7 had a BIMS score of 05 which indicated the resident's cognition was severely impaired. <BR/>Record review of a care plan for Resident #7 dated 07/27/23 revealed a focus area I take melatonin for insomnia and interventions to give med as ordered notify MD if not effective for sleep, dated 09/28/23. <BR/>Record review of Resident #7's order summary report dated 11/06/23 revealed the following orders: Melatonin oral tablet 5 mg (melatonin) Give 1 tablet by mouth at bedtime related to Insomnia, unspecified, dated 08/17/23.<BR/>Record review of Resident #7's medication administration records undated for the month of November 2023 revealed resident received Melatonin 5mg at 08:00 PM on 11/1/23, 11/2/23, 11/3/23, 11/4/23, 11/5/23, and 11/6/23. <BR/>Record review of Resident #7's electronic medical record scanned documents on 11/07/23 revealed no consent for melatonin. <BR/>The surveyor attempted to interview Resident #7 on 11/08/23 at 8:40 AM but she was asleep.<BR/>Resident #22<BR/>Record review of Resident #22's admission record, dated 11/06/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease, unspecified (breathing disorder), Insomnia, unspecified (sleep disorder) and anxiety disorder unspecified (psychological disorder).<BR/>Record review of the quarterly MDS assessment for Resident #22, dated 8/24/23 revealed that the resident had a BIMS score of 12 indicating that he was cognitively intact. <BR/>Record review of the care plan for Resident #22 dated 11/6/23 revealed the following Focus, I have insomnia. Medication: melatonin. Interventions included, Assess for cause of insomnia and document in clinical record. Date initiated: 8/1/23.<BR/>Record review of Resident #22's order summary report dated 11/06/23 revealed the following orders: Melatonin oral tablet 5 mg (melatonin) Give two tablets by mouth at bedtime related to insomnia, dated 07/12/23. <BR/>Record review of the clinical records for Resident #22 regarding medications revealed that the resident had no documentation of a consent for melatonin.<BR/>Interview on 11/08/23 at 8:42 AM, Resident #22 stated he knew about the medication melatonin but did not remember the facility staff going over risks and benefits for the medication. <BR/>Resident #25 <BR/>Record review of Resident #25's admission record, dated 11/06/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include sepsis (the body's extreme response to infection), type 2 diabetes mellitus (high blood sugar), and insomnia (difficulty sleeping).<BR/>Record review of the comprehensive MDS assessment dated [DATE] revealed Resident #25 was understood. The MDS revealed Resident #25 had a BIMS score of 15 which indicated the resident's cognition was intact. <BR/>Record review of a care plan dated 08/18/23 for Resident #25 revealed a Focus - I have insomnia Medication: melatonin; Goal - I will sleep 6-8 hours per night through the review period; Interventions - Administer medications as ordered by MD.<BR/>Record review of Resident #25's order summary report dated 11/06/23 revealed the following orders: Melatonin Oral Tablet 5mg Give 2 tablets by mouth at bedtime related to insomnia, dated 06/09/23.<BR/>Record review of Resident #25's electronic medical record revealed no consent for melatonin.<BR/>Interview on 11/08/23 at 9:25 AM, Resident #25 stated she was aware that she was taking the medication melatonin but did not remember the facility going over risks and side effects of the medication. Resident #25 stated she did not remember giving consent for melatonin to be added to her medications. <BR/>Resident #33<BR/>Record review of Resident #33's admission record, dated 11/06/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses to include major depressive disorder (psychological disorder), anxiety disorder (psychological disorder), insomnia (sleep disorder), and Alzheimer's disease with early onset (cognitive disorder).<BR/>Record review of the quarterly MDS assessment dated [DATE] revealed that Resident #33 had a BIMS score of 2 indicating that the resident was cognitively impaired. <BR/>Record review of the current care plan for Resident #33 dated 8/23/23 revealed a Focus, I have insomnia. Medication's: temazepam, melatonin. Interventions, Assess for cause of insomnia and document in the clinical record. Date initiated: 8/23/22.<BR/>Record review of Resident #33's order summary report revealed the following order: Melatonin oral tablet 5 mg (melatonin) Give two tablets by mouth at bedtime for insomnia, dated 6/20/23. <BR/>Record review of the clinical record for a Resident on #33 revealed that he had no documentation of a consent for the use of melatonin which was ordered for insomnia. <BR/>Resident #37<BR/>Record review of Resident #37's admission record, dated 11/07/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus with hyperglycemia (blood sugar disorder), anxiety disorder (psychological disorder), dependence on renal dialysis (kidney dysfunction), and end-stage renal disease (kidney failure).<BR/>Record review of the admission MDS assessment dated [DATE] revealed that Resident #37 had a BIMS score of 14 indicating she was cognitively intact.<BR/>Record review of the current care plan for Resident #37 dated 10/29/23 revealed a Focus - DX: CHF. Ms. (Resident #37) has congestive heart failure. Interventions - monitor/document sleeping pattern. Inform physician of any insomnia or anxiety. Give sedatives as ordered.<BR/>Record review of Resident #37's order summary report revealed an order: Melatonin oral tablet 3 mg (melatonin) Give one tablet by mouth every 24 hours as needed for insomnia, dated 10/23/23. <BR/>Record review of the clinical records for Resident #37 revealed that she had no documentation of a consent for melatonin.<BR/>Resident 57 <BR/>Record review of Resident #57's face sheet, dated 11/06/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus (high blood sugar), pain in unspecified joint, and muscle weakness. <BR/>Record review of comprehensive MDS assessment dated [DATE] revealed Resident #57 was understood. The MDS revealed Resident #57 had a BIMS score of 08 which indicated the resident's cognition was moderately impaired. <BR/>Record review of a care plan dated 08/29/23, for Resident #57 revealed a Focus - I have insomnia Medications: Melatonin; Goal - I will sleep 6-8 hours per night through review period; Interventions - Administer medications as ordered by MD. <BR/>Record review of Resident #57's order summary report dated 11/06/23 revealed the following order: Melatonin Oral Tablet 5mg Give 1 tablet by mouth every 24 hours as needed for insomnia, dated 02/16/23.<BR/>Record review of Resident #57's electronic medical record revealed no consent for melatonin. <BR/>Interview on 11/08/23 at 9:30 AM, Resident #57 stated he was not aware of the order for medication melatonin. Resident #57 stated he was not informed of the risks and side effects regarding the medication melatonin. <BR/>Interview on 11/08/23 at 10:05 AM, the ADON and DON stated they were both responsible for obtaining psychotropic medication consents. The ADON and DON stated the melatonin consents were not obtained due to training from corporate to follow a list of psychotropic medications requiring consent, dated 01/23. The ADON and DON observed Texas Health and Human Services Form 8763, dated 05/23, and confirmed melatonin was on the list of psychotropic medications requiring a consent. The DON stated the potential negative outcome to the residents was they may not be aware of the side-effects of the medication.<BR/>Interview on 11/08/23 at 10:13 AM, the ADM stated the nursing administration staff (DON and ADON) were both responsible for ensuring psychotropic consents were in place. The ADM stated the consents were missed because the facility missed the memo about the psychotropic medication list being updated to include melatonin. The ADM stated the potential negative outcome to the residents was resident right concerns and the resident could have an allergic reaction to the medication.<BR/>Record review of facility policy titled, Psychotropic Medication Use, dated 07/22, reflected the following: Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. <BR/>Policy Interpretation and Implementation:<BR/>1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. <BR/>2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications:<BR/> .d. Hypnotics<BR/>3. Residents, families, and/or the representative are involved in the medication management process.<BR/>Resident Evaluations:<BR/> .4. Residents (and/or representatives) have a right to decline treatment with psychotropic medications.<BR/>a. <BR/>The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.<BR/>Record review of the facility's policy titled, Drug Therapy, dated 01/01, reflected the following: Policy Statement: Each resident's drug regimen shall be free from unnecessary drugs.<BR/>Policy Interpretation and Implementation: <BR/> .2. A comprehensive assessment of the resident's drug therapy will include:<BR/> .e. consent for psychoactive drugs <BR/>Record review of the Texas Health and Human Services Form 8763 titled, Informed Consent or Authorization for Administration of Psychotropic Medication, dated 05/23, reflected that melatonin was on the list of psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I screening accurately reflected the resident's status for 4 of 6 residents (Residents #37, #43, #48, and #50) reviewed for PASRR services.<BR/>The facility failed to ensure the accuracy of the PASRR Level 1 screening for Residents #37, #43, #48, and #50, which resulted in the residents not receiving a PASRR Level II evaluation. <BR/>This failure could place residents who have a mental illness at risk of not receiving individually specialized services to meet their needs.<BR/>Findings included:<BR/>Resident #43:<BR/>Record review of Resident #43's face sheet, dated 9/14/2020, revealed an [AGE] year-old female originally admitted on [DATE], with diagnoses including paranoid schizophrenia (onset date 6/27/2020), disorganized schizophrenia (onset date of 6/27/2020), schizophrenia unspecified (onset date 6/27/2020), schizoaffective disorder - bipolar type (onset date of 6/27/2020), major depressive disorder (onset date of 1/27/2020), and psychotic disorder with delusions due to know physiological condition (onset date of 6/27/2020). <BR/>Record review of Resident #43's MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 indicating she was severely cognitively impacted. <BR/>Record review of Resident #43's PASRR Level 1 screen dated 05/5/2020, with an Effective and Entered date listed in the electronic medical records system of 6/29/2020, revealed the following in part, .C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness . The answer was No.<BR/>During an interview with the MDS Coordinator on 09/14/22 at 2:43 PM, she was asked if she could provide a more current PASRR Level screening or level 2 evaluation and she said she would look for one.<BR/>During an interview with the MDS Coordinator on 09/15/22 at 07:50 AM, I asked if she was ever able to locate the requested PL1 or PL2 for Resident #43 and she said they did not have one. She said she had contacted the Local Mental Health Care Authority to come to the facility today to reevaluate Resident #43. No evidence of an updated or accurate PASRR Level 1 screening was provided prior to exit date of 9/16/2022.<BR/>During an interview on 09/15/22 at 11:14 AM with the MDS Coordinator, she said PASRR Level 1 screening is usually already done when a resident is admitted to the facility. She said if the PASRR Level 1 was not already completed, like if a resident came from home for example, then the social worker was supposed to get it done and the MDS coordinator was responsible for reviewing and documenting the information into the electronic medical records system. She said the information should be entered within about two days of resident admission. She then clarified the social worker completes the PASSAR level 1 screening, and the MDS nurse enters information into SimpleLTC. When asked who was responsible for checking that PASRR Level 1 screening was documented correctly, she said she usually makes sure they are done correctly or her supervisor. When asked if diagnoses of bipolar disorder, schizophrenia or major depressive disorder are conditions that should have triggered a level 2 evaluation, she said yes, they would be marked as a yes under section C0100 which screens for mental illnesses and triggered a PASRR Level 2 screening for services. She said if the PASRR Level 1 was not accurate related to mental illness diagnoses, then the resident may not receive specialized services needed.<BR/>During an interview with the Social Worker on 09/15/22 at 11:24 AM, she said PASRR Level 1 screenings should be done when a resident admits to the facility, and they would like to get it before if the resident transferred from another facility. She said if a resident came from home, she is responsible for completing it. She said she thought the MDS Coordinator's supervisor was responsible for verifying accuracy of PASRR Level 1 screening forms. When asked if schizophrenia or major depressive disorder are conditions that should have triggered a level 2 evaluation, she said yes, they would be under mental illness and should have been indicated as a yes for C0100. She said the risk to the resident was that the resident would have missed out on needed services. <BR/>Resident #50:<BR/>Record review of the face sheet and Order Summary Report dated 9/13/22 for Resident #50 revealed that he was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old and had diagnoses of Schizoaffective Disorder, Bipolar Type(F25.0), Bipolar Disorder, Unspecified, Acute Kidney Failure, Unspecified, Generalized Anxiety Disorder, Hemiplegia and hemiparesis Following Unspecified Cerebrovascular Disease Affecting Unspecified Side (paralysis), Peripheral Vascular Disease, Type 2 Diabetes Mellitus Without Complications, Other Specified Mental Disorders Due To Known Physiological Condition, Bipolar Disorder, Current Episode Depressed, Severe, With Psychotic Features, Major Depressive Disorder, Single Episode, Unspecified, Other Chronic Pain, Essential (Primary) Hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease, Unspecified (lung disorder), Alcoholic Cirrhosis Of Liver Without Ascites(liver disease), Unspecified Convulsions, and Human Immunodeficiency Virus Disease (HIV).<BR/>Record review of the facility submitted list of PASRR positive residents, dated 9/13/22, revealed that there were seven residents listed, but Resident #50 was not on this list.<BR/>Record review of the PASRR Level 1 Screening for Resident #50 dated 9/16/21 revealed that the resident was negative for mental illness, intellectual disability and developmental disability. This PASRR screening was conducted by the resident's previous facility.<BR/>On 9/13/22 at 1:40 PM an interview and observation were made of Resident #50. He stated he had been in the facility since November 2021. The resident was obese, was seated in a wheelchair and the room was dark. The resident had depressive appearance/affect.<BR/>On 9/14/22 at 1:10 PM an interview was held with the MDS Coordinator regarding the PASRR assessment for Resident #50. She stated, the PASRR Level 1, completed by the hospital and previous nursing home, were both negative. She added that their facility had missed his diagnosis of Schizoaffective Disorder, Bipolar Type and Bipolar Disorder. She further stated the PASRR representative said that he was not eligible for services due to the negative MI, ID and DD from the 9/16/21 assessment. She added that she became the MDS Coordinator in April 2022.<BR/>On 9/15/22 at 3:48 PM an interview was conducted with the MDS Coordinator regarding the incorrect PASRR assessment for Resident #50. She stated the incorrect assessment occurred because she went by the negative assessment from the previous nursing home and failed to check the resident's diagnosis. She added that she did not know she needed to check the accuracy of the assessments. She stated that she was responsible ensuring that the assessments were correct regarding PASRR. She added if residents received incorrect assessments, they may not receive the services they needed or correct placement. She stated that she had not observed any schizophrenic or bipolar behavior with Resident #50. She further stated she had heard the resident gets upset but she had not seen it.<BR/>On 9/15/22 at 4:01 PM an interview was conducted with the Administrator. Regarding incorrect PASRR assessments, she stated she expected staff to work with corporate to have the proper training. She added staff must be aware of resident diagnoses and PASRR mistakes and not take for granted the PASRR assessments were correct. she stated that incorrect PASRR assessments could result in resident needs not being met.<BR/>Resident 48:<BR/>Based on record review of the face sheet, accessed 09/14/22, Resident 48 is an [AGE] year old female admitted to the facility 03/17/2016 with diagnoses including: schizoaffective disorder, bipolar type (severe mental illness), other specified anxiety disorders, metabolic encephalopathy (brain problems), Alzheimer's disease with late onset, psychotic disorder with hallucinations due to known (mental illness, seeing things that are not there), major depressive disorder, recurrent severe without psychotic (mental illness makes you sad due to brain chemical imbalance), psychotic disorder with delusions due to known physiological (mental illness, believing things that are not true), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of the brain), and hallucinations (seeing things that are not there).<BR/>In an interview on 09/14/22 with MDS Coordinator, Resident #48's Level II PASRR was requested and the facility informed surveyors that there was no Level II PASRR for Resident #48. <BR/>In addition, based on record review, on her annual MDS done on 10/14/2021, Section A, question 1500 Preadmission Screening and Resident Review (PASRR) which asks if the resident is considered by the state level II process to have a serious mental illness and/or intellectual disability or related condition, the answer is no despite the resident having a diagnosis of schizoaffective disorder, bipolar type; psychotic disorder with hallucination and delusions, and an anxiety disorder. <BR/>Record review of Resident 48's PASRR I revealed a negative screening, with question C0100. Mental Illness marked as 0, which is a no, despite the resident admissions diagnosis of multiple mental illnesses including schizoaffective disorder, bipolar type.<BR/>Resident 37:<BR/>Based on record review of Resident 37's face sheet, accessed 09/14/22, Resident 37 was a [AGE] year old female admitted to the facility 01/21/2019 with diagnoses including Generalized Anxiety Disorder, Bipolar Disorder (severe mental illness with mood swings), and Anxiety Disorder, Unspecified.<BR/>In an interview on 09/14/22 with MDS Coordinator, Resident #37's Level II PASRR was requested and the facility informed surveyors that there was no Level II PASRR for Resident #37. <BR/>Record Review of Resident 37's Level I PASRR revealed a negative screening, with question C0100. Mental Illness was marked as 0, which is a no. Resident #37 was admitted to the facility with a diagnosis of Bipolar Disorder and Generalized Anxiety Disorder. <BR/>Record review of the transfer-discharge return anticipated note in Resident 37's medical record, Resident #37 was transferred to the hospital for Cognitive impairment possible mental health crisis according to the transfer form section 1 in her medical chart, which also states relevant diagnosis of bipolar. Section II of the transfer form states resident's husband is concerned that the resident is experiencing a mental health crisis. Stated, 'this has happened before and she had to get treatment from covenant's mental health hospital.'<BR/>Record review of Form 1012, Texas Health and Human Services Mental Illness/Dementia Resident Review found at https://www.hhs.texas.gov/regulations/forms/1000-1999/form-1012-mental-illnessdementia-resident-review (accessed on 09/21/2022) read in part, .Examples of MI (mental illness) are: a schizophrenic, mood disorder (bipolar, major depression, or other mood disorder), paranoid disorder; somatoform disorder; schizoaffective disorder; panic or other disorder that may lead to a chronic disability diagnosable under the current Diagnostic and Statistical Manual of Mental Disorders . <BR/>Record review of the facility's undated current policy titled, Policy and Procedure for PL1 (PASRR Level 1 Screening)/PASRR/ . Revised 1/16/2019 revealed the following documentation, Rationale: The facility will ensure compliance with all Phase I and II guidelines of the PASRR process for long-term care. Responsibilities: MDS coordinators, marketing/admissions team members/social worker/administrator/DON/IDT members. Procedures: 1. Submit a PL1 form for every person entering your facility regardless of payer source within 72 hours of admission. A. The LTC facility is only allowed to complete/submit the PL1 form for LTC facility to LTC facility transfer, all other PL1 forms are completed by the referring entity or family, if the person is coming from home, staff may assist the family with completing the PL1 information and fax in to the local authority. The local authority must submit PL 1 forms prior to admission to the facility and facility must certify they can care for the resident.<BR/>Additional record review of facility's undated policy titled Policy and Procedure for PL1/PASRR/NFSS/1012/PCSP read in part, . If at any time a resident has a significant change, admits to Hospice, discharging to another facility, or you receive information that might indicate the resident may have a MI/ID/DD (mental illness/ intellectual disability/ developmental disability) diagnosis or condition not contained in the medical record, please submit a PL1 form for the resident to be evaluated by the Local Authority .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 2 residents fed by gastrostomy tube (Resident #21).<BR/>1)The facility failed to ensure nursing staff provided G-tube (gastrostomy tube) care in a sanitary manner and followed physician orders for Resident #21. <BR/>These failures could result in the spread of resident infections. <BR/>The findings include:<BR/>Record review of the Order Summary Report dated 11/6/23 for male Resident #21 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of dysphagia oropharyngeal phase (swallowing disorder), gastrostomy status (nutrition delivered through abdominal wall), contracture, unspecified, joint (reduced joint flexibility), personal history of traumatic brain injury (brain injury), anoxic brain damage, not elsewhere, classified (loss of oxygen to the brain), gastrostomy, complication, unspecified (difficulty with nutrition delivered through abdominal wall), moderate protein calorie malnutrition (malnutrition), and quadriplegia, unspecified (paralysis of all 4 limbs).<BR/>Further record review of the Order Summary Report revealed the following orders:<BR/>Peg tube residual check every shift, if over 100 ml hold feeding and notify physician every shift related to gastrostomy complication, unspecified. Order status active. Order date 6/9/23. Start date 6/9/23.<BR/>Clean area around peg to with NS, pat dry, cover with split 4 x 4 gauze, one time a day related to quadriplegia, unspecified; gastrostomy complication, unspecified. Clean area around peg tube with NS pat dry, apply Calazinc and cover with split 4 x 4 gauze. Order status active. Order date 6/12/23. Start date 6/13/23. Tube feeding: H2O 51 ML/HR X 20 hours total water 1020 ML, two times a day for enteral feeding off at 8 AM and resume at 12 PM. Order status active. Order date 4/19/23. Start date 4/19/23.<BR/>Tube feeding: Isosource 1.5 at 70 ML/HR X 20 hours with/H2O flush of 51ML/HR X 20 hours to provide 1400 ML formula volume 2100 kcals, 95 g proteins and 2090 ML H20 pump on at 12 PM and off at 8 AM two times a day for enteral feeding off at 8 AM and resume at 12 PM. Period. Order status active. Order date 4/19/23. Start date 4/20/23 <BR/>Record review of the quarterly MDS assessment dated [DATE] for Resident #21 revealed that the resident had no BIMS score and was documented as severely impaired cognitively - never/rarely made decisions. Further record review of this MDS documented the resident had Active Diagnoses that included quadriplegia, malnutrition, and aphasia (difficulty speaking). Additional diagnoses included gastrostomy complication, unspecified, indicated by ICD code K94.20.<BR/>Record review of the current care plan dated 8/02/23 for Resident #21 revealed the following Focus. (Resident #21) requires tube feeding R/T malnutrition dysphasia, weight expected to fluctuate R/T TF and dependent edema secondary to quadriplegia. Isosource 1.5 at 70 ML/HR HR X 20 hours. Flush with 30 ML before and after meds. Change syringe every night. Check residual every shift, hold, if 100 or above for one hour. Peg site care daily. Water flush 51ML/HR X 20 hours continuous. Pump at 12 PM and off at 8 AM. May use Coca-Cola to unclog G-tube2 PRN. Folic acid. Date initiated: 9/15/16. Revision on: 8/2/23. The Goal included, He will remain free of side effects or complications related to tube feeding through review date. Date initiated: 9/15/16. Revision on: 4/24/23. Target date: 1/21/24. Interventions/Tasks included, Checked for tube placement and gastric contents/residual, violent volume per facility protocol and record. Hold feed times one hour, if greater than 100 cc aspirate. Date initiated: 9/15/16. Revision on: 9/15/16. He needs total assistance with tube feeding and water flushes. See MD orders for current feeding orders. Date initiated: 9/15/16. Revision on: 9/15/16. Provide local care to G-tube site as ordered and monitor for S/SX of infection and/or skin breakdown. Report site problems to MD. Date initiated: 9/15/16. Revision on: 12/29/16. The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Date initiated: 9/15/16.<BR/>On 11/6/23 at 10:43 AM Resident #21 was observed. The resident was on an air bed and was leaning to the left side in bed. The resident's hands were contracted and had random arm movements. A tube feeding pump was present with formula and water flush hanging. The tube feeding pump was off and the formula tubing was disconnected from the resident. The G-tube feeding formula tubing was looped over the pump pole and the end was uncovered/uncapped. The feeding formula was Isosource 1.5 CAL and the documentation on the bag was 11/5/23, 2100 70 ml/hr. The feeding formula level was approximately 450 mL. The water bag level was approximately 600 ml and was labeled, 11/3/23 1530 70 ML/HR.<BR/>On 11/6/23 at 2:08 PM Resident #21 was observed in his room sleep on his air bed. The G-tube was on and connected. The water bag level was approximately at 575 ml and the Isosource feed level was approximately at 300 mL. There was a used flushing syringe present that was labeled 11/5/23 and had the initials for LVN D. The flushing syringe plunger was stored inside the barrel. The display on the Feeding pump was Feed rate 70 ml/hr, 2510 Flush, 8027 Feed, Flush 50 mL Every one hour. <BR/>On 11/6/23 at 5:34 PM Resident #21 was observed in bed in his room. The G-tube was on, and the display read as follows: Feed rate 70 mL/hr, 2710 flush, 8255 Fed, Flush 50 ml Every one hour.<BR/>The water bag level was approximately at 400 ml. The Isosource level was approximately at 100 ml. The used flushing syringe was stored in a bag with the plunger inside the barrel and the bag was dated 11/5/23 with the initials for LVN D. <BR/>On 11/7/23 at 8:48 a.m. Resident #21 was observed in bed on an air bed. The G-tube pump was off. The flushing syringe was stored in a bag and the plunger was inside the barrel. The interior of the flushing syringe was wet. The level of the feeding Isosource was approximately at 475 ml and the water was approximately 900 at ml. The Isosource bag was labeled 70 mL/hour 11/6/23, 2145 and the water bag was labeled 11/6/23, 2145 H2O. Both bags were initialed by LVN B.<BR/>On 11/7/23 at 10:26 AM an interview was conducted with Station 2 LVN A. She stated Resident #21 was reconnected to the G-tube at noon and disconnected at 8:00 AM. She added that his formula rate was 70 ml/hr and the water flush was 50 ml/hr. <BR/>On 11/7/23 at 11:58 AM an observation was made of, and interview conducted with LVN A of Resident #21 being reconnected back to the G-tube pump feeding. At this time, she stated the feed was 70 ml an hour and the water flush was 51 ml an hour. This was what she was reading from the MAR documentation on her computer screen. Upon entering the room, the resident was in bed and had cracked dry and peeling skin on his lips. LVN A then brought in 2 cups of water, clean dressings and gloves on a tray and placed it on the overbed tray table. She also had a new flushing syringe. She washed her hands and donned pair of gloves. She checked for placement and bowel sounds. She checked for residual, and there was no residual. She flushed with 15 mL of water. She turned on the pump and the screen displayed the following: <BR/>70 mL/hr Feed, 3212 Flush, 8961 Fed, 50 mL flush every one hour. <BR/>The level of the feeding Isosource was still approximately at 475 ml and the water flush was still approximately at 900 ml. The resident was reconnected to the g-tube and the flush amount remained at 50 ml every one hour and was not changed to 51 ml as ordered. LVN A removed the soiled dressing from the G-tube site and removed her soiled gloves and placed them on the same tray where there was a clean dressing to be placed on the G-tube site of the resident. She cleaned the site and placed clean dressings back on the G-tube site. Regarding why she had placed the soiled gloves and dressings on the tray with the clean dressing, she stated, she was trying to get the dressing on the resident's G-tube site. She further stated that normally she did not place the soiled dressings and gloves on the same tray with the clean items. She stated this was not the ideal way of performing the procedure by placing clean and soiled items on the same tray. She added she did place the soiled dressings and gloves near the dirty cups. Prior to leaving Resident #21's room, the LVN tossed all the soiled gloves and dressings and trash loosely and unbagged in the room trashcan that was on the A bed side. This resulted in a soiled glove from the treatment hanging on the outside of the trashcan. <BR/>On 11/7/23 at 1:38 PM Resident #21 was observed in bed sleeping. Dried skin was peeling on his lips and he had contracted hands and foot drop. The display on the feeding pump was: <BR/>Feed 70 mL/hr, 9060 Fed, 3262 Flush, Flush 50 mL every one hour. The feed level was at 375ml approximately and the water level was approximately at 800 mL. <BR/>On 11/7/23 at 4:40 PM an interview was conducted with LVN A regarding the soiled dressing being on the tray with a clean dressing. She stated that she had messed up and that she knew the correct procedures. She stated she was focused on the feed and then noticed his dressing needed to be replaced. She stated she should have put the dirty dressing in her gloves and dispose of it and then re-washed her hands and finished the clean process. She added that the procedure was kind of quickly done. She stated she normally carried a trash bag with her to dispose of the soiled items She stated she was in a hurry and the area was not set up like it should have been. She stated that dirty items could touch the clean and could cause cross-contamination. <BR/>On 11/7/23 at 4:51 PM an observation was made of the G-tube pump for Resident #21 and an interview was conducted with LVN A at this time. Observation of the pump display revealed the water flush was still set at 50ml every 1 hour and not 51 ml flush as ordered. LVN A stated she did not know why it was set at 50ml instead of 51 ml. At that time, she corrected the dosage of water flush to 51 ml on the pump. She added she had not noticed this error with the flush and had just hit the prime button when she reconnected the resident to the feeding. She stated the pump was set on 50 ml flush prior to her coming on shift at 6:00 AM (11/07/23). Regarding why the G-tube setting was on 50ml flush, she stated it must have been set by the previous shift. She added it was her responsibility to ensure it was set at the correct rate. Regarding what could result from the incorrect setting on the water flush, she stated luckily it was a small amount error, but if it were a higher rate, it could have affected the resident and possibly caused dehydration. She stated, that there had been no skills check or additional instruction regarding G-tubes. She added, the G-tube system used by Resident #21 was the first G-tube flush system of its kind that she had encountered. <BR/>On 11/8/23 at 8:43 AM Resident #21 was observed on his air bed. The used G-tube flushing syringe was stored in a bag with the plunger inside the barrel and liquid was in the tip. There was white debris inside the syringe.<BR/>On 11/8/23 at 10:23 AM an observation was made of Resident #21 asleep in bed and the G-tube pump was turned off. There was a G-tube flushing syringe in a bag hung on the pump pole. The documentation on the bag was 11/8/23 and the plunger was stored inside the barrel and the syringe was wet on the interior with white debris inside. <BR/>On 11/8/23 at 11:44 AM an observation was made of agency LVN C reconnect Resident #21 to his G-tube pump. Upon entering the room there were 4 cups of water on the over bed tray table and the new bag of Isosource 1.5 cal formula was also on the over bed tray table. LVN C then used the same soiled flushing syringe that had been stored with the plunger in the barrel with debris inside. She used the flushing syringe to check the residual and she received 20 ml of residual in return and dispensed it back into the resident. She listened for bowel sounds and then flushed the G-tube with 15 mils of water using the same flushing syringe. She did not clean the flushing syringe after use and left it stored together with the plunger in the barrel and soiled. The water flush bag was hung, and the bag of formula was hung and connected to the resident. She placed the soiled flushing syringe in the same bag that it had been in and hung the bag on the pole for use. The flushing syringe had water/stomach contents in the tip of the flushing syringe. The screen on the pump displayed the following: 70 ml/hr Feed, 51 ml flush every 1 hour, 3566 flush, 9524 Fed. LVN C then placed the formula tubing cap on one of the hooks on the pump pole and the hook was not clean.<BR/>On 11/8/23 at 12:03 PM an interview was conducted with LVN C regarding Resident #21's G-tube hanging. She stated the signature on the flushing syringe bag (LVN B) was from the night shift. She added, she was told by staff change out the flushing syringes every night. Regarding the storage of the plunger in the flushing syringe barrel, she stated, this was how she had seen them stored everywhere. Regarding the tubing cap being stored on the soiled pole she stated she could store it in a baggy instead. Regarding what could result from her actions related to the storage of the flushing syringe and the endcap for the feeding tube she stated there could be infection control issues. She added the flushing syringe was stored with the plunger in the barrel when she came on duty at 6:00 AM (11/08/23). Regarding any orientation that included G-tube flushing syringes, she stated that the facility did not go over proper storage of used flushing syringes prior to starting to work in the facility. <BR/>On 11/8/23 at 12:11 PM an interview was conducted with the DON regarding G-tube procedures. Regarding how staff were instructed to store the used flushing syringes, she stated, they are changed daily, and packaging dated when opened. She added staff should rinse the flushing syringe out with water and store it in the bag. She added, the parts (plunger and barrel) should be stored together with the plunger in the barrel. Regarding dressing changes, she stated, the dirty items should have been tossed in the trash. The soiled should have gone in the trash and then the nurse should have washed her hands and donned gloves. The nurse should have then continued with the clean dressing . She added if staff placed the soiled items in the trash, they should have taken the trash out immediately or ideally bring their own trash bag in for the procedure. Regarding if she had conducted any in-services related to G-tube care, she stated not recently and that she just talked to staff about G-tube procedures. Regarding why the situation occurred with the dressing change, she stated the nurse was just flustered. Regarding any monitoring she conducted related to G-tube services for residents, she stated for new staff, nursing administration checked them and then they checked what was given to the resident. She added nursing administration checked that all things go as ordered and conduct direct monitoring. Regarding what she expected staff to have done, she stated to follow policy and procedure. Regarding what could result from the actions observe related to G-tubes, she stated regarding not following the order, if it goes a long time, a resident could experience dehydration. Regarding the dressing changes there could be cross-contamination. Regarding the stored cap on the pole, it could be cross contamination. Regarding improper flushing syringe storage, there could be cross-contamination, an increase in bacterial growth and the resident could get sick.<BR/>On 11/8/23 at 12:45 PM an interview was conducted with the Administrator regarding G-tube procedures observed. Regarding why he felt the situations occurred, he stated staff not following policy. Regarding what he expected staff to have done, he stated be familiar with the policy and follow procedures better. Regarding what could result from the G-tube issues observed, he stated residents could get an infection and not receive proper nutrition and lose weight.<BR/>Record review of the facility policy, titled Gastrostomy/Jejunostomy Site Care, Level III, revised October 2011, revealed the following documentation, Purpose. The purpose of this procedure are to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection. Preparation. 1. Verify that there is a physician's order for the procedure. 3. Assemble equipment and supplies needed. Steps and Procedure. 2. Wash hands and dry thoroughly. 10. Discard disposable supplies in designated containers.<BR/>Record review of the facility policy, titled Enternal Tube Feeding Via Continuous Pump, Level III, revise November 2018, revealed the following documentation, Purpose. The purpose of this procedure is to provide a guideline for the use of pump for enteral feedings. Preparation. <BR/>1. Verify that there is a physician's order for this procedure. General Guidelines. 1. Use aseptic technique when preparing or administering enteral feedings. <BR/>3. Check the enteral nutrition label against the order before administration. Check the following information. <BR/>g. Rate of administration (ML/hour) . <BR/>Steps In Procedure. <BR/>1. Placed equipment on the bedside stand or over bed table. Arrange the supplies so they can be easily reached. <BR/>2. Wash hands and dry thoroughly. <BR/>5. Check the label on the enteral formula against the physician's order. <BR/>Initiate Feeding. <BR/>5. On the formula label .initial that the label was checked against the order. <BR/>7. Discard disposable supplies in the designated containers. <BR/>8. Clean reusable equipment according to the manufacture's instructions. <BR/>12. Remove gloves and discard into designated container. <BR/>13. Wash your hands.<BR/>Record review of the facility policy, titled Enteral, Feeding Syringes, Sanitization Of Reusable, Level II, revised March 2015, revealed the following documentation, Purpose. The purpose of this procedure is to guide the proper sanitizing of reusable enteral feeding syringes. Preparation. Assemble equipment and supplies needed. Equipment and Supplies. The following equipment and supplies will be necessary when performing this procedure . <BR/>4. Sixty (60) ML enteral feeding syringe. <BR/>Steps in the Procedure. In the absence of manufactures, specific care and maintenance instructions, sanitize reusable enteral feeding syringes as follows. <BR/>4. Rinse 60 ml enteral feeding syringe with running water if the syringe had contact with stomach secretions or enteral feeding. <BR/>7. Disassemble the enteral feeding syringe. place syringes in bleach solution in the container. <BR/>8. Place a lid on the container. <BR/>11. Place syringe parts on top of the lid. <BR/>13. Shake moisture off of the container and sanitized items. <BR/>14. Place syringe parts inside the container. <BR/>15. Placed the lid on top . <BR/>16. When ready to use, rinse the syringe with fresh tap water. <BR/>17. Discard the syringe weekly or whenever obviously soiled or malfunctioning. <BR/>Record review of a facility policy titled Enteral Feedings - Safety Precautions, Level III, revised November 2018, revealed the following documentation, Purpose. To ensure the safe administration of enteral nutrition. Preparation. <BR/>1. All personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified, and competent, in his or her responsibilities. <BR/>2. The facility will remain current and follow excepted best practices in enteral nutrition. <BR/>General Guidelines. <BR/>Preventing Contamination. <BR/>1. Maintain strict aseptic technique at all times when working with enteral nutrition systems, and formulas. <BR/>Preventing errors in administration. <BR/>1. Check the enteral nutrition label against the order before administration. Check the following information. Rate of administration (ML/hour) .<BR/>Record review of the facility policy titled Standard Precautions, revised October 2018, revealed the following documentation, Policy Statement. Standard precautions are used in the care of all residents regardless of their diagnosis or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Policy Interpretation and Implementation . <BR/>1. Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. <BR/>2. Personnel are trained in the various aspects of standard precautions to ensure appropriate decision making in various clinical situations . <BR/>Standard precautions include the following practices . <BR/>5. Resident care equipment. <BR/>a. Resident care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents skin and mucus membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments . <BR/>c. Single use items are properly discarded .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments on for 2 medication cart (South-hall Medication Cart and North-hall Medication Cart)) of 2 carts reviewed for storage and 1 treatment cart (Station 2) of 2 treatment carts. <BR/>The facility failed to ensure two narcotic boxes for 1 medication cart was always locked. <BR/>The facility failed to ensure that medications were properly labeled and stored properly. <BR/>The facility failed to ensure treatment cart medications were stored in a secure locked manner, while unattended, for 1 of 2 treatment carts (Station 2).<BR/>This failure could place residents at risk of having access to unauthorized narcotic medications and/or lead to possible harm, drug overdose, or drug diversions. <BR/>Findings included: <BR/>On 11/06/2023 at 4:07 pm, an observation and interview was done for medication cart check and medication pass for the south cart on south hall with LVN E. During the observation the narcotic box located inside of the medication cart was left unlocked with heavy duty tape on the outside to help open the door of the narcotic box. LVN E continued to leave the narcotic box unlocked while closing the medication cart. When asked about leaving the narcotic box unlocked LVN E stated that she just leaves it open because it makes it easier when she goes to give her medications. When LVN E was told that she could not leave the narcotic box unlocked, LVN E closed the box and then opened it again and closed the medication cart. LVN E continued to leave the narcotic box unlocked for the duration of the medication pass and gently closing the door to the narcotic box making sure to not completely close the narcotic box. <BR/>On 11/6/23 at 5:27 PM a treatment cart was observed on Station 2 near the nurse station. The cart was unlocked and unattended near room [ROOM NUMBER]. <BR/>On 11/6/23 at 5:28 PM an observation and interview were conducted with LVN A, charge nurse on Station 2. She stated she thought she locked the treatment cart. She further stated that inside of the treatment cart were insulin pens and the medications given to Resident #21 via G-tube. Observation of the cart interior revealed containers of resident ointments, insulin pens and medications for Resident #21 (pills). <BR/>On 11/6/23 at 5:32 PM an interview was conducted with LVN A. LVN A stated the nurse and medication aide were responsible for ensuring the medications were stored in a secure manner. She added that the treatment cart should have been locked. Regarding what could result from medications not being secured properly, she stated residents could get into the treatment cart and medications and it could be dangerous for them.<BR/>On 11/07/2023 at 8:36 am an observation of medication pass and medication cart check for north hall was conducted with MA. During the medication cart check, it was observed that two loose pills were in the area of the medication punch cards. The two medications were identified as lisinopril and Amlodipine 10 mg, located in the second drawer of the medication cart. It was observed that the MA's medication cart stored some fragrances along with the medications that was identified as Scentsy fresh 16 fl. Oz (apple cinnamon), and sure scents (Hawaiian scent) automatic refill 4.5 oz. During medication cart check it was observed that the north cart had expired medications listed as: calcium carbonate expired on 08/2023 (500 mg), albuterol sulfate for Resident #24, there was no label on the inhaler but there was a label on the box, but the box was open with the potential of the inhaler not secured. Symbicort 80/45 mcg was observed for Resident #32 with no label on the medication and not secured in the box. Observed Ventolin HFA 90 mcg for Resident #49 with no pharmacy label. Observed nasal decongestant OTC designated for Resident #43 with no pharmacy label. Observed Fluctuant 200/25 mcg for Resident #49 with no pharmacy label. <BR/>On 11/07/2023 at 8:59 am an Interview was conducted with MA. MA stated that she does not know why there was loose pills on the cart and that she may have responsibility for the cart now, but it was also a shared cart. MA stated that when she assumes responsibility, she does check her cart but did not notice the two loose pills in her medication cart when she previously checked it. MA stated that the pink loose pill was definitely a lisinopril because she always gives this mediation, and it looked familiar to her. MA stated that the medication that was stored with an open box such as inhalers should be labeled on the medication and the box because if the medication was to fall out of the designated box, then they would not know whose medication and where their medication was located. MA stated that the negative potential outcome for having loose pills or no label on medications could be accidentally giving the wrong patient the wrong medication. MA stated that the negative potential outcome for giving a resident an expired medication would be the loss of potency and the resident would not be getting the medication that was required for them to have and possibly causing their health to decline. MA stated that she has been trained on medications labeling. MA stated that the training is randomly through in-services and are approximately held monthly. MA stated that the scents that were found on the cart during medication cart check was not hers but another MA that worked at the facility. MA stated they usually do not keep fragrances on the carts. MA stated that the negative potential outcome was that a resident could possibly ingest a chemical that they do not need to ingest and possibly affecting their health. MA stated that it goes back to the 5 rights of medications: the right patient, the right drug, the right time, the right dose, and the right route. <BR/>On 11/07/2023 at 9:17 am an observation was completed of LVN E during medication pass. LVN E demonstrated to Surveyors that the narcotic box was left unlocked and there was heavy duty tape on the medication to help her to be able to lift the box door to the unlocked narcotics. LVN E demonstrated to the Surveyors that she had the key on her keychain that was kept in her pocket. LVN E demonstrated to Surveyors that the key fit the narcotic box and was able to successfully open the narcotic box. During the entire medication pass, LVN E left the narcotic box unlocked even after she had been asked about why she had left the narcotic box unlocked on several occasions. LVN E continued with the medication pass and gently lowering the lid to the narcotic box down so that she did not lock the box. LVN E demonstrated to the Surveyors that the box would lock and open with the key when she was asked by Surveyors to lock the box and then to open the box with the key. <BR/>On 11/07/2023 at 9:17 am an Interview was conducted with LVN E. LVN E stated that she was aware that there was tape on the narcotic box and that the narcotic box was open and not locked. LVN E stated that the reason that there was tape on the narcotic box was because it was hard to open the box every time, she needed to get a narcotic out of the box. LVN E stated that the protocol for narcotic box on the medication cart was that the narcotics should be double locked. LVN E stated that if a medication cart was to be left unlocked then a resident could accidentally get a narcotic. LVN E stated that the reason she just leaves the narcotic box open was because it was too heavy to open and makes it difficult, but she was aware that she was supposed to have it locked at all times. LVN E stated that she was just doing it to save time to get to her medications quicker. <BR/>Interview with the Administrator on 11/07/2023 at 10:40 am., the Administrator stated that the policy states that the medication cart should be double locked, and the narcotics were to be locked in a separate compartment within the locked medication cart. The Administrator stated that his expectations for all employees that have assumed responsibility for the medication cart was to have the medication cart locked at all times when not getting medications out of the medication cart. The Administrator stated that in-services has been completed for narcotics but not on locked carts with narcotics. The Administrator stated that the negative potential outcome for not locking narcotics within the medication cart was that a resident could potentially get hurt by overdosing and, It could be really bad, and it should be locked. The Administrator stated that in-services for medication administration has been completed by the DON. The Administrator stated that the carts should not have loose pills and that the day that the State came into the building he advised the staff to check the carts to make sure they were in good shape. The Administrator stated that for the labeling that all medication should be labeled correctly and anytime there was an unlabeled medication or a medication that was not labeled correctly, not to take it, and send it back to the pharmacy. The Administrator stated that the policy states that the medication must be labeled. The Administrator stated that his expectations was for an open boxed inhaler should be labeled on the medication and the box because if the medication came out of the box and the medication was not labeled then the wrong resident could be getting the wrong medication. The Administrator stated that this goes back to the 5 rights of medication. The Administrator stated that the 5 rights of medication were: the right patient, the right drug, the right time, the right dose, and the right route.<BR/>On 11/8/23 at 11:07 AM an interview was conducted with the DON related to the unlocked unattended treatment cart. She stated staff were instructed to lock their carts when not with it. Regarding why the situation occurred, she stated more than likely the person was in a hurry and forgot to lock it. Regarding what she expected of staff, she stated staff should always lock the cart. Regarding whom was responsible for ensuring medications were secured on the carts, she stated the nurse on duty, DON and ADON. She added that spot checks of carts were conducted. Regarding what could result from medications not being secured on the medication or treatment carts, she stated residents could get into the carts and eat creams and take pills. DON stated that staff has been in-serviced on medications through in-services and she will make sure to complete another in-service. <BR/>Record Review of facility provided policy, labeled, Storage of Medication, date revised in November 2020, revealed:<BR/>Policy heading:<BR/>The facility stores all drugs and biologicals in a safe, secure, and orderly manner.<BR/>Policy Interpretation:<BR/>1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. <BR/>2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. <BR/>3. The nursing staff is responsible for maintaining medications storage and preparation areas in a clean, safe, and sanitary manner. <BR/>4. Drug containers that have missing, incomplete, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy destroyed. <BR/>5. Hazardous drugs are clearly marked and stored separately from other medications. <BR/>6. Compartments (including, cut not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left attended. <BR/>8. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medications is separate from access to non-controlled medications. A). Controlled medications that are part of a single unit dose distribution system may be stored with non-controlled medications when the supply is minimal, and shortages are readily detectable. <BR/>Record Review of facility provided policy, labeled, Administering Oral Medications, date revised on October 2010, revealed:<BR/>Purpose:<BR/>The purpose of this procedure is to provide guidelines for the safe administration of oral medications.<BR/>General Guidelines:<BR/>Follow the medication administration guidelines in the policy entitled Administering Medications. <BR/>Steps in the procedure:<BR/>7. Check the expiration date on the medication. Return any expired medications to the pharmacy. <BR/>10. Confirm the identity of the resident <BR/>11. Explain the procedure to the resident <BR/>Record Review of facility provided policy, labeled, Controlled Substances, date revised in April 2019, revealed:<BR/>Policy Statement:<BR/>The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. <BR/>Policy Interpretation and Implementation<BR/>6. Keys to controlled substance containers are kept on a single key ring separate from any other keys. <BR/>Record Review of facility provided In-Services, labeled, Medication, dated on 03/27/2023 revealed under Summary of Subject Matter: 10 rights of Medication Administration. 12 employees signed and attended. <BR/>Record Review of facility provided In-Services, labeled, Random Cart Checks, dated on 06/ 05/2023 stated under Summary of Subject Matter: Random checks for narcotics and disposals of medication must be done daily. Shows 7 employees signed and attended. <BR/>Record Review of facility provided In-Services, labeled, Weekly cart audits must be performing along with narcotic counts with medication and nurses, dated on 06/07/2023 revealed that 6 employees signed and attended. <BR/>Record review of the facility policy, titled Storage of Medications, revised November 2020 revealed the following documentation, Policy Heading. The facility stores, all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation. <BR/>1.Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. <BR/>6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. <BR/>Record Review of CMS Appendix PP State Operations Manual Medication Access and Storage last revised 02/03/2023, revealed A facility is required to secure all medications in a locked storage area and to limit access to authorized personnel .During a medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area/cart.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>1)The facility failed to ensure the kitchen was free of insect infestations (roaches),<BR/>2) The facility failed to ensure food and non-food contact surfaces were clean, and<BR/>3) The facility failed to ensure foods and food contact equipment were protected from possible contamination during processing, storage and service. <BR/>These failures could place residents at risk for food contamination and foodborne illness. <BR/>The findings include:<BR/>~ The following observations were made during a kitchen tour that began on 9/13/22 at 9:19 AM and concluded at 10:36 AM:<BR/>The spout had a buildup of residue and dirt on the drink dispensing machine drink gun.<BR/>Observation of 1 of 2 ovens, right side, revealed that there were too numerous to count adult, nymph (pre adult), and adult roaches with egg cases crawling in the oven. There was also a heavy accumulation of roach specs/feces.<BR/>On 9/13/22 at 9:33 AM the Dietary Manager stated regarding the roaches that the pest control operator sprayed for roaches last week. She added that the section of the oven, with roaches, was not used. She stated that the roach population had worsened recently, and she reported it to the administrator. Then the pest control came. <BR/>The plastic food bin exteriors were gummy and soiled.<BR/>The small plastic scoop storage cabinets had a buildup of dirt on the exterior and had a gummy feel.<BR/>There was one roach crawling on the floor when a large pot was moved on the floor under the convection oven.<BR/>There was a buildup of gummy grease on the convection oven top and sides.<BR/>There was a dead roach on the cart where the toaster oven was stored next to the steam table.<BR/>There was a heavy accumulation of roach specs (feces) on the piping behind the steam table.<BR/>There was an area of wallboard that was buckled at the steam table. The interior of the gap revealed there was a heavy accumulation of roach specs.<BR/>The drink gun/drink dispensing area table had buckling paint and a sticky buildup.<BR/>The pump type drink carafes had a gummy exterior.<BR/>There was a heavy accumulation of roach specs on the encased electrical outlet next to the three-compartment sink.<BR/>There were five dead roaches observed stuck to the wall behind the fire extinguisher sign near the three-compartment sink.<BR/>Inside the Dietary Manager's office in the kitchen, there was a box of thickened water next two containers of Avistat-D spray disinfectant labeled, . If swallowed: call a poison control center or doctor immediately. Caution. Causes moderate eye irritation. There were also boxes of Nepro supplement and 5 large cans of coffee stored on the same shelf.<BR/>On 9/13/22 at 10:06 AM Dietary Manager stated the cans of coffee were used for residents.<BR/>These five large cans of coffee were also on the shelf next to Champion Oven Cleaner labeled, Danger: contains sodium hydroxide. Avoid contact with skin. Injurious if sprayed in eyes. There was a box of teabags on top of this box of oven cleaner. Also on the shelf was Handy Klenz Lime Descaler which was labeled, Danger. Causes serious eye damage. Causes severe skin burns and eye damage. May be corrosive to metals There were bottles of steak sauce, coffee filters, hot sauces and oven bags next to the chemicals. <BR/>There were chemicals on the top shelf above the cans of coffee and other foods which included Pro Power Heavy Duty Oven and Grill Cleaner, labeled, Danger: causes severe skin burns and serious eye damage. There was a can of Enforcer Flea Spray stored on the same shelf.<BR/>An adult roach was crawling on the floor of the water heater closet inside the Dietary Manager's office. T his closet had holes in the ceiling and around the pipes entering the ceiling and wall.<BR/>Observation of a cart at the front of the kitchen revealed that the cart had Champion Oven Cleaner stored next to apple juice and a backpack on the same shelf. The oven cleaner was also stored above boxes of coffee filters that were on a lower shelf.<BR/>The refrigerator and freezer storage area, adjacent to the assist dining room, had an icemaker in which the interior flashing needed cleaning. <BR/>There were two of two unshielded ceiling fluorescent lights in the refrigerator and freezer storage area.<BR/>Observation on 9/13/22 at 10:35 AM the Dietary Manager stated previously roaches come out continuously and were worse at one time. She added that the roaches were wherever you turned your head.<BR/>~ The following observations were made during a kitchen tour that began on 9/13/22 at 11:35 AM and concluded at 12:45 PM:<BR/>The exterior of the large mixer had an accumulation of hardened splattered food.<BR/>Dietary staff A was observed preparing pur&eacute;es. Prior to putting the food in the processor, the surveyor asked to see the interior and blade of the processor. The blade had a sudsy film and was wet and the interior of the processor was wet. She then placed scoops of pot roast and milk into the processor and pureed it. She then placed it in a pan to be placed on the steam table.<BR/>On 9/13/22 at 11:48 AM Dietary staff A was observed washing the processor parts in the dishwasher.<BR/>On 9/13/22 at 11:50 AM the dishwasher cycle ended, and the processor parts were wet (blade and interior of the processor pot).<BR/>On 9/13/22 at 11:51 AM Dietary staff A placed scoops of carrots into the processor and pur&eacute;ed it while the interior and parts were still wet.<BR/>Record review and observation of the Auto Chlor System Super 8 chlorine sanitizer, used in the dishwasher, revealed the following, .Sanitizing Food Contact Surfaces. 5. Drain and allow equipment or utensils to air dry.<BR/>There were two sets of soiled keys stored on the prep table.<BR/>On 9/13/22 at 12:14 PM an adult roach was observed crawling on the floor near the steam table during meal service.<BR/>The following observations were made during a kitchen tour that began on 9/13/22 at 4:35 PM and concluded at 5:56 PM:<BR/>There were 2 bottles of blue colored personal drinks stored on the lower shelf of the prep table next to pans.<BR/>On 9/15/22 at 3:05 PM, an interview was conducted with a Dietary Manager. Regarding the roaches she stated they were pretty much there in the facility. Regarding not allowing the processor to air dry she stated Dietary staff A, felt under pressure. Regarding cleaning of equipment, she stated staff were responsible and they clean as they go. She added that she knew chemicals had to be stored away from food but did not know coffee was an issue. She added that staff conduct deep cleaning on Sundays which included cleaning the fryers and soaking the cups for coffee stains. She stated that she ensured staff follow proper food service procedures and protocols by going by the cleaning schedule and monitoring staff. She further stated that she expected Dietary staff A to let the processor air dry as she normally does. She stated that the problems found in the dietary department could result in residents getting chemicals in their food and residents becoming ill. She stated that staff and the dietary manager were responsible for ensuring staff follow all appropriate food service policies and procedures.<BR/>On 9/15/22 at 4:01 PM, an interview was conducted with the Administrator . Regarding dietary sanitation issues, she stated that residents could be affected by toxics in the food. She added that she expected dietary staff to ensure toxics were stored properly. She further stated she expected the Dietary Manager to check staff and ensure that they do what they are supposed to. She stated she did not know what to do about the roaches. She added the German cockroaches were only treated every six months. She further stated she would take the oven out and fumigate it. She stated the increase in roaches could cause infection control issues.<BR/>Record review of the facility policy titled Sanitization, Revised October 2008 revealed the following documentation, Policy Statement. The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation. 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. 3. All equipment, food contact surfaces and utensils shall be washed to remove or clean completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 10. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. 11. For fixed equipment or utensils that do not fit in the dishwashing machine, washing shell consist of the following steps: a. Equipment will be disassembled as necessary to allow access of detergent/solution to all parts; b. Removable components will be scraped to remove food particle accumulation and washed according to manual or dishwashing procedures. 12. Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. 16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 17. The food services manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.<BR/>Record review of the facility policy titled Food Receiving and Storage, Revised October 2017, revealed the following documentation, Policy Statement. Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation. 15. Pesticides and other toxic substances and drugs will not be stored in the kitchen area or in store rooms for food or food preparation equipment and utensils. 16. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly in 1 of 2 dumpsters (west) and dumpster area.<BR/>The facility failed to maintain the dumpster/refuse disposal containers and area in a manner that effectively prevented the harborage and attraction of pest. <BR/>This failure could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility.<BR/>The findings include:<BR/>On 11/6/23 at 10:02 AM an observation was made at the dumpster area. There was a mattress with a torn cover on the ground behind the two dumpsters. There was trash scattered around the dumpster area that was approximately in an L shape pattern of more than 20 feet each way behind the dumpsters. The area had trash, which included cups, weeds, shopping cart, and the mattress with the torn cover. There was also a large amount of trash along the fence line in the area that included trash and cigarette butts. Behind the oxygen storage building that was adjacent to the dumpsters there was an approximately 5' x 8' area filled with trash and paper, cups, etc. <BR/>On 11/6/23 at 2:40 PM an observation was made of 1 of 2 dumpsters (west) that was actively leaking in two areas at the bottom front area of the dumpster. The waste water was pooling on the concrete slab in an approximately a 2' x 3' area. There was trash still in the area as before, which included a mattress with a torn cover, shopping cart, scattered bottles, gloves, and other debris. The leaking wastewater was trailing approximately 16 feet from the dumpster. The immediate area of pooling wastewater was approximately 2 feet to 4 feet away from the source of the leak.<BR/>Observation on 11/7/23 at 8:43 AM revealed one of two dumpsters (west) was leaking from the bottom front and waste water was pooling in an approximately 6'x 3'area. There was still trash, weeds, mattress, shopping cart, and other scattered trash in the area.<BR/>On 11/7/23 at 9:30 AM an interview and observations were conducted with the Maintenance Supervisor. He stated, he had been trying to get out to the dumpster area, but he was busy with other facility duties. He added he tried to get out to the dumpster area last week to clean up. He stated, the dumpster was probably leaking since he was hired in January 2023. He added that he had not received no orientation related to the grounds and dumpster maintenance. He stated, all he was aware of was he needed to keep the dumpster lids closed. He stated trash situation was caused by trash from the dumpster coming out when it was dumped by the dumpster company. He added the leaks were due to the dumpsters being old. He tried to come out one time a week and clean the area. He stated he was not sure what could result from the dumpster and trash accumulation situation. He stated the area should have been sprayed down and cleaned. Observation of the dumpster area revealed the dumpster was still leaking and trash was still in the dumpster area which included the mattress, shopping cart, loose debris and trash. He stated it was the Maintenance Supervisor's responsibility to ensure the grounds and dumpster were maintained in a sanitary manner. <BR/>On 11/8/23 at 9:04 AM an observation was made at the dumpster area and one of two dumpsters (west). The west dumpster had one of two side doors open. There was wastewater pooling at the front of the dumpster where it had leaked. There was still trash, shopping cart, broken ceramics, and a mattress surrounding the dumpster area.<BR/>On 11/8/23 at 11:28 AM an interview was conducted with the Administrator regarding issues found in the facility. He stated staff were not making daily rounds and they needed to make rounds of the grounds. He stated staff should have picked up the stuff and should have reported the leaking of the dumpster. He stated the Maintenance Supervisor was responsible for ensuring that the grounds and dumpsters were maintained in a sanitary condition. He stated infection control, bugs, and flies attracted to the area could result from the grounds and dumpster problems observed.<BR/>Record review of the facility policy, titled Grounds, revised May 2008, revealed the following documentation, Policy Statement. Facility grounds shall be maintained in a safe and attractive manner. Policy Interpretation and Implementation. <BR/>1. Maintenance shall be responsible for keeping the grounds free of litter. <BR/>3. Areas around the building (i.e., sidewalks, patios, gardens, etc.) shall be maintained in a safe and orderly manner at all times.<BR/>Record review of the facility policy, titled Maintenance Service, revised December 2009, revealed the following documentation, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy interpretation, and implementation. <BR/>1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. <BR/>2. Functions of maintenance personnel include but are not limited to: . <BR/>h. Maintaining the grounds, sidewalks, parking, lots, etc., in good order. <BR/>j. Others that may become necessary or appropriate. <BR/>3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. <BR/>10. Maintenance personnel shall follow Established safety regulations to ensure the safety and well-being of all concerned .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #1, Resident #2 and #3) reviewed for infection control.1. CNA A failed to change gloves when going from dirty to clean when providing incontinence care for Residents #1, #2, and #3. These failures could place residents at risk for cross contamination and infection. The findings include: Resident #1 Record review of the admission record for Resident #1, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (a group of permanent movement disorders that affect brain-controlled muscle functions), schizoaffective disorder, bipolar type (mental health disorder) and anemia (not enough red blood cells to carry oxygen throughout the body). Record review of the quarterly MDS assessment for Resident #1, dated 08/27/25 revealed Resident #1 was always incontinent of bladder and bowels. Record review of the current care plan for Resident #1, last reviewed on 06/27/25, revealed there was a focus area: Bladder/Bowel Incontinence: I have bowel and bladder incontinence. During an observation on 09/05/25 at 11:30 AM, CNA A provided incontinence care and catheter care for Resident #1 with the help of CNA B. CNA A and CNA B washed their hands with soap and water and put on a clean pair of gloves. CNA A then unfastened the brief for Resident #1 and began cleaning his groin area with wipes. Resident #1 was turned on his side and CNA A removed the old brief. CNA A then wiped Resident #1's buttocks and placed a clean brief under Resident #1. CNA A secured the new brief and pulled up Resident #1's pants with the help of CNA B. CNA A then removed her gloves and used hand sanitizer to clean her hands. CNA A did not change her gloves and perform hand hygiene before going from dirty to clean during the procedure. Resident #2 Record review of the admission record for Resident #2, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: atherosclerotic heart disease (thickening or hardening of the arteries) dysphagia (difficulty swallowing), and aphasia (a language disorder that makes it difficult to communicate). Record review of the quarterly MDS assessment for Resident #2, dated 08/17/25, revealed Resident #2 was always incontinent of bladder and bowels. Record review of the current care plan for Resident #2, last reviewed on 09/04/25, revealed there was a focus area: [Resident #2] has bladder incontinence r/t history of UTI (Urinary Tract Infection). During an observation on 09/05/25 at 11:00 AM, CNA A provided incontinence care for Resident #2 with the help of CNA B. CNA A and CNA B washed their hands with soap and water and put on clean gloves. CNA A then unfastened Resident #2's brief and cleansed his groin with wipes. Resident #2 was turned on his side and CNA A wiped his buttocks with wipes. CNA A then removed the dirty brief and placed a clean brief under Resident #2 without changing her gloves. CNA A then secured Resident #2's brief and pulled his pants up. CNA A then transferred Resident #2 to his wheelchair and removed her gloves. CNA A then used hand sanitizer to cleanse her hands. CNA A did not change her gloves and perform hand hygiene before going from dirty to clean during the procedure. Resident #3 Record review of the admission record for Resident #3, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (a group of permanent movement disorders that affect brain-controlled muscle functions), strabismus (crossed eyes or squint), and mild intellectual disabilities. Record review of the comprehensive MDS assessment for Resident #3, dated 07/30/25, revealed Resident #3 was frequently incontinent of bladder and always incontinent of bowels. Record review of the current care plan for Resident #3, last reviewed on 09/04/25, revealed there was a focus area: [Resident #3] has bowel and bladder incontinence. During an observation on 09/05/25 at 11:45 AM, CNA A provided incontinence care for Resident #3 with the help of CNA B. CNA A and CNA B washed their hands with soap and water and put on clean gloves. CNA A pulled down Resident #3's shorts and then unfastened Resident #3's brief. CNA A then cleansed Resident #3's groin with wipes. CNA A then removed Resident #3's old brief and then wiped his buttocks with wipes. CNA A placed a clean brief under Resident #3. CNA A secured Resident #3's brief and pulled up Resident #3's shorts. CNA A then transferred Resident #3 to his wheelchair. CNA A then removed her gloves and used hand sanitizer to cleanse her hands. CNA A did not change her gloves and perform hand hygiene before going from dirty to clean during the procedure. During an interview on 09/05/25 at 11:53 AM, CNA A stated she had received training regarding changing her gloves and performing hand hygiene when going from dirty to clean during a procedure. CNA A stated she could not remember the last time she was trained for incontinence care and infection control. CNA A stated she did not change her gloves and perform hand hygiene when going from dirty to clean because she did not think about it. CNA A stated the residents had an increased risk for UTI's and germs. During an interview on 09/05/25 at 11:54 AM, the DON stated she expected the staff to change their gloves and perform hand hygiene when going from dirty to clean when providing care to a resident. The DON stated she did not remember when the last training was for incontinence care/infection control and stated the staff were scheduled to be trained that month regarding infection control. The DON stated CNA A usually did transport for the facility but would get pulled to the floor if a CNA called in. The DON stated a potential negative outcome to the residents was possible infections or UTI's. During an interview on 09/05/25 at 2:35 PM, the Admin stated she expected the staff to change their gloves when going from dirty to clean when providing care. The Admin stated CNA A probably was not paying attention or was nervous and that was why she forgot to change her gloves and perform hand hygiene when going from dirty to clean. The Admin stated CNA A was usually the van driver for the facility, but she was pulled to the floor because someone call in that day. The Admin stated CNA A was trained to change her gloves when going from dirty to clean. The Admin stated the residents had a potential negative outcome for spreading infection. Record review of the facility policy titled, Policies and Practices - Infection Control, with a revised date of October 2018 reflected the following: Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area in 5 of 11 resident rooms (104, 107, 116, 119 and 120) on Station 2 (East wing).<BR/>1)The facility failed to ensure that 5 of 11 resident rooms had operable call systems at the bedroom and toilet. <BR/> These failures could place residents at risk of not receiving assistance when needed. <BR/>The findings include:<BR/>On 11/6/23 at 11:18 AM an interview was conducted with Maintenance Supervisor. He stated sometimes the facility had problems with the call system. Repairmen have told the facility in the past that parts for the system cannot be obtained because they stopped making them. <BR/>On 11/6/23 at 3:25 PM an interview was conducted with LVN A. She stated that some of the call lights do not illuminate at the Station 2 nurses station call board. <BR/>On 11/6/23 at 3:26 PM an interview was conducted with CNA A regarding the call system indication board at the Station 2 nurses station. She stated, not all of the call board lights illuminate.<BR/>Observation on 11/6/23 at 3:31 PM in room [ROOM NUMBER], revealed Resident #21 was in the B bed. The resident had an activation pad type call system, and when pressed would not stay on. The call system shut off as soon as pressure was not placed on the pad. <BR/>Observation on 11/6/23 at 3:16 PM revealed when a call was registered from room [ROOM NUMBER] from either A or B bed or the bath there was no light illuminated at the nurse station call board. There was an audible sound, and the dome light was functioning. <BR/>Observation on 11/7/23 at 8:23 AM revealed there was a call registered from room [ROOM NUMBER] and there was no light illuminated for 107 at the nurse station. The dome light illuminated and there was an audible sound.<BR/>On 11/7/23 at 8:25 AM an interview was conducted with the Maintenance Supervisor regarding the call system. He stated, some light up and some don't. It's been like that since January (2023) when he was hired. He added he replaced the bulbs at the nurse station call board and they did not illuminate; he replaced six or seven of them. He stated those rooms that did not illuminate at the nurse call board were rooms 100, 102, 107, 110, and 116. He added there were three or four other ones that also did not illuminate. He stated the Call System Vendor was located out of town and it would take a while for them to come to the facility. He further stated the Call System Vendor had recommended the call system be replaced, then sent in a quote to have it repaired approximately 4 or 5 months ago. He stated the company was given a list of rooms and restrooms that needed repair. He stated, he checked the system one time a month, when it comes up on TELS online maintenance scheduling and documentation system. He added he goes checked each room. Regarding whom was responsible for ensuring that the call system worked, he stated that he was. He stated, the facility would move residents to rooms that had working call systems and would call the Call System Vendor to repair it. He added residents may not get the help they needed due to the partially functioning call system.<BR/>On 11/7/23 at 9:30 AM an interview was conducted with the Maintenance Supervisor. Regarding why part of the call system was not functioning correctly, he stated, he could not get parts for the system. He added he was not familiar with the nurse call panel system. He stated he had called the Call System Vendor to repair it. He further stated he was not provided training on this call system. <BR/>Observation on 11/7/23 at 10:44 AM revealed a call was registered from room [ROOM NUMBER]. The dome light was illuminated at the room, and the sound emitted when a call was placed. There was no light at the nurses station call board indicating room [ROOM NUMBER]. <BR/>During an interview with LVN A on 11/7/23 at 10:44 AM, she stated staff had been complaining about the call system not fully functioning since day one. No specific date was provided. <BR/>Observation on 11/7/23 at 11:35 AM in room [ROOM NUMBER], the call light was tested and there was no light illuminated at the nurse's station call board for room [ROOM NUMBER]. This was when a call was initiated from the bedroom or bath. A sound was emitted, and dome light illuminated. <BR/>On 11/7/23 at 4:51 PM an observation and interview was made of Resident #21 in room [ROOM NUMBER]. LVN A pressed the resident's call pad, and it would not stay on. LVN A revealed she was not aware of this call pad not fully functioning. <BR/>Observation on 11/8/23 at 8:44 AM revealed the call pad in room [ROOM NUMBER] still would not stay on once pressed.<BR/>On 11/8/23 at 11:28 AM an interview was conducted with the Administrator regarding issues found in the facility. Regarding why the call system was not fully functioning on Station 2, he stated the facility had worked on it and the call system was old. He added the system had been worked on a lot. Regarding what he expected staff to have done, he stated double check the call system and see that it was working. Regarding whom was responsible for ensuring that the call system worked properly, he stated that it was the Maintenance Supervisor. Regarding what could result from the call system not being fully functional, he stated residents may not be taken care of.<BR/>Record review of the invoice from the Call Repair Vendor revealed and invoice dated 6/27/23 which documented, Notes. Repaired nurse call on southside of facility.<BR/>Record review of the facility policy, titled Call System, Resident, revised September 2022, revealed the following documentation, Policy Heading. Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy Interpretation, and Implementation. <BR/>1. Each resident is provided with a means to call staff directly for assistance from her his/her bed, from toileting/bathing facilities, and from the floor. <BR/>3. The resident call system remains functional at all times. <BR/>4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan. <BR/>5. The resident call system is routinely maintained and tested by the maintenance department.

Based on observation and interview, the facility failed to promote the resident's right to have respect and dignity for 2 of 16 residents (Resident #15 and Resident #19) reviewed for dignity, in that:<BR/>During activities conducted by the activity director for 11 residents in the dining room, activity director stood up and yelled in a high-pitched voice, Shut up, sit down, and listen to me. <BR/>This deficient practice could place residents at-risk of loss of dignity and feelings of shame. <BR/>The findings were:<BR/>Record review of Resident #15 face sheet revealed an admission date of 03/02/202 and a diagnoses that included: quadriplegia, alcohol dependence, major depressive disorder, anxiety disorder, intermittent explosive disorder, muscle weakness, personal history of transient ischemic attack (TIA) and cerebral infarction. <BR/>Record Review of Resident #15s admission MDS dated on 03/09/2022 revealed Resident #15 has a BIMs Summary Score (Brief Interview for Mental Status) of 14 meaning that the resident is cognitively intact. <BR/> Record review of Resident #19 face sheet revealed an admission date of 07/06/2016 and a diagnoses that included: hemiplegia following cerebral infarction, anxiety disorder, schizoaffective disorder, Bipolar type, depressive disorder. <BR/>Record Review of Resident #19s quarterly MDS dated on 08/01/2022 revealed Resident #15 has a BIMs Summary Score (Brief Interview for Mental Status) of 15 meaning that the resident is cognitively intact. <BR/>Observation on 09/15/2022 at 8:41 am revealed activity director performing activities with 11 residents in the dining room. Residents in the dining room were observed not being loud and a couple of the residents were talking amongst themselves while doing the activity. Activity director stood up in the middle of the dining room and yelled, Shut up, sit down, and listen to me. Residents stop talking all together and did not say anything. <BR/>During an interview on 09/15/2022 at 9:12 am with Resident #15. Resident #15 stated that he did not like the way that the activity director had yelled at all of them in the dining room. Resident #15 stated that it made him not even want to play any activities anymore and that is why he immediately left the dining room. Resident #15 stated that it makes him feel belittled, made him feel bad. Resident #15 stated that he could not believe that the activity director was talking to them like that and it made him feel angry when she yelled. <BR/>During an interview on 09/15/2022 at 9:36 am with Resident #19. Resident #19 stated that he was bothered by the way that the activity director had yelled at the group like that. Resident #19 stated that this is not the first time that the activity director has yelled at the residents like this. Resident #19 stated that it makes him feel like not even wanting to talk at all and made him feel like a child being scolded. Resident #19 stated that all they were doing was talking to each other and stated that he thought they were adults and could do that. Resident #19 stated, I did not feel like we were doing anything wrong. <BR/>During an interview with activity director on 09/15/2022 at 10:39 am. Activity director immediately stated, I'm sorry, I'm sorry, I just get frustrated and lose my cool sometimes when the residents won't listen to me. I know that I should not have talked to them like that. That will not happen again, I'm sorry. Activity director stated that she is aware that talking to residents like that is not acceptable. Activity director stated that instead of getting so upset at the residents she should have asked them to listen to her instead of yelling at them. Activity director stated that the negative potential outcome for yelling at the residents that it could make them feel worthless and like children. <BR/>During an interview with DON on 09/16/2022 at 8:07 am. DON stated that the behavior of the activity director while performing activities was unacceptable and uncalled for. DON stated that she did visit with the activity director and made her aware that this behavior will not be tolerated. DON stated that she expects if a staff member gets frustrated to take a cooling off period and come to her for advice if they are unsure how to handle the situation. DON stated that an in-service will be completed for dignity with the activity director. DON stated that the negative potential outcome for yelling at residents is that it could potentially make them feel like they do not want to live in the facility, make them feel depressed and change their attitude and the way that they feel and look at life for them. <BR/>During an interview with administrator on 09/16/2022 at 2:33 pm. Administrator stated that she is aware of the situation that happened with the activity director yelling at the residents in the dining room and it does call for disciplinary action and will be taken immediately. Administrator stated that she expects all staff members to have respect for all residents at all times. Administrator stated that the negative potential outcome for the residents getting yelled at by the activity director could make the residents embarrassed, loss of self-respect about themselves and others, loose trust and safety in the staff. <BR/>Record review of the facility provided policy titled Dignity, date revised on February 2021, revealed:<BR/>Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. <BR/>Policy Interpretation and Implementation: <BR/>1). Residents are treated with dignity and respect at all times. <BR/>8). Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his/her room number, diagnosis, or care need. <BR/>Record review of the facility' provided information sheet by the Texas Health and Human services titled Resident's Rights, dated on April 2019, revealed, Under section Dignity and Respect: You have the right to: Be treated with dignity, consideration, courtesy, and respect. Under the section Freedom of Choice: Participate in activities inside and outside the facility. <BR/>Record review of the facility provided in-service titled Please treat our residents with dignity and respect. Freedom of choice. Privacy and confidentiality. Participation in care. Complaints, dated on 07/29/2022. <BR/>Record review of the facility provided in-service titled Just a reminder to care for these residents like they are your own family. Be kind and smile, they are going through a lot and kindness and a smile goes a long way. Provide them with the care that you were trained to give and show compassion, dated on 08/12/2022. <BR/>Record review of the facility provided in-service titled Treat residents with dignity and respect. They can have what food and drink that they want. If there is a question about thickness of dining and diet of food nurse can be asked. Residents can ask for meds and if they have a question, they can have a copy of their MARS. Facial expressions, body language tells a lot about you, please watch how you talk to residents. They can sense your mood. No yelling down the hall. Residents have rights to showers, right to refuse care or meds. Knock on doors and wait for them to answer before entering. Please do not be rude to our residents since this is their home and usually live out their lives in the facility, dated on 07/29/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accommodate the needs and preferences of 4 of 16 residents (Residents #6, #15, #24, #43) reviewed for accommodation of needs.<BR/>The facility failed to place Resident # 6, #15, #24, #43 call-light within reach.<BR/>These failure could place residents at risk of not having their needs and preferences met and a decreased quality of life.<BR/>Findings include:<BR/>Resident #6<BR/>Record review of Resident #6s face-sheet revealed a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included: dementia, anxiety, essential hypertension, muscle weakness, lack of coordination, age-related physical disability, feeding difficulties, fracture of unspecified part of neck of left upper thigh. <BR/>Record Review of Resident #6s admission MDS dated on 06/27/2022 revealed Resident #6 has a BIMs Summary Score (Brief Interview for Mental Status) of 4 meaning that the resident is severely impaired. Under section G: Functional Status (a). Bed mobility listed as 3: extensive assistance (i). toilet use listed as 4: total dependence. Under Section G: Balance during Transition and Walking, (a). Moving from seated to standing position listed as 8: activity did not occur, (c). Turning around listed as 8: activity did not occur (d). Moving on and off toilet listed as 8: activity did not occur Under section H: Bladder and Bowel: urinary continence: always incontinent. Bowel continence: Always incontinent. <BR/>Observation and interview on 09/13/2022, at 9:05 AM, resident #6 was observed lying in bed, call-light was tied on the side of the bed and was dangling down towards the floor. <BR/>Resident #15<BR/>Record review of Resident #15 face sheet revealed an admission date of 03/02/2022 and diagnoses that included: quadriplegia, alcohol dependence, major depressive disorder, anxiety disorder, intermittent explosive disorder, muscle weakness, personal history of transient ischemic attack (TIA) and cerebral infarction. <BR/>Record Review of Resident #15s admission MDS dated on 03/09/2022 revealed Resident #15 has a BIMs Summary Score (Brief Interview for Mental Status) of 14 meaning that the resident is cognitively intact. Under section G: Functional Status (a). Bed mobility listed as 3: extensive assistance (i). toilet use listed as 3: extensive assistance. Under Section G: Balance during Transition and Walking, (a). Moving from seated to standing position listed as 2: not steady but able to stabilize with staff assistance, (c). Turning around listed as 2: not steady but able to stabilize with staff assistance. (d). Moving on and off toilet listed as 2: not steady but able to stabilize with staff assistance. Under section H: Bladder and Bowel: urinary continence: occasionally incontinent. Bowel continence: Always incontinent. <BR/>In an observation on 09/15/2022 at 6:32 am revealed that Resident #15 in bed at 06:32AM with call light out of reach on his dresser next to his bed. <BR/>Resident #24<BR/>Record review of Resident #24s face sheet revealed an admission date of 02/18/2022. With a diagnosis that included: senile degeneration of brain, depression, anxiety disorder, insomnia, heart failure, peripheral vascular disease, acid reflux, overactive bladder, dysphagia, dementia.<BR/>Record Review of Resident #24s admission MDS dated on 02/25/2022 revealed Resident #24 has no BIMs Summary Score (Brief Interview for Mental Status) listed. Under section G: Functional Status (a). Bed mobility listed as 4: total dependence (i). toilet use listed as 4: total dependence. Under Section G: Balance during Transition and Walking, (a). Moving from seated to standing position listed as 2: not steady but able to stabilize with staff assistance, (c). Turning around listed as 8activity did not occur. (d). Moving on and off toilet listed as 2: not steady but able to stabilize with staff assistance. Under section H: Bladder and Bowel: urinary continence: always incontinent. Bowel continence: Always incontinent. <BR/>Observation on 1/23/18 at 9:20 AM, Resident #24 was observed sleeping in bed and observed call light across the other side of the room where there were no other resident. <BR/>Resident #43<BR/>Record review of Resident #43 face-sheet revealed a [AGE] year-old female, admitted to the facility on [DATE], with a diagnosis included: type 2 diabetes, cystitis, feeding difficulties, depression, paranoid schizophrenia, vitamin D deficient, anxiety, edema, lack of coordination, dysphagia, muscle weakness, gait abnormalities, aphagia, age-related physical disability. <BR/>Record Review of Resident #43s admission MDS dated on 08/12/2022 revealed Resident #43 has a BIMs Summary Score (Brief Interview for Mental Status) of 3 meaning that the resident is severely impaired. Under section G: Functional Status (a). Bed mobility listed as 3: extensive assistance (i). toilet use listed as 4: total dependence. Under Section G: Balance during Transition and Walking, (a). Moving from seated to standing position listed as 8: activity did not occur, (c). Turning around listed as 8: activity did not occur. (d). Moving on and off toilet listed as 8: activity did not occur. Under section H: Bladder and Bowel: urinary continence: always incontinent. Bowel continence: Always incontinent. <BR/>In an observation on 09/15/2022 at 6:28 am revealed that Resident #43 sleeping in her bed at 06:28 AM with call light sitting out of reach in her recliner. <BR/>Interview on 09/14/2022 at 4:29 pm, with LVN B. LVN B stated that it is the responsibility of all the staff on the floor to make sure that the residents call lights are in place. LVN B stated that she is not sure why some residents call lights were not in place and would make sure to correct this issue. LVN B stated that normally the staff check the call lights every 2 hours. LVN B stated that she had been trained to make sure that call lights are in place and does know to make sure that they are in place. LVN B stated that she just gets busy and sometimes forgets to check. LVN B stated that the negative potential outcome for the residents not having the call light in place would be that the resident could fall and become injured. <BR/>Interview on 09/14/2022 at 4:35 pm, with CNA H. CNA H stated that all aides are responsible for making sure that call lights are in resident's reach. CNA H stated that she has been trained to place call lights within resident's reach. CNA H stated that usually after aides provide care, they would have placed the call light next to the resident. CNA H stated that she was not aware that Resident #6, #15, #24, and #43 had no call light in reach. CNA H stated that she has not personally made sure that the call lights were in place. CNA H stated that she did not have a specific reason for why the call lights were not in place. CNA H stated that the negative potential outcome if the resident could not reach the call light would be that they could fall or if the resident became disoriented and could not call for help they could get hurt badly. CNA H stated that the outcome of that would not be good. <BR/>Interview on 09/14/2022 at 4:48 pm, with administrator. Administrator stated that if the resident needed to use the call light and could not reach it then it could cause the resident to get hurt. Administrator stated that she expects the staff to make sure that all resident's call lights are within their reach. Administrator stated that the facility makes a promise to the residents that they would be able to keep them safe and it will become a trust issue if the facility fails to comply with these standards. Administrator stated that it is the responsibility of all staff to make sure that all residents have their call lights within reach. <BR/>Interview on 09/14/2022 at 5:00 pm, with DON. DON stated that it is the responsibility of all staff to ensure that the resident is in reach of their call light. DON stated that she would make sure to do another in-service for call lights. DON stated that she expects all staff to make sure that the residents are safe by making sure they have their call light in reach. DON stated that the negative potential outcome for a resident not being able to reach their call light would be that the resident could fall, not able to notify staff when they need help, and could potentially end up in death. <BR/>Record review of facility provided in-service, labeled, Make sure call lights are in reach before you leave a resident's room. Dated 08/08/2022<BR/>Record review of facility provided policy, labeled, Answering call lights, dated revised on March 202, Under general guidelines: (5). When a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I screening accurately reflected the resident's status for 4 of 6 residents (Residents #37, #43, #48, and #50) reviewed for PASRR services.<BR/>The facility failed to ensure the accuracy of the PASRR Level 1 screening for Residents #37, #43, #48, and #50, which resulted in the residents not receiving a PASRR Level II evaluation. <BR/>This failure could place residents who have a mental illness at risk of not receiving individually specialized services to meet their needs.<BR/>Findings included:<BR/>Resident #43:<BR/>Record review of Resident #43's face sheet, dated 9/14/2020, revealed an [AGE] year-old female originally admitted on [DATE], with diagnoses including paranoid schizophrenia (onset date 6/27/2020), disorganized schizophrenia (onset date of 6/27/2020), schizophrenia unspecified (onset date 6/27/2020), schizoaffective disorder - bipolar type (onset date of 6/27/2020), major depressive disorder (onset date of 1/27/2020), and psychotic disorder with delusions due to know physiological condition (onset date of 6/27/2020). <BR/>Record review of Resident #43's MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 indicating she was severely cognitively impacted. <BR/>Record review of Resident #43's PASRR Level 1 screen dated 05/5/2020, with an Effective and Entered date listed in the electronic medical records system of 6/29/2020, revealed the following in part, .C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness . The answer was No.<BR/>During an interview with the MDS Coordinator on 09/14/22 at 2:43 PM, she was asked if she could provide a more current PASRR Level screening or level 2 evaluation and she said she would look for one.<BR/>During an interview with the MDS Coordinator on 09/15/22 at 07:50 AM, I asked if she was ever able to locate the requested PL1 or PL2 for Resident #43 and she said they did not have one. She said she had contacted the Local Mental Health Care Authority to come to the facility today to reevaluate Resident #43. No evidence of an updated or accurate PASRR Level 1 screening was provided prior to exit date of 9/16/2022.<BR/>During an interview on 09/15/22 at 11:14 AM with the MDS Coordinator, she said PASRR Level 1 screening is usually already done when a resident is admitted to the facility. She said if the PASRR Level 1 was not already completed, like if a resident came from home for example, then the social worker was supposed to get it done and the MDS coordinator was responsible for reviewing and documenting the information into the electronic medical records system. She said the information should be entered within about two days of resident admission. She then clarified the social worker completes the PASSAR level 1 screening, and the MDS nurse enters information into SimpleLTC. When asked who was responsible for checking that PASRR Level 1 screening was documented correctly, she said she usually makes sure they are done correctly or her supervisor. When asked if diagnoses of bipolar disorder, schizophrenia or major depressive disorder are conditions that should have triggered a level 2 evaluation, she said yes, they would be marked as a yes under section C0100 which screens for mental illnesses and triggered a PASRR Level 2 screening for services. She said if the PASRR Level 1 was not accurate related to mental illness diagnoses, then the resident may not receive specialized services needed.<BR/>During an interview with the Social Worker on 09/15/22 at 11:24 AM, she said PASRR Level 1 screenings should be done when a resident admits to the facility, and they would like to get it before if the resident transferred from another facility. She said if a resident came from home, she is responsible for completing it. She said she thought the MDS Coordinator's supervisor was responsible for verifying accuracy of PASRR Level 1 screening forms. When asked if schizophrenia or major depressive disorder are conditions that should have triggered a level 2 evaluation, she said yes, they would be under mental illness and should have been indicated as a yes for C0100. She said the risk to the resident was that the resident would have missed out on needed services. <BR/>Resident #50:<BR/>Record review of the face sheet and Order Summary Report dated 9/13/22 for Resident #50 revealed that he was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old and had diagnoses of Schizoaffective Disorder, Bipolar Type(F25.0), Bipolar Disorder, Unspecified, Acute Kidney Failure, Unspecified, Generalized Anxiety Disorder, Hemiplegia and hemiparesis Following Unspecified Cerebrovascular Disease Affecting Unspecified Side (paralysis), Peripheral Vascular Disease, Type 2 Diabetes Mellitus Without Complications, Other Specified Mental Disorders Due To Known Physiological Condition, Bipolar Disorder, Current Episode Depressed, Severe, With Psychotic Features, Major Depressive Disorder, Single Episode, Unspecified, Other Chronic Pain, Essential (Primary) Hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease, Unspecified (lung disorder), Alcoholic Cirrhosis Of Liver Without Ascites(liver disease), Unspecified Convulsions, and Human Immunodeficiency Virus Disease (HIV).<BR/>Record review of the facility submitted list of PASRR positive residents, dated 9/13/22, revealed that there were seven residents listed, but Resident #50 was not on this list.<BR/>Record review of the PASRR Level 1 Screening for Resident #50 dated 9/16/21 revealed that the resident was negative for mental illness, intellectual disability and developmental disability. This PASRR screening was conducted by the resident's previous facility.<BR/>On 9/13/22 at 1:40 PM an interview and observation were made of Resident #50. He stated he had been in the facility since November 2021. The resident was obese, was seated in a wheelchair and the room was dark. The resident had depressive appearance/affect.<BR/>On 9/14/22 at 1:10 PM an interview was held with the MDS Coordinator regarding the PASRR assessment for Resident #50. She stated, the PASRR Level 1, completed by the hospital and previous nursing home, were both negative. She added that their facility had missed his diagnosis of Schizoaffective Disorder, Bipolar Type and Bipolar Disorder. She further stated the PASRR representative said that he was not eligible for services due to the negative MI, ID and DD from the 9/16/21 assessment. She added that she became the MDS Coordinator in April 2022.<BR/>On 9/15/22 at 3:48 PM an interview was conducted with the MDS Coordinator regarding the incorrect PASRR assessment for Resident #50. She stated the incorrect assessment occurred because she went by the negative assessment from the previous nursing home and failed to check the resident's diagnosis. She added that she did not know she needed to check the accuracy of the assessments. She stated that she was responsible ensuring that the assessments were correct regarding PASRR. She added if residents received incorrect assessments, they may not receive the services they needed or correct placement. She stated that she had not observed any schizophrenic or bipolar behavior with Resident #50. She further stated she had heard the resident gets upset but she had not seen it.<BR/>On 9/15/22 at 4:01 PM an interview was conducted with the Administrator. Regarding incorrect PASRR assessments, she stated she expected staff to work with corporate to have the proper training. She added staff must be aware of resident diagnoses and PASRR mistakes and not take for granted the PASRR assessments were correct. she stated that incorrect PASRR assessments could result in resident needs not being met.<BR/>Resident 48:<BR/>Based on record review of the face sheet, accessed 09/14/22, Resident 48 is an [AGE] year old female admitted to the facility 03/17/2016 with diagnoses including: schizoaffective disorder, bipolar type (severe mental illness), other specified anxiety disorders, metabolic encephalopathy (brain problems), Alzheimer's disease with late onset, psychotic disorder with hallucinations due to known (mental illness, seeing things that are not there), major depressive disorder, recurrent severe without psychotic (mental illness makes you sad due to brain chemical imbalance), psychotic disorder with delusions due to known physiological (mental illness, believing things that are not true), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (deterioration of the brain), and hallucinations (seeing things that are not there).<BR/>In an interview on 09/14/22 with MDS Coordinator, Resident #48's Level II PASRR was requested and the facility informed surveyors that there was no Level II PASRR for Resident #48. <BR/>In addition, based on record review, on her annual MDS done on 10/14/2021, Section A, question 1500 Preadmission Screening and Resident Review (PASRR) which asks if the resident is considered by the state level II process to have a serious mental illness and/or intellectual disability or related condition, the answer is no despite the resident having a diagnosis of schizoaffective disorder, bipolar type; psychotic disorder with hallucination and delusions, and an anxiety disorder. <BR/>Record review of Resident 48's PASRR I revealed a negative screening, with question C0100. Mental Illness marked as 0, which is a no, despite the resident admissions diagnosis of multiple mental illnesses including schizoaffective disorder, bipolar type.<BR/>Resident 37:<BR/>Based on record review of Resident 37's face sheet, accessed 09/14/22, Resident 37 was a [AGE] year old female admitted to the facility 01/21/2019 with diagnoses including Generalized Anxiety Disorder, Bipolar Disorder (severe mental illness with mood swings), and Anxiety Disorder, Unspecified.<BR/>In an interview on 09/14/22 with MDS Coordinator, Resident #37's Level II PASRR was requested and the facility informed surveyors that there was no Level II PASRR for Resident #37. <BR/>Record Review of Resident 37's Level I PASRR revealed a negative screening, with question C0100. Mental Illness was marked as 0, which is a no. Resident #37 was admitted to the facility with a diagnosis of Bipolar Disorder and Generalized Anxiety Disorder. <BR/>Record review of the transfer-discharge return anticipated note in Resident 37's medical record, Resident #37 was transferred to the hospital for Cognitive impairment possible mental health crisis according to the transfer form section 1 in her medical chart, which also states relevant diagnosis of bipolar. Section II of the transfer form states resident's husband is concerned that the resident is experiencing a mental health crisis. Stated, 'this has happened before and she had to get treatment from covenant's mental health hospital.'<BR/>Record review of Form 1012, Texas Health and Human Services Mental Illness/Dementia Resident Review found at https://www.hhs.texas.gov/regulations/forms/1000-1999/form-1012-mental-illnessdementia-resident-review (accessed on 09/21/2022) read in part, .Examples of MI (mental illness) are: a schizophrenic, mood disorder (bipolar, major depression, or other mood disorder), paranoid disorder; somatoform disorder; schizoaffective disorder; panic or other disorder that may lead to a chronic disability diagnosable under the current Diagnostic and Statistical Manual of Mental Disorders . <BR/>Record review of the facility's undated current policy titled, Policy and Procedure for PL1 (PASRR Level 1 Screening)/PASRR/ . Revised 1/16/2019 revealed the following documentation, Rationale: The facility will ensure compliance with all Phase I and II guidelines of the PASRR process for long-term care. Responsibilities: MDS coordinators, marketing/admissions team members/social worker/administrator/DON/IDT members. Procedures: 1. Submit a PL1 form for every person entering your facility regardless of payer source within 72 hours of admission. A. The LTC facility is only allowed to complete/submit the PL1 form for LTC facility to LTC facility transfer, all other PL1 forms are completed by the referring entity or family, if the person is coming from home, staff may assist the family with completing the PL1 information and fax in to the local authority. The local authority must submit PL 1 forms prior to admission to the facility and facility must certify they can care for the resident.<BR/>Additional record review of facility's undated policy titled Policy and Procedure for PL1/PASRR/NFSS/1012/PCSP read in part, . If at any time a resident has a significant change, admits to Hospice, discharging to another facility, or you receive information that might indicate the resident may have a MI/ID/DD (mental illness/ intellectual disability/ developmental disability) diagnosis or condition not contained in the medical record, please submit a PL1 form for the resident to be evaluated by the Local Authority .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial needs for 3 of 13 residents (Residents #'s 5, 29, 48) reviewed for care plans as follows:<BR/>Resident 5 did not have a care plan for BiPAP, back injury, nor for Urinary Incontinence.<BR/>Resident 29 did not have a care plan for pain, indwelling urinary catheter, oxygen, pressure ulcers, diabetes mellitus, atrial fibrillation, arthritis, hyperlipidemia, and vision with corrective lenses used.<BR/>Resident 48 did not have a care plan for pain, communication, osteoarthritis, schizoaffective disorder (bipolar type), nor correct assistance with toileting.<BR/>This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs to attain or maintain their highest practicable physical, mental, and psychosocial outcome. <BR/>Findings include:<BR/>Resident 5<BR/>Record Review of Resident 5's face sheet revealed an [AGE] year old female admitted [DATE] for diagnoses that included the following : Chronic Respiratory Failure Whether With Hypoxia Or Hypercapnia (failure of lungs to provide oxygen), Cerebrospinal Fluid Leak, Unilateral Primary Osteoarthritis Knee (inflammation in knee joint), Spondylosis Without Myelopathy Or Radiculopathy, Lumbar Region (narrowing of the spine in the lower back), Other Intervertebral Disc Degeneration, Lumbosacral Region (breakdown of cushion between discs of spine in lower back), Dorsalgia (back pain), Post laminectomy Syndrome, Not Elsewhere Classified (pain in back after surgery to remove part of the spinal bone called the lamina), Arthrodesis Status (fusion of 2 bones in a joint), Radiculopathy, Site Unspecified (pain or tingling caused by damage to a spinal nerve).<BR/>Record Review of Resident 5's comprehensive MDS (Minimum Data Set) dated 06/01/22 documented the following: <BR/> Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 15, no cognitive deficit.<BR/> Section O - Special Treatments, Procedures, and Programs - O0100. C. Oxygen Therapy = Yes while a resident. G. Non-Invasive Mechanical Ventilation (BiPAP/CPAP) was left blank. <BR/> Section V - Care Area Assessment (CAA Summary) triggered for 06. Urinary Incontinence.<BR/>Record Review of Resident 5's Active Orders showed an order dated 01/28/22 for BIPAP SETTINGS INSPIRATORY PRESSURE 5 WITH 02 BLEED IN OF 2-3LPM, VERIFIED BY RT.<BR/>Observation on 09/13/22 at 10:06 AM revealed Resident 5 had a BiPAP machine on the small table next to the head of the bed.<BR/>Record Review of Resident 5's active care plan, last reviewed on 08/30/22, did not reveal a care plan for a BiPAP, for Urinary Incontinence, nor for multiple injuries to her back listed on her face sheet as current diagnoses (including CSF leak, abscess of the back, spondylosis of the lumbar region, intervertebral disc degeneration in the lumbo-sacral region, dorsalgia, and post-laminectomy syndrome).<BR/>Resident 29<BR/>Record review of Resident 29's face sheet revealed a [AGE] year old female admitted [DATE] with the following diagnoses: Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; pain in unspecified joint; muscle weakness; unspecified lack of coordination; cognitive communication deficit; age-related physical debility; COVID-19; type 2 diabetes without complications; other hyperlipidemia (high cholesterol); metabolic encephalopathy (problems in the brain); secondary hypertension (high blood pressure); unspecified atrial fibrillation (irregular heart rhythm); other specified arthritis, unspecified joint; and altered mental status, unspecified.<BR/>Record review of Resident 29's comprehensive MDS (Minimum Data Set) dated 08/12/22 documented the following: <BR/> Section B - Hearing, Speech, and Vision - B1200 Corrective Lenses is marked 1 (yes). <BR/> Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 07, severe cognitive deficit.<BR/> Section H - Bladder and Bowel - H0100 Appliances. A. Indwelling Catheter = checked indicating device present. <BR/> Section I. Active Diagnoses. I0300 Atrial fibrillation was marked, I2900 Diabetes Mellitus is marked, I 3300 Hyperlipidemia is marked, and I3700 Arthritis was marked, <BR/> Section V - Care Area Assessment (CAA Summary) triggered for 06. Urinary Incontinence and Indwelling Catheter and 16. Pressure Ulcer.<BR/>Record review of Resident 29's active orders showed an order entered on 08/23/22 for 02 continuous 2Lpm via NC to keep sats above 90%; an order placed on 08/15/22 for CATHETER CARE EVERY SHIFT FOR INFECTION PREVENTION MAINTENANCE every shift ENSURE EACH SHIFT THE CATHETER IS ANCHORED PER PROTOCOL AND THE PRIVACY/DIGNITY COVER IS IN PLACE every shift; an order on 08/05/22 for Atorvastatin Calcium Tablet 10 MG Give 1 tablet by mouth one time a day related to OTHER HYPERLIPIDEMIA; Tylenol Tablet 325 MG (Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain, fever. <BR/>An observation of Resident #29 on 9/15/22 at 8:48 am revealed that there was an indwelling urinary catheter present, and the catheter bag was over full and bulging; urine that was present in the tubing of the catheter bag was cloudy and chunky looking.<BR/>A record review of Resident 29's active care plan, initiated on 08/09/22 with some updates 08/20/22 and one update 08/23/22 lacked the following: a care plan for pain, despite a diagnosis of pain in unspecified joint and an order for pain medicine as needed; a care plan for the indwelling urinary catheter; a care plan for oxygen despite an order for oxygen; a care plan for pressure ulcers despite it triggering on the MDS Section V; a care plan for diabetes mellitus, atrial fibrillation, arthritis, and hyperlipidemia despite the active diagnoses on the list and being marking on the MDS; and there is no care plan for the resident's vision that requires corrective lenses as marked in the MDS. The care plan had a section stating the resident has bladder incontinence r/t Confusion and Dementia and a goal of the resident will remain free from skin breakdown due to incontinence and brief use through the review date. The activities to address the focus were notify nursing if incontinent during activities and check the resident every two hours and as needed and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. The resident has an indwelling urinary catheter, so there can't be any bladder incontinent issues. <BR/>Resident 48<BR/>Record review of Resident 48's face sheet revealed an [AGE] year old female admitted [DATE] who had diagnoses including: Schizoaffective Disorder Bipolar Type, Other Specified Anxiety Disorders, Hereditary And Idiopathic Neuropathy, Polyosteoarthritis, Alzheimer's Disease With Late Onset, Psychotic Disorder With Delusions Due To Known Physiological Condition, Unspecified Dementia with Unspecified Severity Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety; Hallucinations, Age-Related Physical Debility, Pain In Unspecified Joint, Shortness Of Breath, Overactive Bladder, and Other Chest Pain.<BR/>Record review of Resident 48's comprehensive MDS (Minimum Data Set) dated 10/14/21 documented the following: <BR/> Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 03, severe cognitive deficit.<BR/> Section I - Active Diagnoses - I3700 Arthritis is marked<BR/> Section V - Care Area Assessment (CAA Summary) triggered for 04. Communication<BR/>Record Review of Resident 48's abbreviated update to the MDS dated [DATE] documented the following:<BR/> Section G - Functional Status - I Toilet Use - Requires 2 person assist <BR/> Section I - Active Diagnoses - I6000 Schizophrenia (e.g., schizoaffective and schizophreniform disorders) is marked<BR/>Record review of Resident 48's active orders revealed an order for Norco Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth three times a day related to PAIN IN UNSPECIFIED JOINT entered on 04/19/22. <BR/>Record review of Resident 48's active care plan, last reviewed 07/05/22, stated TOILET USE: The resident requires (extensive assistance x 1-person physical assist) to use toilet or bedpan despite the 8/16/22 MDS stating 2 persons are required to assist. In addition, the care plan states the resident requires psychotropic medications for diagnosis of psychosis, delusions and hallucinations, Seroquel Tablet (Quetiapine Fumarate), however there is no active order for Seroquel for Resident 48. Further review of the active care plan revealed no care plan for communication existed despite it triggering in Section V of the latest complete MDS. The care plan also failed to address Resident 48's pain and nor did it address the use of the narcotic hydrocodone for her pain. The care plan did not address Resident 48's active diagnosis of osteoarthritis that was marked on the MDS active diagnoses list. There was no care plan present for the active diagnosis of schizoaffective disorder (bipolar type) which was also marked on the MDS active diagnoses list.<BR/>During an interview with the ADON on 09/16/22 at 11:25 AM, she explained the process for creating the MDS. She stated the responsibility rests with the MDS Coordinator, who is relatively new to the position. She stated that some of the diagnoses come from the electronic health record, but that the MDS Coordinator may pull some from the admission paperwork or hospital discharge paperwork. From the MDS that is created, there is a care plan team that meets daily and consists of the DON, Social Worker, MDS Coordinator, Administrator, and each specialty area such as Dietary and Therapies. She stated that the care plan is developed from the active diagnoses, the orders, and from the MDS results. She stated that inaccurate MDS information can lead to improper care plans and improper care plans can lead to improper care for a resident, which would be harmful to that resident. <BR/>During an interview with the MDS Coordinator on 09/16/22 at 11:43 am, I stated I had found errors in the MDS and Care Plans, and I asked what was the process for creating the MDS and Care Plan, and there was a corporate MDS advisor present, as the MDS Coordinator was new. The MDS Coordinator stated that the electronic health record automatically takes the diagnoses entered for the residents and auto populates the MDS worksheets. She stated that there is a team, the interdisciplinary team (IDT) that meets daily and includes MDS Coordinator, DON, ADON, Social Work, Dietary, Therapy, Activities, and the Administrator to discuss issues for each patient that may need to be updated on the MDS or the Care Plan for the resident. She stated that the nurses discuss skin issues and other direct care issues at these meetings. She said the nurses are responsible for most of the resident assessments, the Braden weekly assessment. If there is a significant change the DON or ADON will bring this up and it will get updated in the MDS and then the care plan. She stated that certain care areas in section V they automatically trigger for every resident, such as dehydration, since all are at risk for these issues. She stated they use the worksheets for the MDS to make sure all major diagnoses, medications, falls, hydration, and pacemaker are added the MDS within 7 days and then discussed at the care plan IDT meeting. She stated that inaccuracies or omissions from MDS lead to inaccurate care planning and services for the resident. <BR/> Record review of the facility policy Goals and Objectives, Care Plans, Published in 2001 and revised in April 2009, revealed the following documentation: <BR/>Policy Statement<BR/>Care Plan shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. <BR/>Policy Interpretation and Implementation<BR/>1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem .<BR/>3. objectives are derived from information in the resident's assessment .<BR/>5. goals and objectives are reviewed and/or revised:<BR/>a.significant change<BR/>b.outcome had not been achieved<BR/>c.readmit from hospital/rehab stay<BR/>d. at least quarterly<BR/>Record review of the facility policy MDS Completion and Submission Timeframes, published in 2001 and revised in July 2017 revealed the following:<BR/> .Assessment Coordinator or designee is responsible for assuring MDS is submitted in required times<BR/> . based on Resident Assessment Instrument Manual

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent elopement for 1 of 7 residents who wandered (Resident #60). The facility further failed to ensure that the resident environment remained as free of accident hazards on 2 of 2 Halls (Hall1/Central and Hall2), in that:<BR/>1). The facility failed to adequately supervise Resident #60 to prevent him from eloping from the facility on 8/18/22 and 9/03/22. <BR/>The facility failed to develop and implement interventions to prevent elopement after multiple verbalizations by Resident #60 of wanting to leave the facility which resulted in him eloping.<BR/>2) The facility failed to store chemicals in a safe manner and were left accessible to residents in common areas on 2 of 2 Halls (Hall 1/Central and Hall 2).<BR/>An immediate jeopardy (IJ) was identified on 9/28/22 at 5:25 PM. While the IJ was removed, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy and a scope of pattern.<BR/>These failures related to adequate supervision could place residents at risk for wandering into unsafe environments outside of the facility and sustaining serious injury, harm, impairment or death. Failures related to chemical storage could place residents at risk for chemical injuries. <BR/>The findings include:<BR/>1) Resident #60<BR/>Record review of the face sheet and Order Summary Report for male Resident #60 dated 9/15/22 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnosis of Hypothyroidism, Unspecified, Major Depressive Disorder, Recurrent, Unspecified, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Muscle Weakness (Generalized), Cognitive Communication Deficit, Unsteadiness on Feet, Major Depressive Disorder, Recurrent Severe Without Psychotic Features, and Anxiety Disorder Due to Known Physiological Condition.<BR/>Record review of the admission MDS assessment for Resident #60 dated 8/19/22 revealed that the resident had a BIMS score of 4 , indicating he was cognitively impaired. Further record review of the MDS revealed the resident had a behavior of rejecting care. This behavior occurred every one to three days. The resident was also documented as wandering and this behavior occurred daily. It was further documented that the residents wandering did not place the resident at significant risk of getting to a potentially dangerous place, such as stairs, outside of the facility.<BR/>Record review of the current undated care plan for Resident #60 revealed that there was a Focus titled, The resident is an elopement risk r/t dementia. ***Patient has a (electronic monitoring device) *** *(Electronic monitoring device) checks 3 times each shift. *Staff will round to lay eyes on patient every 1 to 2 hours and as needed. Patient eloped on 08/18/2022* WAS FOUND SAFE AND RETURNED TO BUILDING Date Initiated: 08/10/2022 Revision on: 08/19/2022. The documented Goal for this Focus was documented as follows, The resident's safety will be maintained through the review date. Date Initiated: 08/10/2022 Revision on: 09/07/2022. Target Date: 11/30/2022. o The resident will not leave facility unattended through the review date. Date Initiated: 08/10/2022 Revision on: 09/07/2022 Target Date: 11/30/2022. The Approach for this Focus was documented as, o Assess for fall risk. Date Initiated: 08/10/2022 o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Date Initiated: 08/10/2022 .<BR/>Record review of the Elopement Risk Assessment for Resident #60 conducted on 8/09/22 by LVN D revealed that the resident made statements and or threats to leave the facility and made frequent request to go home. It also documented that the resident had confused expressions related to tasks to complete. It further documented that the resident verbalized anger and frustration related to his placement. The document stated that the resident had restless behavior such as wandering. Additional information listed on the form revealed that the resident did not recognize stoplights and signs, did not know precautions when crossing streets and did not know the location of his current residence. It was further documented that the resident does not recognize all needs but some. Related to physical capacity it documented that the resident ambulates independently or with device. Cognitive skills for daily decision-making were listed as modified independence - some difficulty in new situation only.<BR/>Record review of the Progress Notes (8/10/22 thru 9/03/22) for Resident #60 revealed:<BR/>-On 8/18/22 at 4:45 PM the resident could not be found in the facility. He was found and returned to the facility at 6:37 PM. The nurse on duty was LVN C (agency). The police were called, and facility staff searched for the resident in the facility and surrounding areas. Family and department heads were informed. On his return it was determined he had no injury and an electronic monitoring device was placed on the resident on his return. <BR/>-On 8/28/22 the resident removed his electronic monitoring device and staff placed another one on his ankle. <BR/>-On 8/30/22 the resident's wife discovered his electronic monitoring device amongst the resident's possessions and staff placed another one on the resident's right wrist. <BR/>-On 9/3/22 at 9:15 AM Resident #60 could not be found in the facility again. He was found by family at 11:43 AM and returned to the facility at 12:00 PM. The LVN on duty was LVN D (agency). The police were called, and facility staff searched for the resident in the facility and surrounding areas. Family and department heads were informed. The resident had no injuries. <BR/>-On 9/03/22, 12:00 PM - Upon entrance to facility, door alarm sounded d/t resident being noted to have electronic monitoring device on wrist. How resident got out of facility with electronic monitoring device on is TBD ADON requested Q 30 min checks for a couple areas then hrly (hourly) until further notice . The resident was discharged from the facility on 9/03/22. <BR/>Record review of the Incident-by-Incident Type list for the facility dated 9/13/22 revealed that there was one resident listed as having an elopement incident. The date range for the list was 3/13/22 to 9/13/22. Resident #60 was not listed on this document as eloping from the facility.<BR/>Record review of the MAR/TAR for Resident #60 for August 2022 revealed that the facility started ordered electronic monitoring device checks on 8/11/22 on the night shift. The electronic monitoring device was checked Q shift. On 8/17/22 there was no documentation that the electronic monitoring device was checked on the dayshift. On 8/18/22 it was documented that the resident had his electronic monitoring device on during the day and night shift. On 8/19/22 at 4:00 PM the residents electronic monitoring device monitoring order changed from Q shift to Q4 hours. Further documentation on the TAR revealed that on 8/25/22 there was no documentation that the electronic monitoring device had been checked at (4:00 AM). The resident's electronic monitoring device was documented as being off him on the following dates and times:<BR/>8/28/22 at (8:00 PM)<BR/>8/30/22 at (4:00 PM and 8:00PM)<BR/>8/31/22 at (12:00 AM and 8:00 AM)<BR/>On 8/31/22 there was no documentation of the electronic monitoring device being checked at (4:00 AM). <BR/>Record review of the September 2022 MAR/TAR for Resident #60 revealed an order for electronic monitoring device checks Q4 hours. There was no documentation on 9/1/22 at (4:00 PM) that the electronic monitoring device was checked. Further record review of this MAR/TAR for Resident #60 revealed that the electronic monitoring device documentation for his right ankle and left wrist on 9/2/22 ( 8:00 AM and 12:00 PM) was documented as Other and to see the nurses notes for an explanation. The resident was documented as having the electronic monitoring device on starting 9/02/22 at (4:00 PM) through (12:00 PM) on 9/3/22. The electronic monitoring device checks on 9/03/22 revealed that the resident had his electronic monitoring device on for the 8:00 AM and 12:00 PM checks. <BR/>Record review of the Progress Notes for Resident #60 revealed no documentation as to why there was no on or off electronic monitoring device documentation on 9/2/22 at (8:00 AM) and (12:00 PM).<BR/>On 9/16/22 at 10:11 AM, an interview and record review was conducted with LVN C (agency) regarding Resident #60's wandering and eloping from the facility. He stated the resident was a wanderer but could converse and state his needs. He added that he would hang around at the exit door near room [ROOM NUMBER]. He was definitely a wanderer. Regarding the day the resident eloped, he stated, on 8/18/22 it was a normal day. Dinner was served. LVN C was in the dining room helping out. Staff report to him at approximately 4:45 PM that they could not find the resident. LVN C searched every room, outside and surrounding areas including businesses. He also called local hospital ERs. Family and law enforcement were called, and the resident was located by police at 82nd street and returned at approximately 6:50 PM. Upon the resident's return, he was assessed, and an electronic monitoring device was placed on him. He further stated the resident had a history of asking for scissors to cut off his electronic monitoring device. The LVN stated he was on duty the next day and monitored him closely. He added he double checked him every hour or two for his whereabouts. There were no other interventions to prevent him from eloping. The LVN stated he was told by staff the resident would remove his electronic monitoring device and ask for scissors to cut it off. He added that the resident never asked him for scissors. LVN C was then asked about their procedures related to electronic monitoring devices. He stated he visually checked the electronic monitoring devices and documented it in the MAR. He added that if a resident wanders to the front of the facility, the electronic monitoring device alarms. He added staff used harder zip type ties to keep the electronic monitoring device on once they knew he could take it off. LVN C then checked the electronic incident documentation system to see if an incident report had been developed for the elopements on 8/18/22 and 9/03/22 and found none. LVN C also stated that he contacted the Administrator, DON and ADON about the 8/18/22 elopement but did not contact the physician. He added that it was not OK not to inform the physician. Regarding the missing incident reports, he stated if there is no documentation it is not done. He further stated he was not sure if the facility had an elopement protocol and did not know what the facility elopement protocol was. He stated, I'm just agency. He also added that there was no documentation of his monitoring of the resident every one or two hours. He stated that his monitoring documentation was only in the nurses' notes .<BR/>On 9/16/22 at 11:14 AM, an interview was conducted with the DON. Regarding Resident #60 she stated he was tall, had dementia, confusion, was a wanderer and was admitted from a secure facility . Regarding wandering intervention for the resident, she stated after the first elopement they increased electronic monitoring device checks and checked the room daily. Staff checked every shift and more often. The second time he eloped, staff implemented checks every 2 hours. She added, the last time he eloped, he still had his electronic monitoring device on. Staff did not know if someone let him out. She was unsure how far he was from the facility the first time he eloped. The second time he eloped he was found outside a new restaurant on 82nd street. Regarding their elopement protocol, she stated nurses are to check each room. Some staff checked the parameters. Within an hour we called the police. Regarding any orientation provided to agency nurses prior to assuming duties in the facility, she stated, staff conduct a quick one. Staff familiarize them with the charting system. Contact information is given to them for the DON and ADON. Regarding residents, agency staff know what to do. They are informed of resident tendencies. <BR/>On 9/16/22 at 11:29 AM, an interview was conducted with the Administrator. Regarding elopement protocols, she stated, if residents are not found they look in-house. The administrator is informed, and the administrator informs staff by group text and the department heads look for the resident. She stated the second elopement was handled this same way. Regarding Resident #60 she stated, he was a dementia resident admitted from a secure nursing home. He did not do any wandering there. He was here two weeks and then was found outside. He was gone about 45 minutes . He was not exit seeking. She added that after meals his dementia tells him to go to work. Staff knew to monitor him after meals. He thought he was trying to get to work when he was found at a restaurant on 82nd and Quaker Avenue (Approximately 0.6 miles from the facility). He was found quickly. She believed, the first time he was found on 76th and Salem Avenue (approximately 0.3 miles from the facility). She further stated, both times he was gone an hour or less . The second time was on a Saturday. <BR/>On 9/16/22 at 11:54 AM, an interview was conducted with the Maintenance Supervisor regarding the electronic monitoring device system. He stated there are two doors with the electronic monitoring device system; the front and the dining room that are exits are alarmed. He added he checks the doors weekly on Mondays. During the generator test it deactivates the electronic monitoring device system and the test lasts 30 minutes . He further stated to test the electronic monitoring devices, he uses an electronic monitoring device and goes to the door to check if it alarms. He also stated that he has a resident, with a monitoring device, go by the door and see if it locks. Regarding Resident #60, he stated the resident got out two times. The first time, staff say he cut off the electronic monitoring device. The second time only thing he could think of was the resident went out with a visitor. He added he did not know if anyone heard the electronic monitoring device alarm go off, but staff should have. <BR/>Record review of the facility documentation on Door Alarm checks revealed that weekly checks were made. Between 8/01/22 and 9/12/22 all door alarms were documented as passing and had no issues (8/01/22, 8/08/22, 8/15/22, 8/23/22, 8/29/22, 9/05/22 and 9/12/22).<BR/>On 9/16/22 at 12:45 PM, an interview was conducted with the ADON regarding Resident #60's elopement. Regarding why the incidents happened, she stated, some family may have let him out. He may have been gone out before staff saw him. It's hit and miss who's around the exit door. LVN D told her she did not hear an alarm. Agency staff was at station one. She added that the first elopement he said he was going to work. It was something all staff knew. These were suggestions of what he was thinking. She stated they ensured residents do not elope outside of the facility by conducting hourly checks , frequent checks. She added if staff hear the alarm, they go straight to the door. She further stated there were no documentation of the (hourly) checks. She added, staff make sure they make rounds. She stated, everyone is responsible to ensure that residents do not elope from the facility. She added, she expected that staff are in the building working and others are out searching for any eloped residents. She stated that if residents were not appropriately monitored and eloped, others could elope from the facility. She also stated that there was no paper documentation of the monitoring that they conducted on Resident #60. <BR/>On 9/16/22 at 2:40 PM, an interview was conducted with the Administrator. Regarding Resident #60 elopements she stated, the staff did not think he would leave prior to the first elopement . She added that staff were supposed to monitor the resident after dinner . She also stated that someone may have let him out. She stated caregivers, charge nurse, nursing and administrator were responsible for ensuring that residents do not elope from the facility. She added she expected staff to provide a better monitoring system to prevent elopements. She further stated she made it clear to staff and they should have taken Resident #60 to his room after his meals. She was asked how an elopement could affect residents. She responded by stating that the facility makes sure residents are in a safe environment, experiencing no harm.<BR/>On 9/16/22 at 3:06 PM, an interview was conducted with agency LVN E (agency). She stated she worked in the facility approximately three times a month. She stated that she was not oriented by the facility regarding missing residents and the elopement protocol prior to working in the facility. She stated that she had been oriented at other facilities. She stated if residents elope from the facility they could be in danger, run over, or multiple things happen to them.<BR/>On 9/19/22 at 7:50 PM an interview was conducted with LVN D (agency at the time of elopement). She stated Resident #60, was a roamer and walked all day and night. He was super confused. Sometimes he would layer his clothes wearing seven or eight shirts at a time. All day he would say he was going somewhere. She stated she was not told specifically to take the resident back to his room after meals, but felt it was a given fact. Regarding the 9/03/22 elopement, she stated, it was an hour and a half after breakfast . She had been looking for him for him for something and then discovered he was missing. She added staff started checking and he was not found. Staff did not hear an alarm; no one did. She stated, if the door is held, it should have alarmed. She added that she did not know what exit he may have gotten out of. She stated she did not develop an incident report but documented the incident in the nurse's notes. She stated the incident occurred on her second day at work and she called the family, ADON and DON. She added that family brought the resident back and she assessed him. She was asked what could result from an elopement of a resident. She stated if residents were to elope from the facility they could be hit by a car and be led to do things they should not do. She added that the resident talked well and presented himself well if you were not aware he had dementia . She stated that she had not call the doctor about the incident. She stated when she started working in the facility, nothing special was told to her about Resident #60, but she was made aware that he removed his electronic monitoring device. She added that she placed it back on him a couple of times and that he would pull real hard and could pull it off.<BR/>During an interview conducted on 09/29/2022 at 9:42 AM with the Administrator , she said she did not recall if they had reviewed camera footage once she was notified the facility had been searched, they started searching outside. She said she was out of town during Resident #60's second elopement. She said it was her understanding that both elopements were through the front door of the facility. She was not sure if an alarm went off, she was told Resident #60 was out on the porch outside of the facility, seen by another visitor, then later found at a restaurant. She said the first time Resident #60 eloped; he was found about a block from his house, which she said was in the area of the facility, talking to the neighbors who called the police while they were at the facility with the Administrator. She further stated the electronic monitoring device alarm on the door goes off until the keypad code is entered by staff.<BR/>Observation made on 09/28/2022 at 8:16 AM showed a camera to be in the lobby facing the entrance to the facility.<BR/>Observation made on 09/28/2022 at 8:45 AM showed a camera facing the first nurses' desk nearest the entrance to the facility (Hall1).<BR/>Observation on 09/28/2022 at 8:47 AM showed a camera facing the facility's dining hall and back door entrance.<BR/>Observation made on 09/28/2022 at 8:48 AM showed a camera facing the break room. <BR/>Observation made on 09/28/2022 at 8:50 AM showed a camera facing the south side door at the end of the east hall (Hall 2).<BR/>Observation made on 09/28/2022 at 8:35 AM showed a camera to be facing the north side door at the end of the east hall (Hall 2).<BR/>During an interview conducted on 09/28/2022 at 8:59 AM with the Administrator, she said all the cameras were working. She said the monitors were in the central supply room in the beauty shop. <BR/>During an observation and interview on 9/28/22 at 9:58 AM with the Maintenance Supervisor, he was asked if it would be possible to check camera footage from specific dates. He was not sure if the cameras saved footage. Observation of the central supply closet inside the beauty salon room with the Maintenance Supervisor revealed a monitor could be seen with several viewing panels for all cameras showing no footage being taken currently on any camera as indicated by a blank black screen. Using the search feature found on the monitor, the Maintenance Supervisor typed in the dates in question (08/18/2022, 09/03/2022) and no footage was found. Observation of the cameras in the Dietary Manager's office showed live footage from only the temperature-scanning camera located in the lobby could be seen. He was unable to show footage of the dates in question (08/18/2022, 09/03/2022).<BR/>During an interview conducted on 09/28/2022 at 9:28 AM with the DON. When asked about the cameras and whether they had ever reviewed camera footage after Resident #60's elopements. She said she did not know how to access them and has never reviewed camera footage. <BR/>During an interview conducted on 09/28/2022 at 10:33 AM, the Maintenance Supervisor stated he had spoken with the facility's IT (Information Technology) department and was told the cameras send footage to the Administrator's computer with storage only for the last 30 days. He said the Administrator did not know that though, and he was going to her office next to see if it was set up on her computer. Based on the time frames of stored footage, he was asked to provide footage from 09/03/2022 for the hours leading up to Resident #60's noted absence from the facility at 9:15 AM. <BR/>During an interview conducted on 09/28/2022 at 11:36 AM with the Administrator, she said they had made progress on finding camera footage from 09/03/2022 and said: they are looking at it right now. <BR/>During an interview conducted on 09/28/2022 at 11:37 AM, the ADON was asked if they had found the footage from 09/03/2022 pertaining to Resident #60 and the elopement from 09/03/2022. She said they were still looking.<BR/>Observation made on 09/28/2022 at 11:37 AM showed staff members in the Business Office Manager's office looking at camera footage on the computer. <BR/>During an interview conducted on 09/29/2022 at 10:39 AM with the Business Office Manager concerning footage that she and the ADON had reviewed the previous day, she said they were not able to see any footage of the resident exiting the building. She said they had reviewed footage from all the cameras in the facility yesterday, and that not all doors exiting the facility had a camera facing them that adequately captured the view of the door. <BR/>On 9/28/22 at 9:10 AM, an interview was conducted LVN A. Regarding Resident #60 she stated, she remembered him. Staff were told to basically watch him and keep an eye on him; Every 30 minutes. She had to check his wander guard four times a day because he would take it off. His roommate was Resident #40. Their room was near the nurse's station. Regarding Resident #60's electronic monitoring device removal, she stated she did not know what he cut it off with. She never witnessed the removal. Staff placed a type of zip tie on it to keep it on. The band looked like it was cut when she saw it. She thought he may have got a butter knife to cut it off. She stated she never checked the resident for a knife and she only kind of looked around his room for an item that could have been used to cut it off. She added, he could get aggressive. She stated Resident #60 mostly watched TV. It seemed lunchtime he might get up. Regarding training about elopements and wandering residents she stated, she had not had any since being in the facility, which was approximately 2 months. She stated she learned from other facilities to keep an eye on them. The other places (facilities) staff saw them and where they were. Regarding any documentation of the 30-minute checks that she conducted on wandering residents, she stated she recently started documenting the checks and added that her weak point in nursing was documentation. She further stated, she could not recall staff asking her to document the one- or two-hour checks on Resident #60's whereabouts. Regarding any interventions told to her after the 8/18/22 elopement, she stated, she was told to make sure to keep an eye on him; her and the CNAs. He was always dressed and ready to go. He mainly stayed in his room. She further stated she never had anything to write on the nurse communication sheets about Resident #60. She stated the nurse communication sheets were placed in the box and then given to the ADON.<BR/>Record review of the Nurse Communication Sheets for 8/18/22 and 9/03/22 - 9/04/22 revealed no documentation related to Resident #60.<BR/>On 9/28/22 at 9:45 AM LVN A was interviewed and stated, sometimes Resident #60 ate in his room and she tried to be in the dining room to feed her residents during meals. She added, because he was an elopement risk, she kept her eyes on him. She further stated that no one had told her that Resident #60 needed to be taken to his room after meals.<BR/>On 9/28/22 at 9:53 AM an interview was conducted with CNA I. She stated staff did one-hour checks on Resident #60 and documented it on their POC (CNA electronic resident documentation kiosk). Staff just checked that he had not wandered off and that his electronic monitoring device was on. He was known to take it off. She stated she never figured out how he got it off. He would tear it off. He was strong. Regarding the 8/18/22 elopement, she stated she was the one that noticed he was gone. Staff searched inside and outside. Staff would see him wandering. He walked with Resident #40. She noticed she had not seen him at her hourly check . It was at supper, and she had not seen him. After he returned, staff was instructed to conduct 30-minute checks. They changed where his wander guard was applied. She added, there was no documentation of the 30-minute checks, it was just every day and it continued. She stated, she received training regarding wandering residents and elopement weeks or months ago. She further stated staff were told Resident #60 should go back to his room after meals by LVN A.<BR/>On 9/28/22 at 10:40 AM, an interview was conducted with the DON. Regarding interventions implemented after the elopement on 8/18/22, she stated, electronic monitoring devices were checked frequently, and redirection using activities. The nurse was to report abnormal behaviors. The nurse also made rounds. Staff were rounding different hours for the electronic monitoring devices. On 8/19/22 they checked the wander guard three times and then later every four hours. Regarding interventions for the resident removing his electronic monitoring device, she stated, place a new one on and provide education to the resident which was not very effective. Staff changed the positions of the electronic monitoring device. Staff made sure the electronic monitoring devices was comfortable. The main intervention was rounding every four hours. She stated that she would check him when she saw him. The Resident spent a lot of time in common areas. Regarding how he got the electronic monitoring devices off, she stated there was nothing in his room to remove it. Staff thought he was just pulling it off. The resident made comments about scissors. Staff checked everywhere they could for something he used to take the electronic monitoring devices off. The DON stated she thought it was irritating to him and he pulled it off. Regarding if staff had been instructed to take the resident to his room after meals, she stated, she instructed staff to conduct more rounding. She further stated she did not instruct staff to take Resident #60 back to his room after meals. Regarding in-services or training provided for wandering residents and elopements, she stated, staff were provided verbal education. She added more attention was given to station two since Resident #60 resided there. She stated she talked to LVN D, who was the charge nurse. LVN A and agency staff. She added she started the verbal education when the electronic monitoring device was placed on him. Regarding the screening process to determine if referred residents were appropriate for admission, she stated, they reviewed the referrals with a whole team. If there were unresolved issues with the referral, the DON was responsible for addressing the issues. She stated that she did not see Resident #60 prior to admission. She added that the referrals for admission for Resident #60 were received by the Administrator. The DON stated she ensured the nurses were competent in their skills in caring for residents that wandered by the DON and ADON talking to them. She added staff do rounds and check on the residents. Regarding what type of plan was in place for wanderers, she stated, the facility has electronic monitoring devices and an electronic monitoring device system. It locks the door. Staff check doors weekly. Staff try to provide activities for wanderers. Regarding any type of in-services provided on wanderers and elopement since admitting residents with those issues, she stated, staff were provided a lot of verbal instruction. The most recent documented in-service was 6/16/22. She stated, she did not think the facility was secure enough for Resident #60. She added that the facility was secure to a certain extent. <BR/>On 9/28/22 at 11:24 AM an interview was conducted with the DON regarding why there was no incident report done for Resident #60's two elopements. She stated, no incident report was done since staff found him within two hours. She stated she was told that by the Administrator.<BR/>During an interview conducted on 9/28/2022 at 1:47 PM with the DON , she was asked if notification to Resident #60's physician regarding his elopement had been made. She said that notification to the resident's physician would be documented in a progress note in the EMR (Electronic Medication Record). She said she would verify with the ADON as well and ask if there is anywhere else that would be documented. This documentation was never provided. <BR/>During an observation and interview on 9/28/22 at 11:28 AM, CNA I demonstrated where the resident monitoring documentation was located in the POC system for CNAs. The dates range checked was 8/19/22 through 9/03/22. There was no documentation in this system of hourly monitoring checks. At this time CNA I stated, she guessed their instructions to monitor were just verbal. Staff were verbally told to do it. She confirmed that there was no documentation on any of those days that one hour or 30 minutes or any resident checks were conducted for Resident #60. The only documentation that she found was on 9/02/22. There was a note that stated, walk with supervision. <BR/>On 9/28/22 at 11:45 AM an interview was conducted with the Administrator. Regarding monitoring documentation, she stated, staff would not be documenting unless he was one-on-one supervision or mandated. She stated, It was just known, especially after meals, that he wandered. There was nothing written. Regarding any viewing of the cameras footage for Resident #60's elopements. She stated, they cannot find anything on camera so far. Regarding in-services offered on wanderers and elopement, she [TRUNCATED]

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>1)The facility failed to ensure the kitchen was free of insect infestations (roaches),<BR/>2) The facility failed to ensure food and non-food contact surfaces were clean, and<BR/>3) The facility failed to ensure foods and food contact equipment were protected from possible contamination during processing, storage and service. <BR/>These failures could place residents at risk for food contamination and foodborne illness. <BR/>The findings include:<BR/>~ The following observations were made during a kitchen tour that began on 9/13/22 at 9:19 AM and concluded at 10:36 AM:<BR/>The spout had a buildup of residue and dirt on the drink dispensing machine drink gun.<BR/>Observation of 1 of 2 ovens, right side, revealed that there were too numerous to count adult, nymph (pre adult), and adult roaches with egg cases crawling in the oven. There was also a heavy accumulation of roach specs/feces.<BR/>On 9/13/22 at 9:33 AM the Dietary Manager stated regarding the roaches that the pest control operator sprayed for roaches last week. She added that the section of the oven, with roaches, was not used. She stated that the roach population had worsened recently, and she reported it to the administrator. Then the pest control came. <BR/>The plastic food bin exteriors were gummy and soiled.<BR/>The small plastic scoop storage cabinets had a buildup of dirt on the exterior and had a gummy feel.<BR/>There was one roach crawling on the floor when a large pot was moved on the floor under the convection oven.<BR/>There was a buildup of gummy grease on the convection oven top and sides.<BR/>There was a dead roach on the cart where the toaster oven was stored next to the steam table.<BR/>There was a heavy accumulation of roach specs (feces) on the piping behind the steam table.<BR/>There was an area of wallboard that was buckled at the steam table. The interior of the gap revealed there was a heavy accumulation of roach specs.<BR/>The drink gun/drink dispensing area table had buckling paint and a sticky buildup.<BR/>The pump type drink carafes had a gummy exterior.<BR/>There was a heavy accumulation of roach specs on the encased electrical outlet next to the three-compartment sink.<BR/>There were five dead roaches observed stuck to the wall behind the fire extinguisher sign near the three-compartment sink.<BR/>Inside the Dietary Manager's office in the kitchen, there was a box of thickened water next two containers of Avistat-D spray disinfectant labeled, . If swallowed: call a poison control center or doctor immediately. Caution. Causes moderate eye irritation. There were also boxes of Nepro supplement and 5 large cans of coffee stored on the same shelf.<BR/>On 9/13/22 at 10:06 AM Dietary Manager stated the cans of coffee were used for residents.<BR/>These five large cans of coffee were also on the shelf next to Champion Oven Cleaner labeled, Danger: contains sodium hydroxide. Avoid contact with skin. Injurious if sprayed in eyes. There was a box of teabags on top of this box of oven cleaner. Also on the shelf was Handy Klenz Lime Descaler which was labeled, Danger. Causes serious eye damage. Causes severe skin burns and eye damage. May be corrosive to metals There were bottles of steak sauce, coffee filters, hot sauces and oven bags next to the chemicals. <BR/>There were chemicals on the top shelf above the cans of coffee and other foods which included Pro Power Heavy Duty Oven and Grill Cleaner, labeled, Danger: causes severe skin burns and serious eye damage. There was a can of Enforcer Flea Spray stored on the same shelf.<BR/>An adult roach was crawling on the floor of the water heater closet inside the Dietary Manager's office. T his closet had holes in the ceiling and around the pipes entering the ceiling and wall.<BR/>Observation of a cart at the front of the kitchen revealed that the cart had Champion Oven Cleaner stored next to apple juice and a backpack on the same shelf. The oven cleaner was also stored above boxes of coffee filters that were on a lower shelf.<BR/>The refrigerator and freezer storage area, adjacent to the assist dining room, had an icemaker in which the interior flashing needed cleaning. <BR/>There were two of two unshielded ceiling fluorescent lights in the refrigerator and freezer storage area.<BR/>Observation on 9/13/22 at 10:35 AM the Dietary Manager stated previously roaches come out continuously and were worse at one time. She added that the roaches were wherever you turned your head.<BR/>~ The following observations were made during a kitchen tour that began on 9/13/22 at 11:35 AM and concluded at 12:45 PM:<BR/>The exterior of the large mixer had an accumulation of hardened splattered food.<BR/>Dietary staff A was observed preparing pur&eacute;es. Prior to putting the food in the processor, the surveyor asked to see the interior and blade of the processor. The blade had a sudsy film and was wet and the interior of the processor was wet. She then placed scoops of pot roast and milk into the processor and pureed it. She then placed it in a pan to be placed on the steam table.<BR/>On 9/13/22 at 11:48 AM Dietary staff A was observed washing the processor parts in the dishwasher.<BR/>On 9/13/22 at 11:50 AM the dishwasher cycle ended, and the processor parts were wet (blade and interior of the processor pot).<BR/>On 9/13/22 at 11:51 AM Dietary staff A placed scoops of carrots into the processor and pur&eacute;ed it while the interior and parts were still wet.<BR/>Record review and observation of the Auto Chlor System Super 8 chlorine sanitizer, used in the dishwasher, revealed the following, .Sanitizing Food Contact Surfaces. 5. Drain and allow equipment or utensils to air dry.<BR/>There were two sets of soiled keys stored on the prep table.<BR/>On 9/13/22 at 12:14 PM an adult roach was observed crawling on the floor near the steam table during meal service.<BR/>The following observations were made during a kitchen tour that began on 9/13/22 at 4:35 PM and concluded at 5:56 PM:<BR/>There were 2 bottles of blue colored personal drinks stored on the lower shelf of the prep table next to pans.<BR/>On 9/15/22 at 3:05 PM, an interview was conducted with a Dietary Manager. Regarding the roaches she stated they were pretty much there in the facility. Regarding not allowing the processor to air dry she stated Dietary staff A, felt under pressure. Regarding cleaning of equipment, she stated staff were responsible and they clean as they go. She added that she knew chemicals had to be stored away from food but did not know coffee was an issue. She added that staff conduct deep cleaning on Sundays which included cleaning the fryers and soaking the cups for coffee stains. She stated that she ensured staff follow proper food service procedures and protocols by going by the cleaning schedule and monitoring staff. She further stated that she expected Dietary staff A to let the processor air dry as she normally does. She stated that the problems found in the dietary department could result in residents getting chemicals in their food and residents becoming ill. She stated that staff and the dietary manager were responsible for ensuring staff follow all appropriate food service policies and procedures.<BR/>On 9/15/22 at 4:01 PM, an interview was conducted with the Administrator . Regarding dietary sanitation issues, she stated that residents could be affected by toxics in the food. She added that she expected dietary staff to ensure toxics were stored properly. She further stated she expected the Dietary Manager to check staff and ensure that they do what they are supposed to. She stated she did not know what to do about the roaches. She added the German cockroaches were only treated every six months. She further stated she would take the oven out and fumigate it. She stated the increase in roaches could cause infection control issues.<BR/>Record review of the facility policy titled Sanitization, Revised October 2008 revealed the following documentation, Policy Statement. The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation. 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. 3. All equipment, food contact surfaces and utensils shall be washed to remove or clean completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 10. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. 11. For fixed equipment or utensils that do not fit in the dishwashing machine, washing shell consist of the following steps: a. Equipment will be disassembled as necessary to allow access of detergent/solution to all parts; b. Removable components will be scraped to remove food particle accumulation and washed according to manual or dishwashing procedures. 12. Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. 16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 17. The food services manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.<BR/>Record review of the facility policy titled Food Receiving and Storage, Revised October 2017, revealed the following documentation, Policy Statement. Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation. 15. Pesticides and other toxic substances and drugs will not be stored in the kitchen area or in store rooms for food or food preparation equipment and utensils. 16. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #1, Resident #2 and #3) reviewed for infection control.1. CNA A failed to change gloves when going from dirty to clean when providing incontinence care for Residents #1, #2, and #3. These failures could place residents at risk for cross contamination and infection. The findings include: Resident #1 Record review of the admission record for Resident #1, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (a group of permanent movement disorders that affect brain-controlled muscle functions), schizoaffective disorder, bipolar type (mental health disorder) and anemia (not enough red blood cells to carry oxygen throughout the body). Record review of the quarterly MDS assessment for Resident #1, dated 08/27/25 revealed Resident #1 was always incontinent of bladder and bowels. Record review of the current care plan for Resident #1, last reviewed on 06/27/25, revealed there was a focus area: Bladder/Bowel Incontinence: I have bowel and bladder incontinence. During an observation on 09/05/25 at 11:30 AM, CNA A provided incontinence care and catheter care for Resident #1 with the help of CNA B. CNA A and CNA B washed their hands with soap and water and put on a clean pair of gloves. CNA A then unfastened the brief for Resident #1 and began cleaning his groin area with wipes. Resident #1 was turned on his side and CNA A removed the old brief. CNA A then wiped Resident #1's buttocks and placed a clean brief under Resident #1. CNA A secured the new brief and pulled up Resident #1's pants with the help of CNA B. CNA A then removed her gloves and used hand sanitizer to clean her hands. CNA A did not change her gloves and perform hand hygiene before going from dirty to clean during the procedure. Resident #2 Record review of the admission record for Resident #2, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: atherosclerotic heart disease (thickening or hardening of the arteries) dysphagia (difficulty swallowing), and aphasia (a language disorder that makes it difficult to communicate). Record review of the quarterly MDS assessment for Resident #2, dated 08/17/25, revealed Resident #2 was always incontinent of bladder and bowels. Record review of the current care plan for Resident #2, last reviewed on 09/04/25, revealed there was a focus area: [Resident #2] has bladder incontinence r/t history of UTI (Urinary Tract Infection). During an observation on 09/05/25 at 11:00 AM, CNA A provided incontinence care for Resident #2 with the help of CNA B. CNA A and CNA B washed their hands with soap and water and put on clean gloves. CNA A then unfastened Resident #2's brief and cleansed his groin with wipes. Resident #2 was turned on his side and CNA A wiped his buttocks with wipes. CNA A then removed the dirty brief and placed a clean brief under Resident #2 without changing her gloves. CNA A then secured Resident #2's brief and pulled his pants up. CNA A then transferred Resident #2 to his wheelchair and removed her gloves. CNA A then used hand sanitizer to cleanse her hands. CNA A did not change her gloves and perform hand hygiene before going from dirty to clean during the procedure. Resident #3 Record review of the admission record for Resident #3, dated 09/05/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (a group of permanent movement disorders that affect brain-controlled muscle functions), strabismus (crossed eyes or squint), and mild intellectual disabilities. Record review of the comprehensive MDS assessment for Resident #3, dated 07/30/25, revealed Resident #3 was frequently incontinent of bladder and always incontinent of bowels. Record review of the current care plan for Resident #3, last reviewed on 09/04/25, revealed there was a focus area: [Resident #3] has bowel and bladder incontinence. During an observation on 09/05/25 at 11:45 AM, CNA A provided incontinence care for Resident #3 with the help of CNA B. CNA A and CNA B washed their hands with soap and water and put on clean gloves. CNA A pulled down Resident #3's shorts and then unfastened Resident #3's brief. CNA A then cleansed Resident #3's groin with wipes. CNA A then removed Resident #3's old brief and then wiped his buttocks with wipes. CNA A placed a clean brief under Resident #3. CNA A secured Resident #3's brief and pulled up Resident #3's shorts. CNA A then transferred Resident #3 to his wheelchair. CNA A then removed her gloves and used hand sanitizer to cleanse her hands. CNA A did not change her gloves and perform hand hygiene before going from dirty to clean during the procedure. During an interview on 09/05/25 at 11:53 AM, CNA A stated she had received training regarding changing her gloves and performing hand hygiene when going from dirty to clean during a procedure. CNA A stated she could not remember the last time she was trained for incontinence care and infection control. CNA A stated she did not change her gloves and perform hand hygiene when going from dirty to clean because she did not think about it. CNA A stated the residents had an increased risk for UTI's and germs. During an interview on 09/05/25 at 11:54 AM, the DON stated she expected the staff to change their gloves and perform hand hygiene when going from dirty to clean when providing care to a resident. The DON stated she did not remember when the last training was for incontinence care/infection control and stated the staff were scheduled to be trained that month regarding infection control. The DON stated CNA A usually did transport for the facility but would get pulled to the floor if a CNA called in. The DON stated a potential negative outcome to the residents was possible infections or UTI's. During an interview on 09/05/25 at 2:35 PM, the Admin stated she expected the staff to change their gloves when going from dirty to clean when providing care. The Admin stated CNA A probably was not paying attention or was nervous and that was why she forgot to change her gloves and perform hand hygiene when going from dirty to clean. The Admin stated CNA A was usually the van driver for the facility, but she was pulled to the floor because someone call in that day. The Admin stated CNA A was trained to change her gloves when going from dirty to clean. The Admin stated the residents had a potential negative outcome for spreading infection. Record review of the facility policy titled, Policies and Practices - Infection Control, with a revised date of October 2018 reflected the following: Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 6 resident rooms (room [ROOM NUMBER]) located on 1 of 2 facility corridors (East Hall):<BR/>1)Roaches were observed crawling on the walls and floor in 1 of 6 resident rooms (room [ROOM NUMBER]) located on 1 of 2 facility corridors (East Hall), and<BR/>2) The pest control program was further compromised due to the facility having harborage areas that were not repaired, clean and/or orderly (hand sink cabinetry and adjacent wall area, clutter).<BR/>These failures could place residents at risk for infections.<BR/>The findings include:<BR/>During confidential resident interviews, 4 of 6 residents stated they had observed roach activity in the facility. One resident stated, I've seen them in the bathroom, closet and bed area. I've seen new hatchlings. He further stated housekeeping in his room varies and could go three or four days without housekeeping coming to his room. He stated, They don't clean under the bed. Another resident stated, They (Pest Control Vendor) sprayed not too long ago. He stated he last saw a roach in the facility approximately a month ago. One other resident stated, I have seen a few. The last I've seen was the first of the month in the room crawling on the floor. Another resident stated he had last seen roaches approximately four months ago and that was when his roommate had food in the room.<BR/>Observation on 6/11/24 at 3:22 PM in room [ROOM NUMBER] (occupied) there was an adult roach crawling on the wall under the hand sink in an area that had a gap near the wall water inlet. The area had a heavy accumulation of specs/roach feces . There were gaps in the hand sink cabinetry where there was specs built up. One small pre-adult/nymph roach fell from the underside of the hand sink cabinet onto the floor and crawled away. There was another large adult roach crawling in one of the gaps between the hand sink cabinetry frame. The roaches were also observed by the Maintenance Supervisor. The room had cluttered areas, and there were 3 extra mattresses stacked on the vacant A bed. The privacy curtains were drawn around the vacant bed and the room was dark.<BR/>On 6/11/24 at 3:30 PM an interview was conducted with the Maintenance Supervisor. He stated that the facility had been sprayed twice in the last month. He added the Pest Control Vendor came last month (May 2024) for roaches. He stated there were bedbugs in room [ROOM NUMBER] and the Pest Control Vendor found no others in the facility; that was approximately two or three weeks ago. He stated, roaches could get out of control, and the facility could get infested. He further stated roaches could get on residents if not controlled. He stated food and poor cleaning could have caused the current increase in roach activity. He stated housekeeping's responsibilities were to keep the facility clean and maintenance was responsible for obtaining pest control .<BR/>On 6/11/24 at 3:37 PM an interview was conducted with LVN A for the East corridor. She stated she had not seen a roach recently, but they used to be really bad. She added some residents kept food in their rooms and she used to see roaches at the nurse's station. She further stated that she reported roach activity to the Maintenance Supervisor, and she had last seen roaches approximately two months ago.<BR/>On 6/11/24 at 3:55 PM an interview was conducted with MA A. She stated the facility had a roach problem a while back. No dates were given as to how far back.<BR/>On 6/11/24 at 4:22 PM an interview was conducted with the Maintenance Supervisor regarding a monitoring system for pest/roach activity in the facility. He stated he looked around the facility and if he saw any, he would call the Pest Control Vendor. He stated he also received staff reports about roaches. He added that if he saw food in a room, he would check it for roaches. He stated he checked for roaches about one time a week.<BR/>On 6/11/24 at 5:10 PM an interview was conducted with the Maintenance Supervisor. He stated the facility had been working on the roach problem on Hall 2 (east corridor) a while. He added, They (roaches) keep coming back .<BR/>On 6/11/24 at 5:38 PM an interview was conducted with Administrator. He stated the facility treated rooms 110, 111 and 112. He added he thought the roach problem stemmed from (room [ROOM NUMBER] ). He further stated residents brought food to their rooms and at times the occupant of room [ROOM NUMBER] was resistant to staff pest control interventions (turning on lights, moving items). He stated when pest issues were reported, they were acted on. He added the food must be removed (resident areas). He also stated there was a book to report issues like pests located at the nurse's stations. He stated the Maintenance Supervisor and Administrator were responsible for ensuring that pests were controlled in the facility. He stated roaches were nasty and could place residents at risk for infections.<BR/>Record review of the Pest Control Vendor Service Form dated 11/7/23 revealed the facility was sprayed one time for Oriental roaches, American roaches, brown banded roaches, spiders, black/brown widow spiders and brown recluse spray spiders. The sites treated were water points and crack and crevice. Further documentation written on the service form revealed that they sprayed the entire East side of the facility. <BR/>Record review of the Pest Control Vendor Service Form dated 1/4/24 and 2/5/24 revealed that the facility was treated at a frequency of monthly and the target pests were Oriental roaches, American roaches, brown banded roaches, and spiders. The sites treated included crack and crevice.<BR/>Record review of the Pest Control Vendor Service Form dated 2/20/24 revealed that the facility was treated on that date for German roaches. The sites treated were water points, crack and crevice and wall joint.<BR/>Record review of the Pest Control Vendor invoices dated 2/20/24 revealed the following documentation, Description of Work. Treated interior cracks and crevices water and entry points and bathroom, German roaches are progressive and can take multiple treatments to gain full control .<BR/>Record review of the three Pest Control Vendor invoices dated 2/21/24 revealed the following documentation, .Description of Work. Treated interior cracks and crevices water and entry points and bathroom. German roaches are progressive and can take multiple treatments to gain full control . The Pest Control Vendor invoice number 266777617 dated 2/21/24 further revealed, . Description of Work. Treated the hallways in the 100s floor, technician did not see any live German roaches at this time. There was a lot of food open, and mini fridges, which are good spots for them to nest, these types of roaches can be brought in by employees and visitors .<BR/>Record review of the Pest Control Vendor Service Form dated 3/14/24 revealed that the facility was treated at a frequency of monthly and was treated that day for ants, roaches, roaches, brown banded roaches, and spiders. The sites treated water points, perimeter, and crack and crevice.<BR/>Record review of the Pest Control Vendor Service Form dated 4/30/24 revealed that the facility was treated that day for termites.<BR/>Review of the Pest Control Vendor Service Form dated 5/10/24 revealed that the facility was treated that day for bedbugs. <BR/>Record review of the Pest Control Vendor invoice dated 5/10/24 revealed, . Description of Work. Technician sprayed the hallways, hallway to past the double doors on the east side of the building. Technician also sprayed inside of 110 per request. Technician also noticed the roaches were German roaches and left an estimate .<BR/>Record review of the Pest Control Vendor Estimate documentation revealed the following, .5/10/24 Estimate details. German roach treatment. <BR/>Record review of the facility policy, titled Maintenance Services, Revised December 2004, Pest Control, revealed the following documentation, Policy Statement. Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation. <BR/>1. The facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. <BR/>2. Pest control services are provided by (Pest Control Vendor), 1/2/23. <BR/>6. Maintenance services assist, when appropriate and necessary, and providing pest control services .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Abuse Coordinator for 3 of 6 residents (Resident #1, #2, and #3) reviewed for abuse. <BR/>A. <BR/>The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding Resident #1 being fed forcibly by CNA A on an unknown date. <BR/>B. <BR/>The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding Resident #2 being transferred in a rough manner (chucked in the bed) by CNA A on an unknown date. <BR/>C. <BR/>The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding Resident #3 being changed improperly by CNA B on an unknown date. <BR/>These failures could place residents as risk for abuse and neglect. <BR/>Findings included:<BR/>Resident #1 <BR/>Record Review of Resident #1's face sheet, dated 1/28/25, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss) and anxiety (increased worry). <BR/>Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 00, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 did not exhibit physical behavior (hitting, kicking, pushing, scratching, grabbing, and abusing) during the review period [E0200]. Section GG revealed Resident #1 was dependent on staff for all her eating needs [GG0130]. Section K revealed that Resident #1 had the following swallowing disorder: coughing or choking during meals [K0100.].<BR/>Record review of Resident #1's progress notes dated from 10/27/24- 1/28/25 did not reveal any information regarding choking or allegation of abuse between the dates of 1/01/25-1/28/25.<BR/>Record review of Resident #1's care plan, dated 1/21/25, revealed a focused area, initiated on 12/13/23, Resident #1 had an ADL self-care performance deficit r/t dementia. The goal initiated on 12/13/23, was Resident #1 would maintain current level of function through the review date review date (02/06/24-01/21/25). The interventions initiated 12/13/23 included while eating Resident #1 would be fed for all meals.<BR/>During an interview on 1/28/25 at 2:50 PM, Resident #1 was unable to answer any questions about the staff's feeding technique. She lay in bed and was nonverbal at the time of the attempted interview.<BR/>Resident #2 <BR/>Record Review of Resident #2's face sheet, dated 1/28/25, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss), pain in unspecified joint and anxiety (increased worry). <BR/>Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 03, indicating the resident was severely cognitively impaired. Section GG revealed Resident #2 requires partial or moderate assistance when it comes to chair/bed to chair transfer.<BR/>Record review of Resident #2's progress notes dated from 10/27/24- 1/28/25 did not reveal any information regarding improper transfer or allegation of abuse between the dates of 1/01/25-1/28/25.<BR/>Record review of Resident #2's care plan, dated 6/14/24, revealed a focused area, initiated on 6/17/24, Resident #2 had an ADL self-care performance deficit r/t left hip and sacrum fracture. The goal initiated on 6/17/24, was Resident #2 would maintain current level of function through the review date review date (08/15/24-06/20/25). The interventions initiated 6/17/24 included Resident #2 required extensive assistance by 1 staff to move between surfaces. <BR/>During an interview on 1/28/25 at 4:15 PM, Resident #2 stated she could not remember if staff had been rough with her. When asked about transfers, she said she could not remember anything. <BR/>Resident #3<BR/>Record Review of Resident #3's face sheet, dated 1/28/25, revealed a [AGE] year-old female that was admitted to the facility on [DATE], with a diagnosis of Alzheimer's (memory loss) and anxiety (increased worry). <BR/>Record Review of Resident #3's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 03, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 did exhibit verbal behavior (threatening, screaming and cursing at others) during the review period [E0200]. Section GG revealed that Resident #3 requires substantial/maximal assistance regarding toileting hygiene [GG0130]. Section H revealed Resident #3 was always incontinent of bowel and urinary [H0300-0400].<BR/>Record review of Resident #3's progress notes dated from 10/27/24- 1/28/25 did not reveal any information regarding improper perineal care or allegation of abuse between the dates of 1/01/25-1/28/25.<BR/>Record review of Resident #3's care plan, dated 3/08/24, revealed a focused area, initiated on 3/18/24, Resident #3 had bladder incontinence r/t Alzheimer's. The goal initiated on 3/18/24, was Resident #3 was at risk for septicemia (life threatening bacterial disease) will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through review date (4/30/24-06/20/25). The interventions initiated 3/18/24 did not include instruction to staff on what to do regarding incontinence care. <BR/>Record review of Resident #3's care plan, dated 3/08/24, revealed a focused area, initiated on 3/18/24, Resident #3 had an ADL Self Care performance deficit r/t Alzheimer's. The goal initiated on 3/18/24, was Resident #3 was to maintain current level of function in eating through the review date (4/30/24-06/20/25). The interventions initiated 3/18/24 stated Resident #3 was totally dependent on staff for toilet use.<BR/>Record review of Resident #3's care plan, dated 3/08/24, revealed a focused area, initiated on 3/18/24, Resident #3 was resistive to care and would refuse to be changed r/t Alzheimer's. The goal initiated on 3/18/24, was Resident #3 would cooperate with care through review date (4/30/24-06/20/25). The interventions initiated 3/18/24 did not include if Resident #3 resisted with ADLs, negotiate a time so that the resident can participate in the decision making process.<BR/>During an interview on 1/28/25 at 4:00 PM, Resident #3 did not provide any pertinent information related to the deficient practice. <BR/>During an interview on 1/28/25 at 12:14 PM, Student C stated that she reported allegations of abuse when she was completing her clinical at the NF. She said she was not in a place where she could talk but could give the information later to the investigator. She said she did write a statement and reported the allegations of abuse to the ADON and the ADM that she had witnessed abuse and neglect at the facility. <BR/>During an interview on 1/28/25 at 1:15 PM, CNA A stated she was unsure of the exact day and time but that Student C had alleged that she was doing something wrong. The CNA stated she did not do anything wrong. She stated that she was asked to write a statement and was addressed about the allegations immediately. She said she focused on providing care for her residents and would not abuse them.<BR/>During an interview on 1/28/25 at 2:00 PM, the DON stated that she was unsure of the date and time but that Student C did not make a report of abuse to her. She said the report was made to the ADON. She said she was not clear on all the allegations, but it was her understanding that CNA A force-fed someone and threw someone on their bed. She said it was her understanding that an investigation was done, the facility cameras were watched, and none of the findings were valid. She stated she was unsure of which resident was force-fed but that she believed the resident who was thrown in bed was Resident #2.<BR/>During an interview on 1/28/25 at 2:20 PM, the ADON stated she was unsure of the date and time, but Student C came to her at least three weeks ago with another employee (CNA D). She stated that she was told by CNA D that Student C needed to speak with her. The ADON stated that she was told by Student C that she (Student C) had an abuse case that she wanted to report. The ADON stated that the DON was off on that day, and as a result, she went to the ADM. She stated she did not want to take a statement regarding abuse by herself. She stated that in the presence of the ADM, CNA Student C stated that CNA A fed a resident with a spoon with too much food, making the resident choke. The ADON stated that Student C reported that CNA B performed perineal care incorrectly. The ADON stated that she could not fully remember what Student C alleged. She stated they had Student C write a statement, which was submitted to the ADM. The ADON stated it was her understanding that the information gathered was submitted to their corporate. She stated that it was told to her that what was told to her (the ADON) and what was on the statement were different. She stated they educated staff on what to do if residents are choking and how to conduct perineal care. She stated that they asked nurses if they had witnessed anything and that no one had reported anything. The ADON stated that after she, the DON, and the ADM got statements and consulted with corporate, it was concluded that Student C was a new CNA and everything was a first for Student C in the nursing home environment. The ADON stated she had been trained on the facility's abuse policy. She stated that failure to report allegations of abuse to HHSC could result in the nursing facility being shut down. She said abuse could continue if it is not reported correctly. She stated that the purpose of reporting allegations of abuse to HHSC was to ensure that residents are treated fairly and keep them free from abuse and that all allegations of abuse are investigated on a higher level. She stated she was unaware that the allegations had not been reported to HHSC. She stated she was unaware that the incident with Student C was supposed to be reported to HHSC. She stated that their system to monitor and ensure that the abuse policy was being followed was that all allegations of abuse should be reported to the abuse coordinator, the ADM. The ADON stated that in-services and education on expectations are conducted. She stated they are trained and train the staff to report anything that seems unjust and anything they would not want to their family members. She said the ADM and the DON will conduct the investigation and report the appropriate information to HHSC. She stated that she expected all allegations of abuse to be reported to the abuse coordinator (ADM), the abuse policy followed, and all staff educated accordingly. The ADON stated that the ADM and DON were responsible for reporting allegations of abuse to HHSC. She said she was unsure of the reason the allegations of abuse reported by Student C were not to HHSC.<BR/>During an interview on 1/28/25 at 3:00 PM, the ADM stated he was unsure of the specific date and time, but Student C reported that she had concerns about how staff at the NF were taking care of the residents. He stated he had her write a statement. He stated that during their interview, Student C reported that a staff (CNA B) was rough with a resident, and the resident was screaming out. He said that he was told by Student C that another staff member (CNA A) had chucked another resident into bed. He said Student C stated that a staff (CNA A) overfed a resident and caused her to choke. The ADM said he took Student C's statement and sent it to his corporate staff. He stated he was instructed to conduct a 1:1 with both staff members, assess all residents, in-service all staff on customer care, and conduct safe surveys with residents. The ADM stated that Student C did not mention the term abuse or neglect. The ADM stated that he interpreted the student's statement that she had concerns but was not alleging abuse. He stated that he felt the student was bringing to his attention that the staff were rushing. He stated he would hope that his staff, when reporting serious incidents, would be specific and use the actual word abuse and neglect. She stated that she did not disclose the resident's names when Student C reported the incident. He stated that in the process of their investigation, they concluded that it was Resident #1 regarding the feeding incident, Resident #2 who was allegedly chucked on the bed, and Resident #3 involved in the perineal care. The ADM stated that because Student C did not provide names, he could not be 100 percent sure those were the residents involved. The ADM stated he did not report the allegations to HHSC because he did not perceive them as allegations of abuse but thought it was a concern in all three instances where staff may have been rushing and needed additional education. He stated that the purpose of reporting allegations to HHSC was to prevent abuse and to ensure that the resident's rights were being taken care of. The ADM stated that the potential negative outcome of not reporting all allegations of abuse to HHSC was that residents could endure abuse. He stated he was familiar with the facility's abuse policy and had been trained on the policy. He stated he was aware that he did not report the concerns to HHSC. He said their system for monitoring the implementation of the facility's abuse policy was to consult with corporate staff to see if they have enough evidence to report the allegation. He stated he had been trained to report all allegations of abuse to HHSC, and he expected all allegations of abuse. He stated he was responsible for reporting allegations of abuse to HHSC. <BR/>During an interview on 1/28/25 at 3:30 PM, CNA D stated that she could not remember the date or the time, but a few weeks before her interview with the investigator, Student C came to her and stated she had observed abuse and neglect in the facility. She stated that she stopped Student C before she could report anything to her and explained to her that she could not take that type of report. She stated she took her to the Administrator's office. She stated they knocked, and he did not answer. CNA D stated she took Student C to the ADON. She stated that after that, she did not know what had happened with the abuse reporting process. <BR/>During an interview on 1/28/25 at 3:40 PM, the DON stated that she had been trained on the facility's abuse policy and was familiar with it. She said she had been trained that all allegations of abuse had to be reported to HHSC. She said the purpose of reporting to HHSC was to protect residents from abuse while the investigations were being conducted. She said the potential negative outcome for the resident is that abuse can continue if not appropriately addressed. She said she was aware that the allegations from Student C were not reported to HHSC, but it was not reported because there were no findings that substantiated what Student C reported. The DON said she expected all allegations of abuse to be reported to HHSC. She said that she and the ADM were responsible for reporting allegations of HHSC.<BR/>During an interview on 1/29/25 at 10:06 AM, CNA B stated she did not remember the exact date and time but had been asked to change Resident #3 with the assistance of student aides. She said that after she changed Resident #3, management asked her to write a statement because it was alleged that she was rough with Resident #3. CNA B told the students that Resident #3 was sensitive. She said that while changing Resident #3, she forgot that Resident #3 needed cream and had intended to tell the night shift to put cream on her. CNA B stated that one of the students (name unknown to her) went and retrieved the cream. She said, Thank you, and put the cream on her. She said she was unaware of any issues or concerns from the student aides at the time of the incident. She said she was given a warning about the incident.<BR/>During an interview on 1/29/25 at 10:12 AM, the Regional Clinical director stated she received an email from the ADM (the email date was not disclosed during the interview). She stated that the email from the ADM stated that he (the ADM) had a grievance from one of the CNA students (she did not disclose which CNA student by name). She said she read Student C's statement that was attached to the email and advised the ADM to investigate, in-service, and conduct safe surveys. She stated that after reading Student C's statement, she considered what she reported to be a concern, not an allegation of abuse. She stated that this instruction was given because there was no merit to the concerns that the CNA student disclosed. The Regional Clinical Director stated that the ADM never stated that there was an allegation of abuse. The Regional Clinical Director stated that if there is a complaint of abuse, it is customary for them to investigate and immediately notify HHSC. She stated she was unaware if the term abuse was used when the concerns were made. She stated that the ADM had been trained on the abuse policy and is the abuse coordinator. She stated she felt comfortable with the ADM interpreting if there was an allegation of abuse. She stated that the ADM received the basic abuse training that all staff receive, but she was unaware of any additional training he may have received as the abuse coordinator. The Regional Clinical director stated she read Student C's statement and considered it a grievance. She stated that it was a strange situation because she is unsure if something is going on in the facility where the staff may be against CNA A. She stated that the ADM was responsible for reporting to HHSC. She said the purpose of reporting all allegations to HHSC was so they (HHSC) could come out and ensure that the facility followed the correct protocol to prevent abuse. She stated the reason the allegations of abuse were not reported was because they were considered a grievance and not an allegation of abuse. <BR/>During an interview on 1/29/25 at 11:17 AM, Student C stated that 1/10/25 she graduated from CNA school. She stated that her experience at the NF was challenging. She stated that on the previous Tuesday (01/7/25) before graduation, she observed CNA B perform perineal care on Resident #3. She stated she observed her partially clean and not put cream on her buttocks. She stated that CNA B would not put the cream on Resident #3, so she retrieved the cream. She stated that CNA B thanked her, and when she went to put the cream on Resident #3, it appeared that CNA B forcibly put the cream in Resident #3 buttocks, and when she removed her hand, there was feces on CNA B's gloves, indicating that Resident #3 was not clean. Student C said CNA B did not attempt to reclean Resident #3. She stated that the next day (1/08/25), while she was feeding Resident #1, CNA A took over feeding Resident #1. Student C stated that she observed CNA A provide at least two large spoonful of mashed potatoes and other unknown sauces and feed them to Resident #1. Student C stated that when CNA A attempted to give her another heaping spoonful of food, Resident #1 appeared to start choking and spit the food out on her clothing protector. Student C stated she provided Resident #1 with a drink, which seemed to help her. She stated that CNA A was feeding Resident #1 all the while eating her own lunch in between providing Resident #1 bites of food. She stated that CNA A threw Resident #2 in the bed the same day. She stated she felt bad for the residents at the NF. She stated that Resident #2 told CNA A she was moving too fast and was crying. Student C stated she felt bad for all the residents at the NF because of the treatment she saw. She stated she went to CNA D, who told her she would have to report what she observed and showed her where to go. She stated she went to the ADON office on her first day. She stated that she made herself clear that she wanted to report abuse. She said the ADON told her she would have to get the ADM as she could not take a statement of that nature herself. She stated that when the ADON retrieved the ADM, they passed CNA A and told her, After this, we will need to talk. She stated that CNA A attempted to walk with the ADON and ADM, but the ADON stopped her. Student C said this made her feel uncomfortable as this would make it obvious that she was the one making the report of abuse. She stated they went to the office, and she reported what she had experienced, including the alleged allegations of abuse with Resident #1 ,#2, and #3. She stated that in the presence of the ADM and ADON, she made herself clear that she was alleging that Resident #1, #2, and #3 had been abused. She stated that she was asked to write a statement. She stated she was placed in the room next to the ADM office and could hear him sucking his teeth and breathing hard as if he was irritated. She stated that this treatment caused her not to focus on her statement as much. She stated that staff were coming in and out, and the ADM would come and ask her if she was done frequently. She stated that she did not include names or the words abuse or neglect because she was instructed by the ADM to only write what she observed. She stated that the tone of the environment set by the ADON and ADM made her rush and forget that she had another incident to report about CNA A. She said that CNA A had made an inappropriate comment to an unknown resident while showering him but did not want to say anything further because she already felt she had caused enough trouble. She stated that while reporting what she observed with Resident #1, #2, and #3, she (Student C) had become emotional and started crying. She stated that no one followed up with her about what she reported. She said she did not consider what she reported a grievance. She said she had received training on ANE during certified nurses aide training from the school but only attended the NF for hands on training with the residents. <BR/>Record review of the email, dated 1/29/25, forwarded by the Regional Clinical Director revealed the following:<BR/>Student C's witness statement was attached.<BR/>The ADM emailed Student C's witness statement to Regional Clinical Director and reported that a student had complaints about staff care.<BR/>Record review of Student C's handwritten statement, dated 1/9/25, revealed the following:<BR/>December 7, 2025<BR/>I witness CNA B not cleaning the patient (Resident #3) in room private area right. She also did not use diaper rash medicine and when I brought it to her and told her to use it she placed it on her hand and forcefully shoved her hand in the lady's legs. The lady was in so much pain she yelled.<BR/>January 8, 2025<BR/>I witnessed CNA A put a over amount of food into the mouth of a patient (Resident #1) who couldn't move and was rushing feeding her. The lady choked so I gave her kool-laid.<BR/>January 9, 2025<BR/>I witnessed CNA A chuck Resident #2 on the bed. CNA A was in a hurry due to trying to leave early.<BR/>Record review of CNA A's handwritten statement, dated 1/08/25, revealed the following:<BR/>I, CNA A, was feeding residents and it was said I over feed, but I truly feel that I over did it, but I will be careful and safe. <BR/>Record review of CNA A's handwritten statement, dated 1/09/25, revealed the following:<BR/>I, CNA A, had 4 students with me to put Resident #2 to bed as asked by my nurse. As I stood her up I smelled her, so I got her brief and wipes and changed her while she was standing when I assisted her to bed.<BR/>There were no provider investigation reports available for review that involved Resident #1, #2 or #3 as of 1/28/25. <BR/>Record review of CNA B's handwritten statement, dated 1/07/25, revealed the following:<BR/>Tuesday January 7th the students asked me for help with Resident #3, so I came to help. I let them know as I was helping that she's (Resident #3) sensitive so when you move her even just a little it hurts her. She (Resident #3) was a little red. It was the last round. I didn't have cream so I was gonna let night shift know she was red so they could put some on her but one of the student aids went and got some cream so I did put dome on her after she was changed.<BR/>Record review of the facility's investigation report, dated 1/11/25, revealed the following:<BR/>The investigation from the student was completed and the conclusion did not show any abuse or neglect. The staff need to be in-serviced on taking their time and more personal care when caring for residents. Safe surveys were completed by the Licensed Social Worker on other residents down the hall and no complaint made at this time.<BR/>The staff (CNA B) that was in question about her perineal care technique: had stated to the student before they went in that the resident will scream out when you touch her in any manner. <BR/>The staff (CNA A) that put Resident #2 to bed, stated she did not chuck as stated or do any type of transfer that would be considered abuse at that time. It may have seemed rough to the student.<BR/>The staff (CNA A) that was feeding the resident (Resident #1) stated she was giving her large spoons, but that was normal for the resident (Resident #1) and she did not choke; and if so the nurse would have intervened.<BR/>Record review of LVN E's handwritten statement, dated 1/09/25, revealed the following:<BR/>Head to toe skin assessment performed on Resident #2.<BR/>One old bruise noted to back of right arm, measuring 1 cm by 1.5 cm , and greenish in color.<BR/>Residents skin is warm/dry to touch. Skin turgor elastic (ability to stretch and return to normal).<BR/>No abnormalities noted, no other skin breakdown noted.<BR/>No rashes/lesions noted to skin.<BR/>Record review of facility's inservice overview, dated 1/10/25, revealed that staff were inserviced on the following:<BR/>Customer service: Respect resident's rights, respect their privacy and show compassion with care<BR/>Direct care Staff: Take your time with personal care, be gentle and use caution with care during transferring, assisting with meals and bathing.<BR/>Record review of a total of 6 safe surveys, dated 1/10/25, revealed the following:<BR/>No resident reported feeling unsafe, abused or handled roughly.<BR/>Record review of facility employee training, dated 1/10/25, revealed the following:<BR/> CNA B was trained on perineal care technique.<BR/>Record review of facility employee training, dated 1/10/25, revealed the following:<BR/> CNA A was trained on transfer technique and assisting residents with feeding.<BR/>Record review of the facility policy, Filing Grievances, revised December 2024, revealed:<BR/>Policy Statement<BR/>Our facility will assist residents, their representatives (sponsors), other interested family members, or resident advocates in filing grievances or complaints when such requests are made.<BR/>Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form.<BR/>The resident, or person filing the grievance and/or complaint in behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the administrator, or his or her designee, within 3 working days of the filing of the grievance or complaint with the facility. A written summary of the report will also be provided to the resident, and a copy will be filed in the business office.<BR/>Record review of the facility grievance log dated from November 2024-January 2025 did not include a concern involving Resident #1, #2 or Resident #3.<BR/>Record review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation, revised April 2021, revealed:<BR/>Policy Statement <BR/>All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations). <BR/> Policy Interpretation and Implementation <BR/>If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.<BR/>The administrator or the individual making the allegation immediately reports his or her suspicion to tl1e following persons or agencies:<BR/>The state licensing/certification agency responsible for surveying/licensing the facility;<BR/>Immediately is defined as:<BR/>within two hours of an allegation involving abuse or result in serious bodily injury; or<BR/>within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.<BR/>Reporting Results of Investigations<BR/>The administrator, or his/her designee, provide the appropriate agencies or individuals listed above witl1 a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 3 of 13 residents (Resident #22, Resident #12, Resident #9) reviewed for accuracy of MDS assessments.<BR/>-The MDS assessment of Resident #22 had errors in ADLs and Falls.<BR/>-The MDS assessment of Resident #12 had errors in ADLs, Nutrition, and Medications.<BR/>-The MDS assessment of Resident #9 had errors in assessment of continence.<BR/>This failure could place residents at risk for not receiving the correct care to meet their physical, mental, and psychosocial needs.<BR/>Findings include:<BR/>Resident 22<BR/>Record review of Resident 22's face sheet revealed an [AGE] year old female admitted [DATE] with diagnoses including: Fracture of right clavicle (collar bone) on 3/11/22, feeding difficulties, hypothyroidism (thyroid underperforming), type 2 diabetes, hyperlipidemia (high cholesterol), dementia, Alzheimer's, heart failure, angina (chest pain from blocked blood vessels), osteoarthritis, cognitive communication deficit, dysphagia (trouble swallowing), and pain in unspecified joint.<BR/>Record review of Resident 22's Care Plan, last reviewed on 08/30/22 showed that under the focus of Activities of Daily Living (ADL's), for eating - the resident requires (supervision to limited assistance x1 person physical assist) for setup/cleanup. Further along in the ADL section, it showed transfer: the resident requires (limited assistance x 1 person physical assist) moving between surfaces including to or from: bed, chair, wheelchair, standing position. In addition, the care plan showed a focus of actual fall on 05/15/22, actual fall with no injury which was added to the care plan on 05/19/22.<BR/>Record review of MDS that was the last annual assessment, dated 05/12/22, showed in section J - Health Conditions, for J1800 has the resident had any falls since admission/entry or reentry or the prior assessment (whichever is more recent? And the answer is 0 which equates to the answer no.<BR/>The newest MDS assessment of Resident #22, a quarterly MDS dated [DATE], indicated in section G - Functional Status, letter B. Transfer was marked 3 (two+ persons physical assist). In the same section, question letter H. Eating was marked 3 (two+ persons physical assist), but the care plan referenced above stated 1 person assist for both activities, eating and transfers. In addition, in section J - Health Conditions, question J1900 Any falls since admission/entry or reentry or prior assessment, whichever is more recent, the facility marked no falls since prior assessment, however a fall was documented as occurring on 5/15/22 in the care plan and the prior MDS was dated prior on 5/12/22. <BR/>Resident 12<BR/>Record review of Resident 12's face sheet revealed a [AGE] year old female admitted [DATE] with diagnoses including: Huntington's Disease (genetic disease that destroys the nerve cells in the brain), dyskinesia (abnormal movements), body mass index (BMI) of 19.9 or less (below healthy), dementia, major depressive disorder, functional urinary incontinence (brain is talking to bladder, but decisions or environment prevent continence), fracture of the right arm, dysphagia (trouble swallowing), and cognitive communication deficit.<BR/>Record review of Resident 12's active orders as of 09/13/22 showed an order for Aspirin 81 mg by mouth 1 time a day for anagesic (should be analgesic - pain relief). No other orders reflect any blood or platelet altering medications.<BR/>Record review of Resident 12's care plan last reviewed 06/07/22 showed a focus of nutrition management with a goal of maintaining a weight of 88 to 98, and interventions of inviting her to activities to promote intake, reporting to MD signs of malnutrition, emaciation (cachexia - defined as weakness and wasting of the body due to severe illness). Under the ADL's focus for Resident 12, the care plan stated in the locomotion on/off unit section: the resident requires (limited to extensive assistance x1 person physical assist) moving between locations in her room, corridor, and distant areas of the facility.<BR/>The MDS assessment of Resident #12 dated 07/05/22, which was an annual assessment, indicated in Section G - Functional status question C. Walk in room a number 2, which represents one-person physical assist. In the same section, question D. Walk in corridor was marked as a 1, which represents setup help only. In section I - active diagnoses, question I5600 Malnutrition (protein or calorie) or at risk for malnutrition, the box is not checked despite the care plan addressing the resident being at risk for this issue. In addition, according to her face sheet, she has a diagnosis of BMI 19.9 or less. In Section N - Medications, question N0410 Medications Received, indicate how many days of the last 7 days were administered, question letter E is anticoagulant and is marked 7 days, but no prescription for an anticoagulant was present, only aspirin which is an antiplatelet (see below for delineation of antiplatelet and anticoagulant). <BR/>In an observation on 09/13/22 at 10:16 am, Resident #12 was observed pacing in her room stating, there's an alarm over and over again; staff was found and informed, they stated this is normal behavior for her. In a further observation on 09/15/22 at 5:00 pm, Resident #12 was seated on her bed when surveyor entered and then she stood up and paced in her room for 10 minutes while surveyor and resident chatted.<BR/>Record review of an article on Medline Plus titled Blood Thinners, last updated 01/31/22, accessed 09/27/22, found at this link: https://medlineplus.gov/bloodthinners.html#:~:text=Anticoagulants%2C%20such%20as%20heparin%20or,a%20heart%20attack%20or%20stroke. <BR/>The article defines blood thinners as medicines that prevent blood clots for forming and it listed two types of blood thinners: anticoagulants, such as heparin or warfarin that slow down the process of making clots, and antiplatelets such as aspirin and clopidogrel prevent cells called platelets from clumping together.<BR/>Resident 9<BR/>Record review of Resident 9's face sheet revealed a [AGE] year old female admitted [DATE] with diagnoses including: Parkinson's (disease affecting nerves in the brain and through the body), cognitive communication deficit, major depression, myopia (near sighted), chronic obstructive pulmonary disease (lungs can't spread oxygen), emphysema (sacs in the lung can't switch oxygen and carbon dioxide leaving person breathless), schizoaffective disorder bipolar type (mood disorder that varies by person but has mania and depression), generalized anxiety, history of falling, post-traumatic stress disorder (PTSD), pain in unspecified joint, bilateral cataract (cloudiness in both eyes), benign neoplasm of left choroid (abnormal cells in the left eye), and insomnia.<BR/>Record review of Resident 9's care plan, last reviewed 07/14/22, stated in the focus of bladder/bowel management that Resident 9 is incontinent of bladder and at risk for fecal incontinence, initiated on 05/07/18 and revised on 04/14/22. It shows a goal of remaining free from skin breakdown due to incontinence and brief use through the review date; this goal was initiated 05/07/18, revised on 09/07/22 and has a target date of 10/28/22. In another focus section of the care plan titled bowel/bladder management, initiated on 09/19/19 and revised on 04/10/22, it stated that Resident 9 has bowel incontinence and one intervention/task is provide pericare after each incontinent episode (entered 09/19/19). <BR/>Record review of the most recent quarterly MDS assessment, dated 07/05/22, of Resident #9 Section H - Bladder and Bowel, question H0300 Urinary Continence was marked as a 0, which corresponded to always continent. Question 0400 Bowel Continence was marked as 0, which corresponded to always continent.<BR/>During an interview with the ADON on 09/16/22 at 11:25 AM, she explained the process for creating the MDS. She stated the responsibility rests with the MDS Coordinator, who is relatively new to the position. She stated that some of the diagnoses come from the electronic health record, but that the MDS Coordinator may pull some from the admission paperwork or hospital discharge paperwork. From the MDS that is created, there is a care plan team that meets daily and consists of the DON, Social Worker, MDS Coordinator, Administrator, and each specialty area such as Dietary and Therapies. She stated that the care plan is developed from the active diagnoses, the orders, and from the MDS results. She stated that inaccurate MDS information can lead to improper care plans and improper care plans can lead to improper care for a resident, which would be harmful to that resident. <BR/>During an interview with the MDS Coordinator on 09/16/22 at 11:43 am, I stated I had found errors in the MDS and Care Plans, and I asked what was the process for creating the MDS and Care Plan, and there was a corporate MDS advisor present, as the MDS Coordinator was new. The MDS Coordinator stated that the electronic health record automatically takes the diagnoses entered for the residents and auto populates the MDS worksheets. She stated that there is a team, the interdisciplinary team (IDT) that meets daily and includes MDS Coordinator, DON, ADON, Social Work, Dietary, Therapy, Activities, and the Administrator to discuss issues for each patient that may need to be updated on the MDS or the Care Plan for the resident. She stated that the nurses discuss skin issues and other direct care issues at these meetings. She said the nurses are responsible for most of the resident assessments, the Braden weekly assessment. If there is a significant change the DON or ADON will bring this up and it will get updated in the MDS and then the care plan. She stated that certain care areas in section V they automatically trigger for every resident, such as dehydration, since all are at risk for these issues. She stated they use the worksheets for the MDS to make sure all major diagnoses, medications, falls, hydration, and pacemaker are added the MDS within 7 days and then discussed at the care plan IDT meeting. She stated that inaccuracies or omissions from MDS lead to inaccurate care planning and services for the resident. <BR/>Record review of the facility policy MDS Completion and Submission Timeframes, published in 2001 and revised in July 2017 revealed the following:<BR/> .Assessment Coordinator or designee is responsible for assuring MDS is submitted in required times<BR/> . based on Resident Assessment Instrument Manual<BR/>Record review of the facility policy Goals and Objectives, Care Plans, Published in 2001 and revised in April 2009, revealed the following documentation: <BR/>Policy Statement<BR/>Care Plan shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. <BR/>Policy Interpretation and Implementation<BR/>1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem .<BR/>3. objectives are derived from information in the resident's assessment .<BR/>5. goals and objectives are reviewed and/or revised:<BR/>a.significant change<BR/>b.outcome had not been achieved<BR/>c.readmit from hospital/rehab stay<BR/>d. at least quarterly

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent elopement for 1 of 7 residents who wandered (Resident #60). The facility further failed to ensure that the resident environment remained as free of accident hazards on 2 of 2 Halls (Hall1/Central and Hall2), in that:<BR/>1). The facility failed to adequately supervise Resident #60 to prevent him from eloping from the facility on 8/18/22 and 9/03/22. <BR/>The facility failed to develop and implement interventions to prevent elopement after multiple verbalizations by Resident #60 of wanting to leave the facility which resulted in him eloping.<BR/>2) The facility failed to store chemicals in a safe manner and were left accessible to residents in common areas on 2 of 2 Halls (Hall 1/Central and Hall 2).<BR/>An immediate jeopardy (IJ) was identified on 9/28/22 at 5:25 PM. While the IJ was removed, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy and a scope of pattern.<BR/>These failures related to adequate supervision could place residents at risk for wandering into unsafe environments outside of the facility and sustaining serious injury, harm, impairment or death. Failures related to chemical storage could place residents at risk for chemical injuries. <BR/>The findings include:<BR/>1) Resident #60<BR/>Record review of the face sheet and Order Summary Report for male Resident #60 dated 9/15/22 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnosis of Hypothyroidism, Unspecified, Major Depressive Disorder, Recurrent, Unspecified, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Muscle Weakness (Generalized), Cognitive Communication Deficit, Unsteadiness on Feet, Major Depressive Disorder, Recurrent Severe Without Psychotic Features, and Anxiety Disorder Due to Known Physiological Condition.<BR/>Record review of the admission MDS assessment for Resident #60 dated 8/19/22 revealed that the resident had a BIMS score of 4 , indicating he was cognitively impaired. Further record review of the MDS revealed the resident had a behavior of rejecting care. This behavior occurred every one to three days. The resident was also documented as wandering and this behavior occurred daily. It was further documented that the residents wandering did not place the resident at significant risk of getting to a potentially dangerous place, such as stairs, outside of the facility.<BR/>Record review of the current undated care plan for Resident #60 revealed that there was a Focus titled, The resident is an elopement risk r/t dementia. ***Patient has a (electronic monitoring device) *** *(Electronic monitoring device) checks 3 times each shift. *Staff will round to lay eyes on patient every 1 to 2 hours and as needed. Patient eloped on 08/18/2022* WAS FOUND SAFE AND RETURNED TO BUILDING Date Initiated: 08/10/2022 Revision on: 08/19/2022. The documented Goal for this Focus was documented as follows, The resident's safety will be maintained through the review date. Date Initiated: 08/10/2022 Revision on: 09/07/2022. Target Date: 11/30/2022. o The resident will not leave facility unattended through the review date. Date Initiated: 08/10/2022 Revision on: 09/07/2022 Target Date: 11/30/2022. The Approach for this Focus was documented as, o Assess for fall risk. Date Initiated: 08/10/2022 o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Date Initiated: 08/10/2022 .<BR/>Record review of the Elopement Risk Assessment for Resident #60 conducted on 8/09/22 by LVN D revealed that the resident made statements and or threats to leave the facility and made frequent request to go home. It also documented that the resident had confused expressions related to tasks to complete. It further documented that the resident verbalized anger and frustration related to his placement. The document stated that the resident had restless behavior such as wandering. Additional information listed on the form revealed that the resident did not recognize stoplights and signs, did not know precautions when crossing streets and did not know the location of his current residence. It was further documented that the resident does not recognize all needs but some. Related to physical capacity it documented that the resident ambulates independently or with device. Cognitive skills for daily decision-making were listed as modified independence - some difficulty in new situation only.<BR/>Record review of the Progress Notes (8/10/22 thru 9/03/22) for Resident #60 revealed:<BR/>-On 8/18/22 at 4:45 PM the resident could not be found in the facility. He was found and returned to the facility at 6:37 PM. The nurse on duty was LVN C (agency). The police were called, and facility staff searched for the resident in the facility and surrounding areas. Family and department heads were informed. On his return it was determined he had no injury and an electronic monitoring device was placed on the resident on his return. <BR/>-On 8/28/22 the resident removed his electronic monitoring device and staff placed another one on his ankle. <BR/>-On 8/30/22 the resident's wife discovered his electronic monitoring device amongst the resident's possessions and staff placed another one on the resident's right wrist. <BR/>-On 9/3/22 at 9:15 AM Resident #60 could not be found in the facility again. He was found by family at 11:43 AM and returned to the facility at 12:00 PM. The LVN on duty was LVN D (agency). The police were called, and facility staff searched for the resident in the facility and surrounding areas. Family and department heads were informed. The resident had no injuries. <BR/>-On 9/03/22, 12:00 PM - Upon entrance to facility, door alarm sounded d/t resident being noted to have electronic monitoring device on wrist. How resident got out of facility with electronic monitoring device on is TBD ADON requested Q 30 min checks for a couple areas then hrly (hourly) until further notice . The resident was discharged from the facility on 9/03/22. <BR/>Record review of the Incident-by-Incident Type list for the facility dated 9/13/22 revealed that there was one resident listed as having an elopement incident. The date range for the list was 3/13/22 to 9/13/22. Resident #60 was not listed on this document as eloping from the facility.<BR/>Record review of the MAR/TAR for Resident #60 for August 2022 revealed that the facility started ordered electronic monitoring device checks on 8/11/22 on the night shift. The electronic monitoring device was checked Q shift. On 8/17/22 there was no documentation that the electronic monitoring device was checked on the dayshift. On 8/18/22 it was documented that the resident had his electronic monitoring device on during the day and night shift. On 8/19/22 at 4:00 PM the residents electronic monitoring device monitoring order changed from Q shift to Q4 hours. Further documentation on the TAR revealed that on 8/25/22 there was no documentation that the electronic monitoring device had been checked at (4:00 AM). The resident's electronic monitoring device was documented as being off him on the following dates and times:<BR/>8/28/22 at (8:00 PM)<BR/>8/30/22 at (4:00 PM and 8:00PM)<BR/>8/31/22 at (12:00 AM and 8:00 AM)<BR/>On 8/31/22 there was no documentation of the electronic monitoring device being checked at (4:00 AM). <BR/>Record review of the September 2022 MAR/TAR for Resident #60 revealed an order for electronic monitoring device checks Q4 hours. There was no documentation on 9/1/22 at (4:00 PM) that the electronic monitoring device was checked. Further record review of this MAR/TAR for Resident #60 revealed that the electronic monitoring device documentation for his right ankle and left wrist on 9/2/22 ( 8:00 AM and 12:00 PM) was documented as Other and to see the nurses notes for an explanation. The resident was documented as having the electronic monitoring device on starting 9/02/22 at (4:00 PM) through (12:00 PM) on 9/3/22. The electronic monitoring device checks on 9/03/22 revealed that the resident had his electronic monitoring device on for the 8:00 AM and 12:00 PM checks. <BR/>Record review of the Progress Notes for Resident #60 revealed no documentation as to why there was no on or off electronic monitoring device documentation on 9/2/22 at (8:00 AM) and (12:00 PM).<BR/>On 9/16/22 at 10:11 AM, an interview and record review was conducted with LVN C (agency) regarding Resident #60's wandering and eloping from the facility. He stated the resident was a wanderer but could converse and state his needs. He added that he would hang around at the exit door near room [ROOM NUMBER]. He was definitely a wanderer. Regarding the day the resident eloped, he stated, on 8/18/22 it was a normal day. Dinner was served. LVN C was in the dining room helping out. Staff report to him at approximately 4:45 PM that they could not find the resident. LVN C searched every room, outside and surrounding areas including businesses. He also called local hospital ERs. Family and law enforcement were called, and the resident was located by police at 82nd street and returned at approximately 6:50 PM. Upon the resident's return, he was assessed, and an electronic monitoring device was placed on him. He further stated the resident had a history of asking for scissors to cut off his electronic monitoring device. The LVN stated he was on duty the next day and monitored him closely. He added he double checked him every hour or two for his whereabouts. There were no other interventions to prevent him from eloping. The LVN stated he was told by staff the resident would remove his electronic monitoring device and ask for scissors to cut it off. He added that the resident never asked him for scissors. LVN C was then asked about their procedures related to electronic monitoring devices. He stated he visually checked the electronic monitoring devices and documented it in the MAR. He added that if a resident wanders to the front of the facility, the electronic monitoring device alarms. He added staff used harder zip type ties to keep the electronic monitoring device on once they knew he could take it off. LVN C then checked the electronic incident documentation system to see if an incident report had been developed for the elopements on 8/18/22 and 9/03/22 and found none. LVN C also stated that he contacted the Administrator, DON and ADON about the 8/18/22 elopement but did not contact the physician. He added that it was not OK not to inform the physician. Regarding the missing incident reports, he stated if there is no documentation it is not done. He further stated he was not sure if the facility had an elopement protocol and did not know what the facility elopement protocol was. He stated, I'm just agency. He also added that there was no documentation of his monitoring of the resident every one or two hours. He stated that his monitoring documentation was only in the nurses' notes .<BR/>On 9/16/22 at 11:14 AM, an interview was conducted with the DON. Regarding Resident #60 she stated he was tall, had dementia, confusion, was a wanderer and was admitted from a secure facility . Regarding wandering intervention for the resident, she stated after the first elopement they increased electronic monitoring device checks and checked the room daily. Staff checked every shift and more often. The second time he eloped, staff implemented checks every 2 hours. She added, the last time he eloped, he still had his electronic monitoring device on. Staff did not know if someone let him out. She was unsure how far he was from the facility the first time he eloped. The second time he eloped he was found outside a new restaurant on 82nd street. Regarding their elopement protocol, she stated nurses are to check each room. Some staff checked the parameters. Within an hour we called the police. Regarding any orientation provided to agency nurses prior to assuming duties in the facility, she stated, staff conduct a quick one. Staff familiarize them with the charting system. Contact information is given to them for the DON and ADON. Regarding residents, agency staff know what to do. They are informed of resident tendencies. <BR/>On 9/16/22 at 11:29 AM, an interview was conducted with the Administrator. Regarding elopement protocols, she stated, if residents are not found they look in-house. The administrator is informed, and the administrator informs staff by group text and the department heads look for the resident. She stated the second elopement was handled this same way. Regarding Resident #60 she stated, he was a dementia resident admitted from a secure nursing home. He did not do any wandering there. He was here two weeks and then was found outside. He was gone about 45 minutes . He was not exit seeking. She added that after meals his dementia tells him to go to work. Staff knew to monitor him after meals. He thought he was trying to get to work when he was found at a restaurant on 82nd and Quaker Avenue (Approximately 0.6 miles from the facility). He was found quickly. She believed, the first time he was found on 76th and Salem Avenue (approximately 0.3 miles from the facility). She further stated, both times he was gone an hour or less . The second time was on a Saturday. <BR/>On 9/16/22 at 11:54 AM, an interview was conducted with the Maintenance Supervisor regarding the electronic monitoring device system. He stated there are two doors with the electronic monitoring device system; the front and the dining room that are exits are alarmed. He added he checks the doors weekly on Mondays. During the generator test it deactivates the electronic monitoring device system and the test lasts 30 minutes . He further stated to test the electronic monitoring devices, he uses an electronic monitoring device and goes to the door to check if it alarms. He also stated that he has a resident, with a monitoring device, go by the door and see if it locks. Regarding Resident #60, he stated the resident got out two times. The first time, staff say he cut off the electronic monitoring device. The second time only thing he could think of was the resident went out with a visitor. He added he did not know if anyone heard the electronic monitoring device alarm go off, but staff should have. <BR/>Record review of the facility documentation on Door Alarm checks revealed that weekly checks were made. Between 8/01/22 and 9/12/22 all door alarms were documented as passing and had no issues (8/01/22, 8/08/22, 8/15/22, 8/23/22, 8/29/22, 9/05/22 and 9/12/22).<BR/>On 9/16/22 at 12:45 PM, an interview was conducted with the ADON regarding Resident #60's elopement. Regarding why the incidents happened, she stated, some family may have let him out. He may have been gone out before staff saw him. It's hit and miss who's around the exit door. LVN D told her she did not hear an alarm. Agency staff was at station one. She added that the first elopement he said he was going to work. It was something all staff knew. These were suggestions of what he was thinking. She stated they ensured residents do not elope outside of the facility by conducting hourly checks , frequent checks. She added if staff hear the alarm, they go straight to the door. She further stated there were no documentation of the (hourly) checks. She added, staff make sure they make rounds. She stated, everyone is responsible to ensure that residents do not elope from the facility. She added, she expected that staff are in the building working and others are out searching for any eloped residents. She stated that if residents were not appropriately monitored and eloped, others could elope from the facility. She also stated that there was no paper documentation of the monitoring that they conducted on Resident #60. <BR/>On 9/16/22 at 2:40 PM, an interview was conducted with the Administrator. Regarding Resident #60 elopements she stated, the staff did not think he would leave prior to the first elopement . She added that staff were supposed to monitor the resident after dinner . She also stated that someone may have let him out. She stated caregivers, charge nurse, nursing and administrator were responsible for ensuring that residents do not elope from the facility. She added she expected staff to provide a better monitoring system to prevent elopements. She further stated she made it clear to staff and they should have taken Resident #60 to his room after his meals. She was asked how an elopement could affect residents. She responded by stating that the facility makes sure residents are in a safe environment, experiencing no harm.<BR/>On 9/16/22 at 3:06 PM, an interview was conducted with agency LVN E (agency). She stated she worked in the facility approximately three times a month. She stated that she was not oriented by the facility regarding missing residents and the elopement protocol prior to working in the facility. She stated that she had been oriented at other facilities. She stated if residents elope from the facility they could be in danger, run over, or multiple things happen to them.<BR/>On 9/19/22 at 7:50 PM an interview was conducted with LVN D (agency at the time of elopement). She stated Resident #60, was a roamer and walked all day and night. He was super confused. Sometimes he would layer his clothes wearing seven or eight shirts at a time. All day he would say he was going somewhere. She stated she was not told specifically to take the resident back to his room after meals, but felt it was a given fact. Regarding the 9/03/22 elopement, she stated, it was an hour and a half after breakfast . She had been looking for him for him for something and then discovered he was missing. She added staff started checking and he was not found. Staff did not hear an alarm; no one did. She stated, if the door is held, it should have alarmed. She added that she did not know what exit he may have gotten out of. She stated she did not develop an incident report but documented the incident in the nurse's notes. She stated the incident occurred on her second day at work and she called the family, ADON and DON. She added that family brought the resident back and she assessed him. She was asked what could result from an elopement of a resident. She stated if residents were to elope from the facility they could be hit by a car and be led to do things they should not do. She added that the resident talked well and presented himself well if you were not aware he had dementia . She stated that she had not call the doctor about the incident. She stated when she started working in the facility, nothing special was told to her about Resident #60, but she was made aware that he removed his electronic monitoring device. She added that she placed it back on him a couple of times and that he would pull real hard and could pull it off.<BR/>During an interview conducted on 09/29/2022 at 9:42 AM with the Administrator , she said she did not recall if they had reviewed camera footage once she was notified the facility had been searched, they started searching outside. She said she was out of town during Resident #60's second elopement. She said it was her understanding that both elopements were through the front door of the facility. She was not sure if an alarm went off, she was told Resident #60 was out on the porch outside of the facility, seen by another visitor, then later found at a restaurant. She said the first time Resident #60 eloped; he was found about a block from his house, which she said was in the area of the facility, talking to the neighbors who called the police while they were at the facility with the Administrator. She further stated the electronic monitoring device alarm on the door goes off until the keypad code is entered by staff.<BR/>Observation made on 09/28/2022 at 8:16 AM showed a camera to be in the lobby facing the entrance to the facility.<BR/>Observation made on 09/28/2022 at 8:45 AM showed a camera facing the first nurses' desk nearest the entrance to the facility (Hall1).<BR/>Observation on 09/28/2022 at 8:47 AM showed a camera facing the facility's dining hall and back door entrance.<BR/>Observation made on 09/28/2022 at 8:48 AM showed a camera facing the break room. <BR/>Observation made on 09/28/2022 at 8:50 AM showed a camera facing the south side door at the end of the east hall (Hall 2).<BR/>Observation made on 09/28/2022 at 8:35 AM showed a camera to be facing the north side door at the end of the east hall (Hall 2).<BR/>During an interview conducted on 09/28/2022 at 8:59 AM with the Administrator, she said all the cameras were working. She said the monitors were in the central supply room in the beauty shop. <BR/>During an observation and interview on 9/28/22 at 9:58 AM with the Maintenance Supervisor, he was asked if it would be possible to check camera footage from specific dates. He was not sure if the cameras saved footage. Observation of the central supply closet inside the beauty salon room with the Maintenance Supervisor revealed a monitor could be seen with several viewing panels for all cameras showing no footage being taken currently on any camera as indicated by a blank black screen. Using the search feature found on the monitor, the Maintenance Supervisor typed in the dates in question (08/18/2022, 09/03/2022) and no footage was found. Observation of the cameras in the Dietary Manager's office showed live footage from only the temperature-scanning camera located in the lobby could be seen. He was unable to show footage of the dates in question (08/18/2022, 09/03/2022).<BR/>During an interview conducted on 09/28/2022 at 9:28 AM with the DON. When asked about the cameras and whether they had ever reviewed camera footage after Resident #60's elopements. She said she did not know how to access them and has never reviewed camera footage. <BR/>During an interview conducted on 09/28/2022 at 10:33 AM, the Maintenance Supervisor stated he had spoken with the facility's IT (Information Technology) department and was told the cameras send footage to the Administrator's computer with storage only for the last 30 days. He said the Administrator did not know that though, and he was going to her office next to see if it was set up on her computer. Based on the time frames of stored footage, he was asked to provide footage from 09/03/2022 for the hours leading up to Resident #60's noted absence from the facility at 9:15 AM. <BR/>During an interview conducted on 09/28/2022 at 11:36 AM with the Administrator, she said they had made progress on finding camera footage from 09/03/2022 and said: they are looking at it right now. <BR/>During an interview conducted on 09/28/2022 at 11:37 AM, the ADON was asked if they had found the footage from 09/03/2022 pertaining to Resident #60 and the elopement from 09/03/2022. She said they were still looking.<BR/>Observation made on 09/28/2022 at 11:37 AM showed staff members in the Business Office Manager's office looking at camera footage on the computer. <BR/>During an interview conducted on 09/29/2022 at 10:39 AM with the Business Office Manager concerning footage that she and the ADON had reviewed the previous day, she said they were not able to see any footage of the resident exiting the building. She said they had reviewed footage from all the cameras in the facility yesterday, and that not all doors exiting the facility had a camera facing them that adequately captured the view of the door. <BR/>On 9/28/22 at 9:10 AM, an interview was conducted LVN A. Regarding Resident #60 she stated, she remembered him. Staff were told to basically watch him and keep an eye on him; Every 30 minutes. She had to check his wander guard four times a day because he would take it off. His roommate was Resident #40. Their room was near the nurse's station. Regarding Resident #60's electronic monitoring device removal, she stated she did not know what he cut it off with. She never witnessed the removal. Staff placed a type of zip tie on it to keep it on. The band looked like it was cut when she saw it. She thought he may have got a butter knife to cut it off. She stated she never checked the resident for a knife and she only kind of looked around his room for an item that could have been used to cut it off. She added, he could get aggressive. She stated Resident #60 mostly watched TV. It seemed lunchtime he might get up. Regarding training about elopements and wandering residents she stated, she had not had any since being in the facility, which was approximately 2 months. She stated she learned from other facilities to keep an eye on them. The other places (facilities) staff saw them and where they were. Regarding any documentation of the 30-minute checks that she conducted on wandering residents, she stated she recently started documenting the checks and added that her weak point in nursing was documentation. She further stated, she could not recall staff asking her to document the one- or two-hour checks on Resident #60's whereabouts. Regarding any interventions told to her after the 8/18/22 elopement, she stated, she was told to make sure to keep an eye on him; her and the CNAs. He was always dressed and ready to go. He mainly stayed in his room. She further stated she never had anything to write on the nurse communication sheets about Resident #60. She stated the nurse communication sheets were placed in the box and then given to the ADON.<BR/>Record review of the Nurse Communication Sheets for 8/18/22 and 9/03/22 - 9/04/22 revealed no documentation related to Resident #60.<BR/>On 9/28/22 at 9:45 AM LVN A was interviewed and stated, sometimes Resident #60 ate in his room and she tried to be in the dining room to feed her residents during meals. She added, because he was an elopement risk, she kept her eyes on him. She further stated that no one had told her that Resident #60 needed to be taken to his room after meals.<BR/>On 9/28/22 at 9:53 AM an interview was conducted with CNA I. She stated staff did one-hour checks on Resident #60 and documented it on their POC (CNA electronic resident documentation kiosk). Staff just checked that he had not wandered off and that his electronic monitoring device was on. He was known to take it off. She stated she never figured out how he got it off. He would tear it off. He was strong. Regarding the 8/18/22 elopement, she stated she was the one that noticed he was gone. Staff searched inside and outside. Staff would see him wandering. He walked with Resident #40. She noticed she had not seen him at her hourly check . It was at supper, and she had not seen him. After he returned, staff was instructed to conduct 30-minute checks. They changed where his wander guard was applied. She added, there was no documentation of the 30-minute checks, it was just every day and it continued. She stated, she received training regarding wandering residents and elopement weeks or months ago. She further stated staff were told Resident #60 should go back to his room after meals by LVN A.<BR/>On 9/28/22 at 10:40 AM, an interview was conducted with the DON. Regarding interventions implemented after the elopement on 8/18/22, she stated, electronic monitoring devices were checked frequently, and redirection using activities. The nurse was to report abnormal behaviors. The nurse also made rounds. Staff were rounding different hours for the electronic monitoring devices. On 8/19/22 they checked the wander guard three times and then later every four hours. Regarding interventions for the resident removing his electronic monitoring device, she stated, place a new one on and provide education to the resident which was not very effective. Staff changed the positions of the electronic monitoring device. Staff made sure the electronic monitoring devices was comfortable. The main intervention was rounding every four hours. She stated that she would check him when she saw him. The Resident spent a lot of time in common areas. Regarding how he got the electronic monitoring devices off, she stated there was nothing in his room to remove it. Staff thought he was just pulling it off. The resident made comments about scissors. Staff checked everywhere they could for something he used to take the electronic monitoring devices off. The DON stated she thought it was irritating to him and he pulled it off. Regarding if staff had been instructed to take the resident to his room after meals, she stated, she instructed staff to conduct more rounding. She further stated she did not instruct staff to take Resident #60 back to his room after meals. Regarding in-services or training provided for wandering residents and elopements, she stated, staff were provided verbal education. She added more attention was given to station two since Resident #60 resided there. She stated she talked to LVN D, who was the charge nurse. LVN A and agency staff. She added she started the verbal education when the electronic monitoring device was placed on him. Regarding the screening process to determine if referred residents were appropriate for admission, she stated, they reviewed the referrals with a whole team. If there were unresolved issues with the referral, the DON was responsible for addressing the issues. She stated that she did not see Resident #60 prior to admission. She added that the referrals for admission for Resident #60 were received by the Administrator. The DON stated she ensured the nurses were competent in their skills in caring for residents that wandered by the DON and ADON talking to them. She added staff do rounds and check on the residents. Regarding what type of plan was in place for wanderers, she stated, the facility has electronic monitoring devices and an electronic monitoring device system. It locks the door. Staff check doors weekly. Staff try to provide activities for wanderers. Regarding any type of in-services provided on wanderers and elopement since admitting residents with those issues, she stated, staff were provided a lot of verbal instruction. The most recent documented in-service was 6/16/22. She stated, she did not think the facility was secure enough for Resident #60. She added that the facility was secure to a certain extent. <BR/>On 9/28/22 at 11:24 AM an interview was conducted with the DON regarding why there was no incident report done for Resident #60's two elopements. She stated, no incident report was done since staff found him within two hours. She stated she was told that by the Administrator.<BR/>During an interview conducted on 9/28/2022 at 1:47 PM with the DON , she was asked if notification to Resident #60's physician regarding his elopement had been made. She said that notification to the resident's physician would be documented in a progress note in the EMR (Electronic Medication Record). She said she would verify with the ADON as well and ask if there is anywhere else that would be documented. This documentation was never provided. <BR/>During an observation and interview on 9/28/22 at 11:28 AM, CNA I demonstrated where the resident monitoring documentation was located in the POC system for CNAs. The dates range checked was 8/19/22 through 9/03/22. There was no documentation in this system of hourly monitoring checks. At this time CNA I stated, she guessed their instructions to monitor were just verbal. Staff were verbally told to do it. She confirmed that there was no documentation on any of those days that one hour or 30 minutes or any resident checks were conducted for Resident #60. The only documentation that she found was on 9/02/22. There was a note that stated, walk with supervision. <BR/>On 9/28/22 at 11:45 AM an interview was conducted with the Administrator. Regarding monitoring documentation, she stated, staff would not be documenting unless he was one-on-one supervision or mandated. She stated, It was just known, especially after meals, that he wandered. There was nothing written. Regarding any viewing of the cameras footage for Resident #60's elopements. She stated, they cannot find anything on camera so far. Regarding in-services offered on wanderers and elopement, she [TRUNCATED]

Based on interview and record review the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen.<BR/>The facility failed to designate a person to serve as the Dietary Manager who met the required qualifications. The facility designated Dietary Manager had not completed the state dietary managers course or had any other qualifying credentials.<BR/>This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met.<BR/>The findings include:<BR/>Record review of the personnel file for the Dietary Manager revealed she had a date of hire of 4/02/18 and there was no documentation of completion of the state required dietary managers course or documentation which indicated she met any of the other qualifying education levels/credentials ( certified dietary manager: certified food service manager: has similar national certification for food service management and safety from a national certifying body; has an associates or a higher degree in food service management or in hospitality, if the core study includes food service or restaurant management, from an accredited institution of higher learning; and in states that have establish standards for food service managers or dietary managers, meets state requirements for food service managers or dietary managers).<BR/>Record review of the facility's Dietician documentation revealed that the Dietician was contract and not full-time.<BR/>Record review of the Food Handler Certificate of Completion for the Dietary Manager revealed that it was issued on 6/13/22 and was valid through 6/13/24.<BR/>On 9/13/22 at 10:26 AM, the Dietary Manager was interviewed regarding her qualifications. She stated, she had been promoted to Dietary Manager in June 2022. She stated that she had recently enrolled in the required Dietary Manager courses yesterday.<BR/>Record review of facility Rates of Pay documentation for the Dietary Manager revealed that she was promoted to Dietary Supervisor on 6/8/22.<BR/>Record review of the document titled Food Handler Card Online, Order Confirmation revealed that the Dietary Manager was enrolled in the Texas Certified Food Manager Training Program and Texas Certified Food Managers Exam on 9/16/22.<BR/>On 9/15/22 at 4:01 PM an interview was conducted with the Administrator regarding the Dietary Manager not being qualified. She stated she was appointed to the position of Dietary Manager prior to the Administrator taking her position in the facility. She stated residents could be affected by this situation because the Dietary Manager would not have the proper education tools to do her job. <BR/>Record review of facility provided documentation titled F tag Help - F801 Qualified Dietary Staff dated 9/16/22 revealed the following documentation, . Staffing. If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the Director of food and nutrition services who is a <BR/>a. Certified dietary manager, or <BR/>b. Certified food service manager; or <BR/>c. Has similar national certification for food service management and safety from a national certifying body; or <BR/>d. Has an associates or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and<BR/>III. In states that have establish standards for food service managers or dietary managers, meets state requirements for food service managers or dietary managers.

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 6 out of 30 (10/15/23, 10/28/23,10/29/23, 10/31/23, 11/04/23, and 11/05/23) reviewed for RN coverage. <BR/>The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days:<BR/>10/15/23, 10/28/23,10/29/23, 10/31/23, 11/04/23, and 11/05/23<BR/>This failure could place residents at risk for inconsistency in care and services.<BR/>Findings include:<BR/>Record review of the facility's employee roster dated 10/31/23 revealed there were two RNs employed at the facility.<BR/>Record review time sheet for DON dated 11/6/23 revealed no hours worked for 10/15/23, 10/28/23,10/29/23, 10/31/23, 11/04/23, and 11/05/23.<BR/>Record review time sheet for RN A dated 11/6/23 revealed no hours worked for 10/15/23, 10/28/23,10/29/23, 10/31/23, 11/04/23, and 11/05/23. <BR/>During an interview on 11/08/23 at 11:30 AM with the DON she stated she was currently the only RN employed. She stated she works Monday through Friday 08:00 AM to 05:00 PM. She stated they had to let one RN go and then the other RN gave her notice effective immediately. She stated they were advertising for RNs. She stated they do have contracts with agency, but she was not allowed to use for RN only LVN. She stated all request for agency must be approved and the request were usually denied. She stated they want agency out of the building, because they were not invested like the employees are. She stated the difference between and RN and LVN was the RN can do more than an LVN. She stated the RN has the critical thinking piece that LVNs don't have. She stated the potential negative outcome could be if something goes wrong and was missed could cause harm to the resident. She stated the worst-case scenario the resident could die. <BR/>During an interview on 11/08/23 at 11:45 AM with the ADM he stated they currently do not have any RNs except for the DON. He stated they were advertising through corporate but was having a difficult time hiring an RN. He stated they do have contracts with agency but do not use them for RN coverage. He stated the difference between an RN and LVN was the LVN cannot do the same task as the RN. He stated the potential negative outcome could be harm to the resident by not picking up on changes in condition. He stated the RN have stronger assessment skills.<BR/>Record review of the facility policy titled Staffing-RN coverage and licensed coverage, updated revealed the following:<BR/>Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.<BR/>Policy Interpretation and Implementation .<BR/>An RN is available for coverage 8 hours a day 7 days a week.