AVIR AT CORPUS CHRISTI

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain clinical records in accordance with accepted professional standards of practice, that were complete and accurately documented, for one resident (Resident #1) of three residents reviewed for personal inventory log. When Resident #1 was admitted on [DATE], LVN A failed to complete an accurate inventory log for Resident #1's belongings. This failure could jeopardize a resident from having their valuables properly recorded, which in turn could result in a resident's valuables being misplaced and/or not returning home with the correct resident. The findings included: Record review of Resident #1's admission record dated 07/15/2025, revealed Resident #1 was a [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE] and later discharged [DATE] to home with hospice. Resident #1's primary stay was for Respite Hospice. Resident #1 had diagnoses of acute diastolic (congestive) heart failure, and type 2 diabetes (sugar irregularity). Record review of Resident #1's Discharge MDS dated [DATE] revealed Resident #1 had a BIMS score of 4 which meant she had severe cognitive impairment and additionally was independent for ADLs. Record review of Resident #1's Care Plan date initiated 06/15/2025 revealed the resident has an ADL self-care performance deficit. Goal: The resident will maintain current level of function through review date. Interventions: BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. DRESSING: Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self. Record review of the facility provider investigation report date of incident 06/18/2025 revealed On Wednesday 6/18/25 resident [Resident #1] was bathed by [hospice agency] C.N.A. Hospice C.N.A left [facility], later in the day [ADON A] received a phone call from [hospice agency], to inform us that the C.N.A who bathed [Resident #1] verbalized resident [Resident #1]'s gold chain with Crucifix pendant was not on her. [ADON A] and [Social Worker] went to speak to [Resident #1] about the jewelry in question. [Resident #1] verbalized she isn't sure what happened to it. [Social Worker] questioned [Resident #1] if resident recalls anyone taking it off of her or taking it in general. [Resident #1] verbalized No, no one took it off of me. [Social Worker] and [ADON A] looked in the resident room, around [facility] nursing facility and the assisted living side, since resident was noted going over to assisted living area and enjoying spending time there. The jewelry was unable to be located on the day it was noted to be missing. [Resident #1] 's [family member] was informed [facility] nursing staff were unable to locate jewelry, but staff will continue to look for it. At this time there were no allegations of theft and [facility] team members continued to look for jewelry in laundry and throughout the nursing home. During an interview on 07/12/2025 at 3:57PM, LVN A stated she recalled admitting Resident #1 into the facility on [DATE]. LVN A stated she recalled Resident #1 wearing a necklace, alongside a matching purple sweater, pants, and shoe attire. LVN A stated typically when admitting a resident, she would fill out all admission documents which included several types of assessments and a personal inventory log of all belongings. LVN A stated on the day of 06/15/2025 there were multiple residents being admitted and during the commotion of the day, she forgot to complete Resident #1's inventory log. LVN A reiterated she recalled seeing a necklace but could not recall the specific details of what the necklace looked like. LVN A stated although filling out the inventory log was a collaborative effort amongst the clinical staff, all personnel were busy on 06/15/2025 and therefore the inventory log was forgotten. LVN A stated filling out Resident #1's inventory was important, as it aided in ensuring Resident #1's belongings returned with her when she returned home. LVN A stated by not filling out Resident #1's inventory log, it jeopardized accurate monitoring of Resident #1's belongings and furthermore resulted in Resident #1 returning home without her sentimental valuables. LVN A stated she should have filled out Resident #1's inventory log but reiterated that day she had multiple admissions and forgot to complete Resident #1's inventory log. LVN A stated after the incident, she ensured to procedurally conduct the admission process which included filling out residents' inventory log of belongings. During an interview on 07/15/2025 at 5:15PM, the DON stated LVN A should have completed Resident #1's inventory log of personal belongings. The DON stated the importance of filling out an inventory log was to ensure a resident's belongings are itemized and accounted for during the resident's stay. Furthermore, once a resident is discharged the inventory log would ensure that the resident's belongings are all returned accurately. The DON reiterated LVN A should have completed Resident #1's inventory log but was not completed due to LVN A having multiple admissions on 06/15/2025. The DON stated Resident #1's well-being could have been negatively affected as the necklace held sentimental value. The DON stated if LVN A had completed Resident #1's inventory log, potentially, Resident #1's crucifix necklace could have been accurately monitored. The DON stated all clinical nurses were educated on admission requirements upon their hiring orientation. The DON stated the incident regarding Resident #1's crucifix necklace was an isolated event and accident. Record review of the facility's Admissions Checklist (Must be checked off by Documenting Nurse) undated revealed, Inventory Sheet Record review of the facility's Personal Property policy revised August 2022 revealed, 10. The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of 5 residents reviewed for supervision. <BR/>The facility failed to ensure Resident #1 received adequate supervision while Resident #1 was unaccounted for approximately 10 minutes from 9:05 PM to 9:15 PM on 12/13/24 before LVN C found Resident #1 alone in the 100-hall shower room on the floor. Resident #1 sustained an injury to his head from the fall and was taken to a local hospital where he was diagnosed with an acute on chronic intracranial subdural hematoma (occurs when a new, acute bleed happens to a pre-existing chronic subdural hematoma, often triggered by even minor trauma. A subdural hematoma is a collection of blood that accumulates between the brain and the innermost layer of the skull).<BR/>The noncompliance was identified as PNC. The PNC began on 12/13/24 and ended on 12/14/24. The facility had corrected the noncompliance before the investigation began.<BR/>This failure could place residents requiring supervision at risk for injury and accidents with potential for more than minimal harm. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet dated 03/25/25 revealed a [AGE] year-old male with an original admission date of 09/17/21 and a current admission date of 12/18/24. Pertinent diagnoses included abnormalities of gait and mobility and lack of coordination.<BR/>Record review of Resident #1's Quarterly MDS assessment dated [DATE] section C, cognitive patterns, revealed a BIMS score of 5 (Severe Impairment). Section GG, functional abilities, revealed no attempt was made for Resident #1 to walk 10 feet due to medical conditions or safety concerns, but Resident #1 was able use his wheelchair to travel 150 feet with partial assistance (helper does less than half the effort). Section J, health conditions, revealed the resident had not had any falls since admission/entry or reentry or the pior assessment, whichever was more recent. <BR/>Record review of Resident #1's care plan dated 03/24/25 revealed the problem [Resident #1] is at risk for falls and injuries r/t Confusion, Gait/balance problems, Incontinence, and episodes of generalized weakness, poor safety awareness and forgets limitations, does not call for assistance with transfers or use call light, hx of falls initiated on 03/01/23 and revised on 12/16/24. Interventions listed for the problem included:<BR/>-Orthostatic Blood Pressures [drop in blood pressure that occurs when a person stands up from a sitting or lying position] to be taken when resident gets up in AM and again before he does to bed at night initiated on 12/11/24 and revised on 12/16/24.<BR/>-9/11/24 Intervention: assessment, neurological checks, encouraged to utilize call bell, medication review, RP and MD notified initiated on 09/11/24.<BR/>-Anticipate and meet the resident's needs initiated on 03/01/23.<BR/>-Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance initiated on 03/01/23.<BR/>-Ensure that the resident is wearing appropriate footwear or non-skid socks during transfers or mobilizing in w/c initiated on 03/01/23.<BR/>-The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position, personal items within reach initiated on 03/01/23.<BR/>-Toileting program Q 2HRS to aide in prevention of falls[.] Placed in tasks for aides to assist initiated on 12/26/24.<BR/>Record review of Resident #1's order summary revealed an active order titled Toileting program Q 2HRS to aide in prevention of falls[.] Placed in tasks for aides to assist initiated on 12/19/24.<BR/>Record review of the provider investigation report dated 12/20/24 revealed the following report of the incident:<BR/>It was reported on 12/13/24 around 9:15 pm that [Resident #1] was observed in 100 hall shower room about 10 minutes after being seen by [LVN C] while he was making his way to his room. [Resident #1] scheduled shower on the 2-10 [PM shift] but was not getting a shower at the time. Currently being treated for UTI. Resident self propels in wheelchair and self transfers at times. Requires frequent education on call light and assistance with transferring. [Resident #1] sustained laceration to left ear, unable to determine the severity initially due to bleeding. Sent to [local hospital] ER for evaluation. [Resident #1] is there currently under observation. [Resident #1's] room is two doors down from the shower room and we believe he mistook it for the correct door. <BR/>Record review of LVN C's progress note dated 12/13/24 at 9:36 PM revealed the following narrative of the incident:<BR/>[LVN C] observed resident on the floor of 100 hall's common bathroom/shower room laying on his left side with his pants around his ankles, brief intact, no shoes and only wearing socks on. Resident's wheelchair noted beside him facing his back. Resident noted to be alone in 100 hall bathroom. [LVN C] observed blood on the floor of resident's cephalic [head] region. Upon further assessment laceration noted to left ear. Resident stated, I was trying to go to the bathroom. This nurse pulled call light located in bathroom then stood at entrance of 100 hall bathroom doorway and shouted Help for additional assistance. Immediately after [LVN D] and [LVN E] arrived at restroom to assist. [LVN E] initiated 911 call after observing resident's condition. This nurse immediately provided treatment to left ear wound while resident in supine [lying down face upward] position. Dressing noted intact to old skin tear to right and left forearm. During treatment this nurse assessed resident's mental status. Resident noted to be alert and oriented to person, place, and situation. Resident answered questions appropriately. Vitals obtained BP 142/97 HR 76 T 97.4 O2 96% on room air PAIN 0/10. Head to toe assessment completed. Patient continued to deny pain and discomfort to this nurse. EMS arrived at scene at approximately 9:30 PM and took over care. EMS transported resident to [local hospital] ER for further evaluation and treatment. MD notified. DON notified. RP notified. <BR/>Record review of Resident #1's hospital Discharge summary dated [DATE] revealed Resident #1 was diagnosed with an acute on chronic intracranial subdural hematoma while at the local hospital after his fall on 12/13/24. <BR/>Record review of Resident #1's fall risk assessment dated [DATE] revealed Resident #1 was a high risk.<BR/>During an observation at 8:30 AM on 03/25/25, the shower rooms on the 100, 200, and 300 halls were all locked and secured with a number combination lock. <BR/>During an observation at 10:55 PM on 03/25/25, the shower rooms on the 100, 200, and 300 halls were all locked and secured with a number combination lock. <BR/>During an observation of Resident #1's room at 11:00 AM on 03/25/25, Resident #1's room was free from clutter, fall mats were in position by his bedside, his bed was in the low position, and his call light was within reach of his bed.<BR/>In an interview with Resident #1 at 11:07 AM on 03/25/25, Resident #1 stated he remembered falling in December, 2024. Resident #1 stated he tripped, went down, and hit his face while he was walking. Resident #1 was not able to recall any more details about the fall on 12/13/24.<BR/>An interview was attempted with LVN C at 3:06 PM on 03/25/25, but LVN C could not be reached so this state surveyor left a message on her voicemail. <BR/>In an interview with the ADM at 3:59 PM on 03/25/25, the ADM stated he remembered getting a call that the resident fell in the shower room and nobody knew how he got in there. The ADM stated the shower door was supposed to be locked, and that Resident #1 should not have been allowed in the room without an employee present. The ADM stated before Resident #1's fall, they used to have a lock and key mechanism on the shower doors, with the key hanging from a chain by the door. The ADM stated they did not know if Resident #1 used the key to enter the shower room or an employee left the door slightly open on accident. The ADM stated the DOM came up to the facility that evening to change the lock on the 100-hall shower door to a number combination lock. The ADM stated the locks on the shower rooms in the 200 and 300 halls were changed the following day.<BR/>In an interview with LVN E at 5:50 PM on 03/25/25, LVN E stated he was working the night Resident #1 fell in the 100-hall shower room. LVN E stated both LVN C and LVN D arrived at the resident before him, so LVN C told him to go call 911. LVN E stated after he called 911, he started getting paperwork ready for EMS and waited for them by the door to direct them to Resident #1 as fast as possible. LVN E stated he did not know how Resident #1 got in the shower room, but that the shower rooms were supposed to be locked at all times. <BR/>In an interview with the DON at 8:57 AM on 03/26/25, the DON stated LVN C notified her that Resident #1 fell in the shower room on the night it occurred. The DON stated she recommended Resident #1 wear a helmet to protect him from future injuries, but the family did not want him to wear it to protect his dignity. The DON stated the shower room doors were always supposed to be locked and Resident #1 was not supposed to be in a shower room without an employee present. The DON stated she did not know how Resident #1 got in the shower room. The DON stated they provided in-services for all staff on ensuring shower room doors were closed and functioning properly at all times, fall prevention, and abuse/neglect. The DON stated they changed the locks on all shower room doors to require a keypad entry instead of just a lock and key. The DON stated Resident #1 had many fall prevention tasks implemented, which included fall mats, keeping his bed in the low position, toileting program to ask him if he needs to go to the bathroom every 2 hours, medication reviews, encouraging Resident #1 to use his call light, keeping his phone and glasses on a bedside table near him, and a camera in his room for his RP to help keep an eye on him. The DON stated it was important for residents to not enter the shower rooms without staff because a resident could fall in the shower room and not be able to call for help. <BR/>In an interview with the DOT at 9:18 AM on 03/26/25, the DOT stated Resident #1 has not regressed physically due to his fall on 12/13/24. The DOT stated any decline Resident #1 has had since then has been due to his natural disease processes. <BR/>In an interview with the DOM at 9:33 AM on 03/26/25, the DOM stated he was notified of Resident #1's fall on 12/13/24 the night it happened. The DOM stated he came up that night and replaced the lock on the 100-hall shower door. The DOM stated he would have replaced all three shower door locks at that time, but they only had one replacement lock in the facility. The DOM stated he went out to a local department store on the morning of 12/14/24 and bought two more locks to replace the locks on the 200 and 300-hall shower doors. The DOM stated all three shower rooms had a new lock on them before the afternoon of 12/14/24. The DOM stated the old locks required a key, but the key was hung by a chain next to the door. The DOM stated he checked the shower doors daily for functionality and they never failed during the month of December, 2024. <BR/>In an interview with LVN D at 2:14 PM on 03/26/25, LVN D stated he worked the night Resident #1 fell in the 100-hall shower room. LVN D stated he heard LVN C call for help, and by the time he got there another staff member had placed a towel on Resident #1's ear to help with the bleeding. LVN D stated he did not remember much about the incident, but that LVN C was the charge nurse at that time, and she provided most of the care that night to Resident #1. LVN D stated he did not know how Resident #1 got in the shower room and that he should not have been in there on his own. <BR/>This surveyor requested a facility policy from the ADM at 4:00 PM on 03/25/25 regarding proper shower room use and keeping the doors locked, but none was provided. <BR/>In interviews beginning at 11:28 AM on 03/25/25 with staff from multiple shifts, the DON, DOT, DOM, ADM, LVN D, LVN E, LVN F, LVN H, MA G, CNA I, CNA J, CNA K, CNA L, CNA M, and CNA N were able to identify the proper procedures to follow when responding to a witnessed or unwitnessed fall. All staff understood the importance of keeping the shower doors locked and secured and were familiar with proper abuse and neglect policies and procedures. <BR/>Record review and verification of the corrective action implemented by the facility beginning on 12/13/24:<BR/>All staff in-serviced on the following procedures:<BR/>- <BR/>Keeping the shower room doors closed at all times,<BR/>- <BR/>Ensuring shower room doors function properly,<BR/>- <BR/>Fall precautions,<BR/>- <BR/>Abuse/Neglect,<BR/>Verified by observations, record review and interviews with various staff.<BR/>All shower door locks replaced by 12/14/24 to provide additional security verified by interview with the DOM.<BR/>Medication review conducted for Resident #1 to help prevent future falls by 12/18/24 verified by record review and interview with the DON.<BR/>Ordered a soft helmet for Resident #1 to wear throughout the day verified by interview with the DON.<BR/>Instituted bathroom checks every 2 hours for Resident #1 to limit him trying to perform a self-transfer verified by interviews with the DON and various CNAs.<BR/>The noncompliance was identified as PNC. The PNC began on 12/13/24 and ended on 12/14/24. The facility had corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, documenting, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 5 residents (Residents #4, #2, and #3) reviewed for pharmacy services. <BR/>The facility failed to ensure LVN-A signed her MAR when she administered PRN narcotics to Residents #4, #2 and #3.<BR/>The facility failed to ensure LVN-A wasted her PRN narcotic medications with another licensed nurse. <BR/>These failures could place residents at risk for not receiving, or receiving more than intended amount of, PRN narcotic medications.<BR/>Findings included:<BR/>Record review of Resident #4's face sheet dated 03/26/25 revealed a [AGE] year-old female with an admission date of 08/25/2024, and a discharge date of 09/06/24. One of her diagnoses included Systemic Inflammatory Response Syndrome (an exaggerated defense response of the body to a harmful stressor, such as infection, trauma, or inflammation, and can cause intense pain).<BR/>Record review of Resident #4's admission MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. <BR/>Record review of Resident #4's physician orders dated 08/25/24 revealed an order for Hydrocodone-Acetaminophen (a narcotic pain medication) Oral Tablet 5-325 MG for pain.<BR/>Record review of Resident #4's MAR dated September 2024 revealed no signatures for the whole month of September 2024 for Hydrocodone-Acetaminophen 5-325 MG.<BR/>Record review of Resident #4's Controlled Substance Administration Record - Hydrocodone/APAP 5-325 MG dated 08/28/24 revealed the starting count was 30 tablets and the ending count was 18 tablets on 09/05/24 with 1 tablet documented as dropped with no witnessed waste on 09/04/24.<BR/>Record review of Resident #2's face sheet dated 03/26/25 revealed a [AGE] year-old male with an original admission date of 07/29/23, and a current admission date of 03/22/25. Resident #2 had a diagnosis of Pain Unspecified. <BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition.<BR/>Record review of Resident #2's physician orders started on 08/26/24 revealed an order for Hydrocodone-Acetaminophen 5-325 MG for pain. <BR/>Record review of Resident #2's MAR dated September 2024 revealed only two signatures for the whole month of September 2024 for Hydrocodone-Acetaminophen 5-325 MG.<BR/>Record review of Resident #2's Controlled Substance Administration Record - Hydrocodone/APAP 5-325 MG, dated 08/30/24, revealed the starting count was 30 tablets and the ending count was 8 tablets on 09/16/24 with 1 extra tablet pulled but no witnessed waste on 09/01/24.<BR/>Record review of Resident #3's face sheet dated 03/25/25 revealed an [AGE] year-old male with a current admission date of 07/30/24, and a discharge date of 02/07/25. Resident #3 had a diagnosis of Gout (a type of arthritis that includes sudden attacks of severe pain).<BR/>Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 10, indicating moderately impaired cognition.<BR/>Record review of Resident #3's physician orders started on 08/01/24 revealed an order for Hydrocodone-Acetaminophen 7.5-325 MG for pain.<BR/>Record review of Resident #3's MAR dated September 2024 revealed no signatures for the whole month of September 2024 for Hydrocodone-Acetaminophen 5-325 MG.<BR/>Record review of Resident #3's Controlled Substance Administration Record - Hydrocodone/APAP 7.5-325 MG, dated 08/31/24, revealed the starting count was 30 tablets and the ending count was 15 tablets on 09/16/24.<BR/>Interview with LVN-A attempted, but she no longer worked for the facility, and her phone number was disconnected.<BR/>Interview with Resident #4 attempted, but she is no longer living at this facility, and she refused to be interviewed by phone. <BR/>In an interview with the ADON on 03/25/25 at 9:30 AM, she stated she never realized the MAR was not being signed off accordingly because with PRN medications there was really no way to tell if they were signed or any type of alert since they were PRN medications and not scheduled. She denied that there was any sort of check or audit in place during that timeframe in which they were checking the MARs against the narcotic count sheets for signatures or accuracy. She stated she and the DON were trying to be more proactive and aware and follow-up on reviewing the PRN medications at the weekly meetings. She stated this could have been an issue because residents may or may not have been getting any or the appropriate amounts of pain medication, which could ultimately not relieve their pain at all or cause the resident harm if too much pain medication was administered. <BR/>In an interview with Resident #2 on 3/25/25 at 9:40 AM, he stated he remembered the nurse, and she was always nice to him. He stated he did not use much pain medication, but she was always good about bringing him his medication. <BR/>In an interview with the DON on 03/25/25 at 9:50 AM, she stated she was not here during this time frame, so she was not sure if any audits were being completed to verify that the MARs were being signed appropriately and checked or verified against the narcotic count logs, or if medications were being wasted appropriately, but she stated she felt like if there were any systems in place to check, this would not have happened, and it should have been noticed or caught by someone. She stated this could have been an issue because if the MARs were not signed appropriately residents may end up getting inappropriate amounts of pain medication, which could ultimately not relieve their pain at all or cause harm if too much pain medication was administered. She stated she was trying to be more proactive and aware and follow-up on reviewing the PRN medications at the weekly meetings. She also stated she and the facility were currently putting a system into place to perform random audits of the MARs of residents with narcotics and compare to the narcotic logs, as well as compare the MARs and logs to resident interviews.<BR/>In an interview with LVN-B on 3/25/25 at 1:37 PM, she stated she never paid attention to whether things were being signed off on the MARs or narcotic logs by other nurses, and she never paid attention to whether other nurses were wasting medications with or without a witness. She stated they had previously been in-serviced over documentation and passing medications so as to keep the residents safe from harm.<BR/> In an interview with the pharmacy director on 3/25/25 at 3:18 PM, he stated he did an audit around September 17th or 18th 2024 and sent the report to the interim DON at the time. He stated he provided dispensing information, but no further recommendations since there were no red flags or discrepancies with the areas that were observed during their audit. He stated they did an observational reconciliation to make sure there were not any discrepancies in medication counts. He stated they did not audit to check against MARS or nursing narcotic count logs because that was not something they performed in their audits, but they basically just checked to make sure the count was correct and that nothing seemed off, so their audits would not have noticed or recognized unsigned MARS or unsigned wasted narcotic medications.<BR/>In an interview with the Administrator on 3/26/25 at 2:30 PM, he stated he did not know what systems or checks were in place during the time frame between August and October to verify that MARs and narcotic logs were being checked for accuracy, but the DON and ADON had been discussing these areas in their weekly meetings in which they review from the previous Friday to the current Friday to look for any red flags with the residents who were on PRN medications. He stated that he did not understand how these things were missed before, and that could have caused harm to the residents if they had been given incorrect or inaccurate dosages of medications. He was unsure if any in-services since September of 2024 had been conducted regarding verification of signing MARS appropriately and wasting narcotics with another licensed nurse. <BR/>In an interview with the DON on 3/26/25 at 2:35 PM, she stated they had been doing spot checks here and there of MARs and Narcotic logs but not performing any actual audits. She stated during the weekly meetings they review pain, pain medications, and other areas of concern. She also stated she met with the nurses each morning went over any concerns with the residents, but she did not think any in-services since September of 2024 had been conducted regarding verification of signing MARS appropriately and wasting narcotics with another licensed nurse. The DON stated after consulting with her regional nurse, and as of today, she would be putting a system check or audit into place where she would look at three residents with a BIMS of 13 or greater on each hall weekly to ensure they received their PRN pain medication, and that it was signed out appropriately on the narcotic log and MAR.<BR/>Record review of the Controlled Substance Policy, 2001 Med-Pass revised November 2022, revealed 6. Unless otherwise instructed by the director of nursing services, when a resident refuses a dose (or it was not given), or a resident receives a partial dose (or it was not given) the medication was destroyed and may not be returned to the container. 7. Waste and/or disposal of controlled medication were done in the presence of the nurse and a witness who also signs the disposition sheet. <BR/>Record review of the Pharmacy Medication Administration Policy (no date listed on policy) revealed 9.4 Following resident medication administration, facility staff should appropriately document medication administration, dispose of unused medication per facility policy, discard used supplies per facility policy, and clean reusable equipment and supplies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately to the administrator of the facility and to the State Survey Agency, for one (R#1) of 18 residents reviewed for abuse/neglect. <BR/>The facility staff did not report an incident of injury when R#1 was observed bleeding from eyebrow during perineal care. <BR/>This failure could place residents at risk for neglect. <BR/>The findings included:<BR/>Record review of R #1's Face Sheet dated 08/07/2023 documented a [AGE] year-old female resident admitted to the facility on [DATE]. Her diagnoses were: muscle wasting, mobility abnormalities, dysphagia (swallowing difficulty), right knee contracture, and left knee contracture. <BR/>Record review of R#1's Annual Minimum Data Set, dated [DATE] noted the following: Brief interview of mental status summary score of 99- (resident was unable to complete the interview). MDS coded R#1 to need total dependence for toilet use, transfers, and bed mobility. Functional Status: required extensive assistance with two-person physical assist/support for toileting, transfers, and bed mobility, as well as one-person physical assist with eating. <BR/>R#1's Care Plan dated 05/27/2023 is has an ADL self-care performance deficit r/t Impaired balance, contracture BIL hips, knees, hx shoulder dislocation, cognitive impairments. Interventions: Position with pillows for comfort d/t contractures. ROM with adls as tolerated. Bathing/showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Bathing/showering: The resident is totally dependent on 1 staff to provide shower. Bed mobility: The resident requires Total assistance by 1 staff to turn and reposition in bed. Dressing: The resident requires total assist by staff to dress. Eating: The resident requires Total assist by staff to eat. Personal hygiene: The resident requires (total assistance) by 1 staff with personal hygiene and oral care. Skin inspection: The resident requires SKIN inspection (daily with adls Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse. Toilet use: The resident requires (Total assistance) by one staff for toileting. <BR/>Record review of R #1's Nurses Note date 08/03/2023 at 8:30 a.m. documented by LVN B, writer received report during change of shift 08/02/2023 6p-6a that resident had small area of discoloration to Lt eye. Upon assessment of resident, she was observed with discoloration to under Lt eye coming up around eye and small [NAME] to Lt eyebrow. Writer spoke to CNA A morning of 08/03/2023 who stated resident had band aid over eyebrow at start of shift morning 08/02/2023. CNA B also stated it was noted 08/02/2023 at beginning of shift. Writer reported findings to DON morning 08/03/2023.<BR/>Record Review of additional progress notes for R#1's, and assessments on 08/04/2023, had no additional mention of R#1's injuries. <BR/>During an observation and interview on 08/04/2023 at 5:45PM, R#1 was in a wheelchair, sitting at a dining room table, being assisted to eat by staff. R#1 was observed to have dark purple discoloration with light green on the left eye, in the eye-ball socket area. Attempted interview with R#1, but R#1 was non-verbal to the questions asked. <BR/>During an interview on 08/04/02023 at 5:16PM, the Administrator stated injury of unknown origin, especially bruises are reportable injury to state. The administrator stated every morning the ADONs and DON, will discuss events that transpired during the previous 24hr. day before, during their morning clinical meeting. The Administrator stated during the morning meetings, any incident and accidents will also be discussed during the morning clinical meeting. with the 24hrs. The Administrator stated if an event transpired during the weekend, the event will be discussed during Monday morning meeting. The Administrator stated he was not aware of event regarding R#1 and would report the incident to state. The Administrator stated he needed to be notified of any injury small or large, to begin an investigation to determine how the injury happened, not just guess. The Administrator stated he was not made aware of any scratch, or bruise for R#1 from 08/02/2023-08/04/2023. The Administrator stated, had the DON known about R#1's injury, the DON should have begun internal investigation to rule out abuse, and should have instructed managerial staff to continue the investigation, while the DON was off. The Administrator stated no definitive answer as to why the internal investigation had not been done. The Administrator verbalized his dismay for his staff not reporting and investigating R#1's injury. <BR/>During an interview on 08/04/2023 at 6:04pm, ADON A stated any time an unexplainable injury was observed, the charge nurse will notify the DON and fill out incident report. The ADON A stated if there was a large or small bruise or injury of unknown origin, there needs to be an incident report and the physician needs to be notified to attain recommendations. ADON A stated bruises are reportable to state. ADON A stated an investigation will begin by the DON to ensure the safety of resident and to rule out abuse. ADON A stated she was aware of the event with R#1, but does not know what transpired, and was not given directions to continue any investigation regarding R#1's bruise. ADON A stated she did not know if the DON had begun the internal investigation for R#1. ADON A stated the event with R#1 was not discussed at morning meeting on 08/03/2023. ADON A stated if the DON could not definitively state what happened, it should be investigated, and reported to state.<BR/>During an interview on 08/04/2023 at 6:18PM ADON B stated she was in the room on 08/03/2023 at 8:30-8:45AM when the charge nurse notified the DON that she had noticed discoloration on R#1's left eye. ADON B stated, the charge nurse notified the DON, there was no documentation nor progress note on R#1's injury. ADON B stated she heard the charge nurse notify the DON, that LVN A had stated in report that R#1 had some slight red discoloration and upon the charge nurse's observation, there was dark purple bruising to R#1's left eye. ADON B stated the DON told the LVN B that she would investigate the injury and get with LVN A. ADON B stated during the morning meeting on 08/03/2023, the topic of R#1's bruising was not brought up and stated the bruising topic should have been discussed due to the injury's unknown origin. ADON B stated she was not given any direction to continue any internal investigations. ADON B stated both nurses LVN A and charge nurse should have filled out an incident report. ADON B stated she conducted an in-service regarding abuse/neglect and reporting criteria given about a month ago to all clinical staff. The ADON B stated the DON should have followed up on R#1's injury and should have begun an internal investigation to rule out abuse, especially due to not knowing of definitive origin of R#1's injury and should have been reported to state. ADON B stated when she was looking at R#1's electronic medical record , no was not incident report for R#1.<BR/>During an interview on 08/04/2023 at 6:55pm, LVN A stated she went into work on 08/01/2023 6:00AM- 6:00PM, no redness or bruising were observed through her shift. On 08/02/2023 LVN A again went to work from 6:00AM- 6:00PM shift. LVN A stated that she was in R#1's room when two CNAs were getting R#1 up. LVN A stated she was notified while in R#1's room, that R#1 had red discoloration to left eye. LVN A stated she assessed the left eye and observed red discoloration on eye but did not feel a cause for concern. LVN A stated R#1 will at times curl hand near her left eye and utilized her previous experience with R#1 to determine the cause of the red discoloration was R#1 rubbing her left eye. LVN A stated there was no bruising on either of R#1's eyes or nose. LVN A allowed the CNAs to place R#1 in wheelchair and take to the dining area for breakfast and then back to bed. LVN A stated she checked and monitored the red discolored eye area throughout her shift on 08/02/2023 and did not fill out an incident report due to her previous experience with R#1 rubbing her eyes. LVN A stated she did not notify the DON nor Administrator about eye discoloration, due to her previous experience with R#1 self-inflicted red discoloration on left eye by scratching and rubbing eyes. LVN A stated she notified the incoming LVN B on 08/02/2023 at 6:00PM to keep an eye on red eye discoloration. LVN A stated when she left work on 08/02/2023 at 6:00PM R#1's left eye had slight red discoloration but nothing big like a black eye. LVN A stated she felt she acted and advocated appropriately for R#1. LVN A was asked if she witnessed R#1 rubbing and scratching her eye during her shift, to which she replied no and was asked how she then definitively ruled out abuse, given that she did not witness R#1 scratching her eyes, LVN A gave no definitive answer. LVN A stated she was last in-serviced about abuse and neglect early August 2023. <BR/>During an interview on 08/11/2023 at 12:53PM the DON stated the expectation of the facility, when dealing with injuries was for the charge nurse to be notified, and for the charge nurse to assess the resident, file an incident report, notify family, doctor and according to injury will report according to the HHSC Guidelines. The DON stated on Thursday 8/3/2023 around 8:30AM in the morning, the night charge nurse notified the DON that she needed to speak with her. The DON stated the charge nurse told her that R#1 had a bruise to her left eye, and that nobody had done anything about it. The DON stated she had not heard anything about R#1's injury and stated she would investigate. The DON stated the injury was not brought up in morning clinical meeting because no incident report was done, no risk management report/incident report was done, and because she did not know extent of bruise. The DON stated on 08/03/2023 she observed R#1 to which she saw R#1 with light purple discoloration on left eye. The DON stated she interviewed LVN A on 08/03/2023, and was told by LVN A, that R#1 had self-inflicted injury with her hands. The DON stated R#1 had tendency to rub her eyes and rest her hands by face. The DON stated upon interviewing LVN A, LVN A stated she saw red discoloration during her 6:00AM- 6:00PM shift on 08/02/2023 but did not see a cause for concern or need for incident report. The DON stated, on 08/03/2023 she told LVN A to complete an incident report and dismissed because she knew R#1 rubbed her eyes. The DON stated she was off on 08/04/2023. The DON continued by stating she started her investigation on 08/03/2023, and assessed for safety hazards, spoke to all clinical staff, and on 08/05/2023 CNA A stated while she was changing R#1, CNA A observed R#1 rubbing her eye with hand on face, and when she turned R#1 back to supine position a little bit of blood was visualized. The DON stated, the CNA A stated she reported the injury to LVN A, and that LVN A forgot to do an incident report. The DON was asked how she ruled out abuse, the DON stated she did recall discussing R#1's injury in the clinical morning meeting on 08/03/2023 and notified the ADONs to continue the internal investigation while she was off on 08/04/2023. The DON stated she continued her investigation on Saturday 08/05/2023 as well as conducted an in-service regarding documenting/abuse/neglect on the same day. The DON stated has attempted to rectify situation by writing a formal write up for LVN A. <BR/>During an interview on 08/11/2023 at 5:17 PM, CNA A stated on 08/01/2023 she went to R#1's room to perform perineal care on R#1 and when she turned R#1 to her left side, she visualized R#1 scratching her eye with her nails. CNA A stated when she turned R#1 back to supine position, she saw that R#1 had blood on the left eyebrow. The CNA A stated she notified LVN A of R#1's bloody eyebrow while LVN A was in the hallway, to which LVN A went into R#1's room and cleaned up R#1's eyebrow, then instructed CNA A to assist R#1 to wheelchair. The CNA A stated R#1's face just had a little bleeding in eyebrow and that was it. The CNA A stated the DON did not ask about the incident until 08/05/2023. The CNA A stated she attended in-service regarding documenting/abuse/neglect on 08/05/2023. <BR/>Attempted interview with LVN B and was told she was not available for interview. <BR/>Record review of facility's Documenting/Abuse/Neglect dated, 08/04/2023, did not have LVN A in attendance, but did have CNA A in attendance. <BR/>Record review of facility's incident/accident reports on 08/04/2023, no report documented for R#1. <BR/>Record review of facility's Accident and Incident-Investigating and Reporting Policy revised July 2020 stated, <BR/>1. <BR/>The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. <BR/>2. <BR/>The following data, as applicable, shall be included in the Risk Management report;<BR/>a. <BR/>The date and time the accident or incident took place;<BR/>b. <BR/>The nature of the injury/illness (e.g. bruise, fall, nausea, etc.); <BR/>c. <BR/>Where the accident or incident took place;<BR/>d. <BR/>The name(s) of witnesses and their account of the accident or incident<BR/>Record review of facility's Charting and Documentation Policy revised July 2017 stated,<BR/>1. <BR/>All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be report by the facility Administrator, or his/her designee, to the following persons or agencies:<BR/>a. <BR/>The State licensing/certification agency responsible for surveying/licensing the facility;<BR/>2. <BR/>An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:<BR/>a. <BR/>Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or <BR/>b. <BR/>Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a baseline care plan which included the instructions for resident care needed to provide effective and person-centered care was implemented within 48 hours of admission for 1 (Resident #100) of 5 residents reviewed for baseline care plans. The facility did not develop a baseline care plan within 48 hours of admission for Resident #100. This failure could place residents at risk of not receiving person-centered care and/or services to meet their physical and/or psychosocial needs.Findings included: Record review of Resident #100's face sheet, dated 09/02/2025, revealed she was a [AGE] year-old female originally admitted on [DATE], readmitted on [DATE], and discharged on 09/02/2025. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (a lung condition caused by damage to the airways and alveoli, usually from smoking or other irritants), Dyspnea (shortness of breath), and Dependence on Supplemental Oxygen (Oxygen therapy to help people with lung disease). Record review of Resident #100's orders, dated 08/28/2025, revealed orders for ProAir (medication to help patients with lung disease), Albuterol (a medication used to help increase airflow to the lungs), and admission to Hospice. Record review of Resident #100's baseline care plan, initiated 08/28/2025, revealed the baseline care plan had been added to Resident #100's chart, but it had never been completed. Record review of Resident #100's MDS admission assessment dated [DATE] revealed a BIMS score of 12, which revealed moderately impaired cognition and hospice care. In an interview on 09/03/2025 at 2:07 PM, the MDS nurse stated she should have completed the clinical portion of the baseline care plan for Resident #100, and the rest of the IDT should have completed the other sections, but it was obviously overlooked by everyone. She stated care plans never got overlooked, so she was not sure how this one got overlooked. She stated she had opened and dated it because it was in Resident #100's chart, but it was just never completed. In an interview on 09/03/2025 at 4:09 PM, the DON stated she thought the care plan for Resident #100 just got overlooked. She stated the MDS nurse should have put in the clinical portion of the baseline care plan, and the IDT should have filled in the other sections which belonged to them by discipline. She stated Resident #100 was a frequent flyer, and she had been there so many times, and the staff knew her, so she thought her information just got overlooked. In an interview on 09/04/2025 at 8:34 AM, MA-B stated the care plans were used to determine residents' wants, needs, likes, and/or dislikes. She stated she did not put in or update the care plans, and this was completed by the MDS nurse, the ADON, or the DON. In an interview on 09/04/2025 at 9:10 AM, the ADON stated she helped with the care plans when she needed to update something, but it was mostly created and updated by the MDS nurse, as it was their job to work on care plans. She stated she was not sure why the care plan for Resident #100 was never completed, but she thought it just got overlooked because the resident admitted at the end of the week, and Resident #100's care plan must have gotten missed. The ADON stated without a baseline care plan information regarding Resident #100's care could have gotten overlooked or missed. Record review of the facility's Care Planning - Interdisciplinary Team policy, with a revision date of 12/2024, revealed The Interdisciplinary Team was responsible for the development of resident care plans. The IDT includes, but is not limited to: the resident's attending physician, a registered nurse with responsibility for the resident, a licensed vocational nurse with responsibility for the resident, a nursing assistant with responsibility for the resident, a member of the food and nutrition services, to the extent practicable the resident and/or resident's representative, and other staff as appropriate or necessary to meet the needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure dialysis services were provided consistent with professional standards of practice for 1 of 1 resident (Resident #6) reviewed for quality of care. The facility failed to ensure Resident #6 had a physician's order to assess the dialysis shunt or fistula (a dialysis access which allows the removal of waste and extra fluid). The facility failed to monitor Resident #6's dialysis catheter by assessing for the thrill and bruit each shift. These failures could place residents at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #6's face sheet, dated 09/04/2025, revealed a [AGE] year-old male with an admission date on 03/09/2022 and readmission on [DATE]. Pertinent diagnoses included End Stage Renal Disease (when the kidneys no longer adequately filter waste products from the blood), Diabetes Mellitus Type 2 (a group of diseases which affect how the body uses blood sugar), and Dependence on Renal Dialysis (process of removing excess water, solutes, and toxins from the blood when the kidneys can no longer perform those functions naturally). Record review of Resident #6's quarterly MDS assessment, dated 06/20/2025, revealed Resident #6 was understood and was able to understand others. The MDS assessment indicated Resident #6 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment also indicated Resident #6 had a dependence on renal dialysis. Record review of Resident #6's comprehensive care plan, dated 03/25/2025, revealed Resident #6 received dialysis on Mondays, Wednesdays, and Fridays with a goal for Resident #6 to have no signs or symptoms of complications from dialysis through the review date. Interventions of this care plan included no blood pressure or venipuncture (blood draws) on extremity with dialysis access site. Record review of Resident #6's progress note, dated 08/19/2025, revealed Resident #6 had a left AV fistula placed (a procedure which connects an artery to a vein **AV - arteriovenous** to allow for a more durable access point for hemodialysis) and was noted to have sutures and Dermabond (a liquid topical skin adhesive) to the area. Record review of Resident #6's physician orders, dated 03/19/2025, revealed an order for Dialysis weekly on Mondays, Wednesdays, and Fridays. Record review of Resident #6's physician orders, after an interview with both the DON and the ADON, revealed there were new orders initiated today (09/03/2025) to include monitor left AV shunt/fistula for bleeding every shift; no blood pressures or venipuncture on extremity with dialysis site; monitor AV shunt/fistula to left arm for thrill (a palpable vibration felt over the fistula) and bruit (a sound produced by turbulent blood flow) every shift In an interview on 09/02/25 at 1:30 PM LVN-A stated to surveyor there was not an order to assess the shunt, but she knew it was supposed to be assessed. LVN-A stated she had assessed the dialysis shunt for thrill and bruit prior to sending to dialysis on Mondays, Wednesdays and Fridays. She stated she did not chart in the assessment in Resident #6's progress notes but charted it on his paperwork which went with him to dialysis. In an interview on 09/02/25 at 1:35 PM, the ADON stated to the surveyor she could not find an order for the nurses to assess the dialysis shunt, but there should have been. She stated Resident #6 had this shunt/fistula placed on the 8/19/25, which was when the order should have been put in. She stated assessing the shunt was a way to monitor it was working properly and had good blood flow. In an interview on 09/02/25 at 1:38 PM, the DON stated to the surveyor she could not find an order for the nurses to assess the dialysis shunt/fistula, but there should have been. She stated Resident #6 had this shunt/fistula placed on the 8/19/25, and the order should have been put in when the resident had the shunt placed. She stated the shunt/fistula needed to be assessed routinely to make sure it was functioning and working properly and not having complications, and she would obtain that order today. Record review of the facility's Physician Orders Policy, dated 02/2025, revealed The purpose is to establish uniform guidelines in the receiving and recording of physician orders to ensure the resident receives the necessary care and services. Physician orders are essential for the comprehensive care of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 5 residents (Residents #42 and #89) reviewed for pharmacy services. 1. The facility failed to clarify the blood pressure parameters for Resident #42's Midodrine (a medication used to treat hypotension, or low blood pressure) orders started [DATE]. 2. The facility failed to administer Resident #42's and Resident #89's Midodrine per the recommended and prescribed order and blood pressure parameters in August of 2025. These failures could place residents at risk for complications and jeopardize their health and safety. 1. Record review of Resident #42's face sheet, dated [DATE], revealed a [AGE] year-old male with an admission date of [DATE]. Pertinent diagnoses included hypotension (low blood pressure). Record review of Resident #42's admission MDS assessment, dated [DATE], revealed a BIMS score of 15, which revealed intact cognition. The MDS also revealed an active diagnosis of orthostatic hypotension. Record review of Resident #42's physician orders, started [DATE] revealed an order for Midodrine 5 MG, give one tablet by mouth twice per day related to hypotension, no blood pressure parameters listed; a current active order, started [DATE], revealed an order for Midodrine 5 MG, give one tablet by mouth twice per day related to hypotension; Hold for blood pressure greater than 120/60. Record review of Resident #42's care plan, initiated [DATE], revealed a care plan related to hypotension with a goal to remain free of complications through review. Interventions included give medications as ordered. Record review of Resident #42's [DATE] MAR revealed Midodrine 5 MG, give 1 tablet by mouth two times per day related to Hypotension, started [DATE] and stopped [DATE]. Record review further revealed Midodrine was administered during this timeframe with no blood pressure parameters and no blood pressures recorded in the MAR for this medication. Record review of Resident #42's [DATE] MAR revealed Midodrine 5 MG, give 1 tablet by mouth two times per day related to hypotension (this order was used until [DATE]), then changed to Midodrine 5 MG, give one tablet by mouth twice per day related to hypotension, hold for blood pressure greater than 120/60. (this order was started [DATE]). Dates when Midodrine was administered incorrectly included: [DATE] 9:00 AM B/P 122/78 Administered[DATE] 9:00 AM B/P 120/65 Administered[DATE] 9:00 AM B/P 115/65 Administered[DATE] 5:00 PM B/P 109/66 Administered[DATE] 9:00 AM B/P 106/62 Administered[DATE] 9:00 AM B/P 122/62 Administered[DATE] 9:00 AM B/P 117/66 Administered[DATE] 9:00 AM B/P 104/67 Administered[DATE] 9:00 AM B/P 116/70 Administered[DATE] 9:00 AM B/P 111/66 Administered[DATE] 5:00 PM B/P 104/62 Administered[DATE] 5:00 PM B/P 109/62 Administered[DATE] 9:00 AM B/P 116/71 Administered 2. Record review of Resident #89's face sheet, dated [DATE], revealed a [AGE] year-old male admitted [DATE], and readmitted on [DATE]. Pertinent diagnosis included hypotension (low blood pressure). Record review of Resident #89's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 15, which revealed intact cognition. Record review of Resident #89's active physician orders, started [DATE] revealed an order for Midodrine 10 MG plus 2.5 MG equals 12.5 mg by mouth daily related to hypotension; Hold for blood pressure greater than 110/60. Record review of Resident #89's care plan, initiated [DATE], revealed a care plan related to hypotension with a goal to remain free of signs and symptoms of cardiac problems. Interventions included give medications as ordered. Record review of the Consultant Pharmacist's recommendations dated [DATE] revealed Resident #89 had an order for Midodrine which included parameters to hold if blood pressure was greater than 110/60. Per documentation on the eMAR it appears Midodrine was administered several times during June although blood pressure was over 110/60. Record review of the Consultant Pharmacist's recommendations dated [DATE] revealed Resident #89 had an order for Midodrine which includes parameters to hold if blood pressure was greater than 110/60. Per documentation on the eMAR it appears Midodrine was still being administered several times during July although blood pressure was over 110/60. Record review of Resident #89's [DATE] MAR revealed Midodrine 12.5 MG by mouth daily related to hypotension (started [DATE]), then changed to Midodrine 5 MG, give one tablet by mouth twice per day related to hypotension, hold for blood pressure greater than 120/60. (this order was started [DATE]). Dates when Midodrine was administered inaccurately included: [DATE] 6:00 AM B/P 107/63 Administered[DATE] 6:00 AM B/P 115/66 Administered[DATE] 6:00 AM B/P 100/62 Administered[DATE] 6:00 AM B/P 140/80 Administered[DATE] 6:00 AM B/P 146/89 Administered[DATE] 6:00 AM B/P 128/77 Administered[DATE] 6:00 AM B/P 114/80 Administered[DATE] 6:00 AM B/P 105/68 Administered[DATE] 6:00 AM B/P 97/65 Administered[DATE] 6:00 AM B/P 110/67 Administered[DATE] 6:00 AM B/P 108/66 Administered[DATE] 6:00 AM B/P 117/73 Administered[DATE] 6:00 AM B/P 119/58 Administered[DATE] 6:00 AM B/P 100/64 Administered[DATE] 6:00 AM B/P 92/65 Administered[DATE] 6:00 AM B/P 151/72 Administered Record review of Resident #89's [DATE] MAR revealed Midodrine 12.5 MG by mouth daily related to hypotension (started [DATE]), then changed to Midodrine 5 MG, give one tablet by mouth twice per day related to hypotension, hold for blood pressure greater than 120/60. (this order was started [DATE]). Dates when Midodrine was administered inaccurately included: [DATE] 6:00 AM B/P 93/67 Administered[DATE] 6:00 AM B/P 106/76 Administered[DATE] 6:00 AM B/P 108/72 Administered[DATE] 6:00 AM B/P 91/64 Administered[DATE] 6:00 AM B/P 109/67 Administered[DATE] 6:00 AM B/P 109/67 Administered[DATE] 6:00 AM B/P 99/63 Administered[DATE] 6:00 AM B/P 100/68 Administered[DATE] 6:00 AM B/P 97/62 Administered In an interview on [DATE] at 4:09 PM the DON stated the floor nurses typically put in orders in the electronic chart. The DON stated nurses and staff had been in-serviced over blood pressure medications and following blood pressure parameter guidelines. The DON stated if a resident was given a medication to increase blood pressure, and their blood pressure was already elevated, they could have had a stroke and died. In an interview on [DATE] at 8:34 AM, MA-B stated she was not sure why she gave the Midodrine outside of parameters other than she was not paying attention. She stated Midodrine was used to bring the blood pressure up and if it was administered while the blood pressure was already elevated, it could continue to rise and cause the resident dizziness, blurred vision, to pass out, or possibly have a stroke. She also stated the pharmacy consultant had in-serviced the nurses and medication-aides previously regarding the fact they had been administering the Midodrine outside of parameters, and she was not sure why it continued to be given outside of parameters. She stated maybe she just got in a hurry and was not paying attention. In an interview on [DATE] at 9:10 AM, the ADON stated she started an in-service last month with the nurses and medication-aides regarding administering blood pressure medications within parameters after it was discussed with her by the Consultant Pharmacist. The ADON stated Midodrine was used to raise the blood pressure, and if the blood pressure became too elevated a resident could have a stroke. Record review of the facility's policy Administering Medication, revised [DATE], revealed Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with the prescriber's orders. 11. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed.<BR/>There was expired chocolate milk in the refrigerator<BR/>There were dirty dishes on the clean rack<BR/>There were dented and scratched pans<BR/>This failure could place residents at serious risk for complications from food contamination.<BR/>Findings were:<BR/>Observation and initial tour of the kitchen on 04/18/23 at 09:30 AM revealed 8, 1/2 gallons of chocolate milk with expiration dates of 04/17/23 in the refrigerator with 2 other 1/2 gallons of unexpired chocolate milk. There were 4 full trays of dirty dessert cups on the clean rack mixed in with clean dessert cups. There were 4 Teflon-type pans that were badly scratched, flaking, and hanging on the rack of pans. A large colander that was badly dented was also hanging on the rack of pans. There were 8 small; size 4, 3 large; size 1/4-6, and 3 shallows; size 1/3-6 food-holding steam table pans, that were badly dented. <BR/>Observation of the clean rack of dishes on 04/20/23 at 01:40 PM revealed stained and/or scratched plastic glasses, coffee cups, and dessert cups on multiple trays.<BR/>An interview with the COOK on 04/18/23 at 09:45 AM stated the 4 full trays of dirty dessert cups on the clean rack were mixed in with clean dessert cups. The COOK stated the Teflon-type pans, and the large, dented colander were in use. The COOK stated the pans and colander should probably not be used in the state they were in because one of the pans was very rusty. The COOK stated whoever washed the dishes was responsible for checking if the dishes were clean.<BR/>Interview with the DM on 04/18/23 at 09:50 AM stated she had ordered new pans about 3 weeks ago but had not received them because of back-orders. The DM stated the dented and scratched pans should not be used because the Teflon could flake off and get in the food and it might cause cancer. The DM stated the entire kitchen staff was responsible for making sure the dishes were clean.<BR/>An interview with the DM and RD on 04/19/23 at 02:38 PM the RD stated the vendor came in weekly, removed expired goods, and credited the facility. The DM stated the expired chocolate milk was not separated from the unexpired chocolate milk or in any way marked for return. The DM stated expired goods could make residents sick if it was served and consumed by them.<BR/>An interview with the DM on 04/20/23 at 01:45 PM stated she had a whole bunch of new dishes that she had not yet put out. The DM stated the dirty dishes got thrown away whenever staff saw them because they were all adults in the kitchen. The DM stated the dirty dishes on the clean racks would have potentially been used.<BR/>An in-service dated 04/19/23 titled, Milk-Best by Dates, Credit, was provided by the DM on 04/19/23 at 2:55 PM. The in-service reflected the objective of the in-service was: if the milk date was prior to the current best-by date, do not use or throw it away. A vendor will arrive weekly on Thursdays to pick up any items and credit our account.<BR/>A record review of the restaurant supply invoice #CS90270 for 2 full sheet pans, 2 small; size 1/6-4, 3 large; size 1/4-6, and 2 shallows; size1/3-6 food-holding steam table pans, dated 04/18/23, documented a cash sale/customer picked up on 04/18/23. Invoice #219576 dated 04/18/23 for 1, 8-inch, 1, 10 inches, and 1, 12-inch aluminum fry pan, 1 saucepan, 1 large and 1 small colander documented customer picked up on 04/18/23. <BR/>The facility failed to produce a food storage policy.<BR/>8-101.10 Public Health Protection: (B) In enforcing the provisions of this Code, the REGULATORY AUTHORITY shall assess existing facilities or EQUIPMENT that were in use before the effective date of this Code based on the following considerations:<BR/>(1) Whether the facilities or EQUIPMENT are in good repair and capable of being maintained in a sanitary condition; (2) Whether FOOD-CONTACT SURFACES comply with Subpart 4-101; 4-101.11 Characteristics. Materials that are used in the construction of UTENSILS and FOOD CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: (A) Safe; (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. 4-101.18 Nonstick Coatings, Use Limitation. Multiuse KITCHENWARE such as frying pans, griddles, sauce pans, cookie sheets, and waffle bakers that have a perfluorocarbon resin coating shall be used with nonscoring or nonscratching UTENSILS and cleaning aids. Refrigeration prevents food from becoming a hazard by significantly slowing the growth of most microbes. The growth of some bacteria, such as Listeria monocytogenes, is significantly slowed but not stopped by refrigeration. Over a period of time, this and <BR/>similar organisms may increase their risk to public health in ready-to-eat foods. Based on a predictive growth curve modeling program for Listeria monocytogenes, ready-to-eat, time/temperature control for safety food may be kept at 5oC (41oF) a total <BR/>of 7 days. Food which is prepared and held, or prepared, frozen, and thawed must be controlled by date marking to ensure its safety based on the total amount of time it was held at refrigeration temperature, and the opportunity for Listeria monocytogenes to <BR/>multiply, before freezing and after thawing. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date <BR/>References: https://www.fda.gov/media/110822/download

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (Resident #44) of four residents observed for infection control practices during personal care, in that: <BR/>1.) The facility failed to ensure LVN D performed hand hygiene for 20 seconds or greater after wound care for Resident #44.<BR/>This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infection.<BR/>The Findings included:<BR/>Record review of Resident #44's face sheet dated 7/31/24 reflected a [AGE] year-old-male with an original admission date of 12/18/20. Diagnoses included type two diabetes (insufficient insulin production in the body), chronic obstructive pulmonary disease (chronic inflammatory lung diseases that causes obstructed air flow from the lungs), and dementia (general decline in cognitive abilities that affects a person's ability to perform everyday tasks). <BR/>During an observation on 07/31/24 08:21 AM LVN D performed wound care on Resident #44 as ordered. After wound care, LVN D removed her gloves and performed hand hygiene for 15 seconds. <BR/>Record review of Resident #44's MD orders dated 7/2/24 stated:<BR/>Apply Santyl External Ointment 250 UNIT/GM to left lateral (to side) lower leg topically one time a day for arterial ulcer. Clean with normal saline, pat dry with 4x4 gauze (fabric that allows fluids from the wound to be absorbed), apply Santyl (used to treat severe skin ulcers in adults) and moistened Hydrofera Blue (antibacterial foam that promotes healing), cover with dry dressing daily and as needed.<BR/>Record review of Resident #44's care plan with a revision date of 5/7/24 stated: <BR/>Resident #44 was at risk for pain r/t diabetes mellitus, Parkinson's, pressure ulcer, arterial ulcer, diabetic ulcers. <BR/>Interventions included:<BR/>Administer analgesia as per orders. Give half hour before treatments or care as needed prior to wound care.<BR/>-Monitor/record/report to nurse any s/s of non-verbal pain: Changes in breathing<BR/>-Notify physician if interventions are unsuccessful or if current complaint was a significant change from residents past experience of pain.<BR/>-Provide nonpharmacological interventions for pain<BR/>In an interview on 07/31/24 at 08:42 AM LVN D stated it was important to wash hands appropriately as to clean hands and to prevent the spread of infections to residents. LVN D sated she thought she counted to 20 seconds while lathering hands but thought she may have counted too fast. LVN D stated she was nervous and could not remember when the last handwashing in-service was conducted as she usually works nights and could have missed the in-services that were provided. <BR/>In an interview on 07/31/24 10:44 AM the DON sated all staff are expected to wash hands for 20 seconds or greater between glove changes and after removing gloves as it is part of the infection prevention process. The DON stated the wound care nurse should have lathered her hands for the allotted time of 20 seconds or greater. The DON stated by not washing hands as per CDC guidelines it could cause cross contamination and the goal of the facility is to stop the spread of germs and infections. The DON stated he could not recall when the last in-service was, but in-services are done annually and as needed. The DON stated an in-service on hand hygiene was going to be conducted immediately. <BR/>Record review of facility's Handwashing/Hand Hygiene policy dated revised 08/2019 documented: The facility considers hand hygiene the primary means to prevent the spread of infections . <BR/>-Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: <BR/>b. Before and after direct contact with residents<BR/>d. Before performing any non-surgical invasive procedures<BR/>g. Before handling clean or soiled dressings, gauze pads, etc.<BR/>j. After contact with blood or bodily fluids<BR/>k. After handling used dressings, contaminated equipment, etc.<BR/>m. After removing gloves.<BR/>www. cdc.gov guidelines states:<BR/>Washing your hands is easy, and it's one of the most effective ways to prevent the spread of germs. Follow these five steps every time.<BR/>Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap.<BR/>Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails.<BR/>Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for four (Residents #254, #26, #66, #86) of fourteen residents reviewed for call light. <BR/>The facility failed to ensure Residents #254, #26, #66, #86's call lights were within reach. <BR/>This failure could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. <BR/>Findings were:<BR/>1.Record Review of Resident #254's face sheet dated 7/31/2024 indicated she was a [AGE] year-old female admitted on [DATE] with the diagnoses of Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease (a chronic lung disease that causes air flow limitation), Encephalopathy (damage or disease that affects the brain), Muscle Weakness, Chronic Kidney Disease Stage 3 (kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood), and Dementia.<BR/>Record Review of Resident #254's Care Plan revised 7/30/24 revealed Resident #254 was at risk for falls r/t confusion, gait/balance problems. Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Record Review of Resident #254's BIMS assessment dated [DATE] revealed Resident #254's score was 0.0. Resident #254 was severely cognitively impaired. <BR/>During an observation on 07/29/24 at 09:48 AM Resident #254 was lying in bed, alert, with the push button call light cord wrapped on the right side rail towards the back end of the rail. Resident #254 attempted to find and reach her call light using her left arm. Resident #254 stated she could not reach the call light. <BR/>During an interview with LVN A on 07/29/24 at 09:05 AM stated that all staff are responsible for placing the call light within resident's reach. She stated it was important for the residents to have call lights within reach so that they can call them for help. The negative outcome was it keeps the resident from falling out of the bed by being able to call for assistance. The resident may not be feeling well and it may take long to have her needs being met if she cannot reach the call light. <BR/>During an interview with CNA D on 07/29/24 at 09:55 AM, stated she normally checks that the call lights are within the resident's reach every day. She has not done that this morning. She stated when she does her rounds, she checks that the call lights are within reach. <BR/>During an interview with Residents #254's family member, on 07/29/24 at 10:38 AM, stated he stays and visits with Resident #254 from 9am until around 2pm. Then another family member comes and after that another family member. He stated if the resident needs anything, he will call staff for assistance. <BR/>During an interview with CNA E on 07/31/24 at 10:00 AM, stated she was responsible for call lights being within resident's reach. She was assigned the first five rooms. She stated some residents tend to mess with the call lights. She tries not to wrap them too much; she prefers to clip them. She stated that Resident #254 usually has family member with her during the day. CNA E stated that the resident should have the call light within reach in case they need something. She rounds every two hours, but she got behind on her rounds today. The negative outcome of the resident not having the call light within reach is that they can be grasping for air, or may need to be changed, and repositioned but they are not able to call them.<BR/>During an interview with ADON on 07/29/24 at 10:10 AM, stated all staff are responsible for placing the call light within the resident's reach. The negative outcome of resident not having the call light within reach was that a resident can have an emergency or fall. <BR/>During an interview with DON on 07/31/24 at 4:04 PM, stated nurses, CNAs, and department heads do rounds for quality-of-life. They are responsible for placing the call lights within the resident's reach. He stated there is no negative outcome except customer service.<BR/>DON stated the facility has no Policy available for call lights on 7/31/24 at 3:30pm. <BR/>2. Record review of the admission record for Resident #86 reflected Resident #86 was admitted to the facility on [DATE], was an [AGE] year-old male with diagnoses that included Unspecified Dementia (loss of cognitive functioning that interferes with daily life), other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, cognitive communication deficit. <BR/>Record review of Resident #86 Care Plan revised on 05/14/24 noted the resident is at risk for falls r/t impaired balance, cognitive deficits, psychoactive med use, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; and the resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position, personal items within reach)<BR/>Record review of Resident #86's MDS assessment dated [DATE] reflected a BIMS score of 03, indicating severely impaired cognition. Section GG Functional Abilities and Goals stated the resident uses a walker and is independent in sit to stand movement, and setup assistance with walk of 10ft, 50ft and 150ft. <BR/>Observation on 07/29/24 at 09:15 AM revealed Resident #86 was observed in bed, with the call light clipped on the privacy curtain out of reach of the resident. <BR/>Observation on 07/31/24 at 10:09 AM revealed Resident #86 lying in bed asleep with the call light clipped to the bedcover within reach of resident.<BR/>3. Record review of the admission record for Resident #26 reflected Resident #26 was admitted to the facility on [DATE], was a [AGE] year-old male with diagnoses that included Alzheimer's Disease (progressive brain disorder that causes gradual decline in memory, thinking behavior and social skills), lack of coordination, muscle wasting and atrophy (wasting or thinning of muscle mass. It can be caused by disuse of your muscles or neurogenic conditions), Chronic Obstructive Pulmonary Disorder (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and Hemiplegia (one-sided paralysis caused by brain, spinal cord or nerve problems) and Hemiparesis (one-sided muscle weakness caused by brain, spinal cord or nerve problems)following cerebral infarct (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood.) affecting left non-dominant side. <BR/>Record review of Resident #26's Care Plan revised on 07/29/24 noted the resident is at risk for falls or injuries r/t impaired balance, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; and the resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position, personal items within reach)<BR/>Record review of Resident #26's MDS assessment dated [DATE] reflected a BIMS score of 99, indicating the resident was unable to complete the interview. Section GG Functional Abilities and Goals stated the resident is independent in sit to stand movement and is independent in sit to stand movement, and setup assistance with walk of 10ft, 50ft and 150ft. <BR/>Observation on 07/29/24 at 09:17 AM revealed Resident #26 was observed in bed, with the call light wrapped down on the left side rail hinge between the rail and mattress, not within reach of the resident. Resident #26 did not respond or answer when asked about call light.<BR/>Observation on 07/31/24 at 10:10 AM revealed Resident #26 lying in bed with the call light clipped to the bed within reach of resident.<BR/>4. Record review of the admission record for Resident #66 reflected Resident #66 was admitted to the facility on [DATE], was a [AGE] year-old female with diagnoses that included Unspecified Dementia (loss of cognitive functioning that interferes with daily life), other abnormalities of gait and mobility, other lack of coordination, muscle wasting and atrophy, cognitive communication deficit and unspecified mood disorder. <BR/>Record review of Resident #66's Care Plan revised on 04/19/24 noted the resident is at risk for falls r/t gait/balance problems, incontinence, psychoactive med use, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; and the resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position, personal items within reach)<BR/>Record review of Resident #66's MDS assessment dated [DATE] reflected a BIMS score of 03, indicating severely impaired cognition. Section GG Functional Abilities and Goals stated the resident is independent in sit to stand movement and is independent with walk of 10ft, 50ft and 150ft. <BR/>Observation on 07/29/24 at 09:27 AM revealed Resident #66 was observed in bed, with the call light clipped on the privacy curtain out of reach of the resident. Resident #66 did not respond when attempted to interview, she continued to watch television.<BR/>Observation on 07/31/24 at 10:07 AM revealed Resident #66 lying in bed with the call light clipped to the bedcover within reach of resident.<BR/>Interview on 07/31/24 at 10:42 AM LVN F stated call lights should be within reach of residents. If the call light is not within reach, the resident would be unable to ask for help if they need assistance or something such as water, or not feeling well, or they could get out of bed and fall. LVN F sated that CNAs and Nursing staff to include herself and any staff including Administration staff do rounds throughout the day to ensure call lights are within reach during rounds. <BR/>Interview on 07/30/24 at 10:58 AM CNA D stated that resident call lights should be within reach. CNA D stated that a call light is usually placed on a resident's chest or close to their upper body based on the resident's preference, abilities or functional ability . CNA D stated that if a call light was not within reach of the resident and if a resident was in pain or had an accident staff would not know their needs. CNA D stated that in addition to rounds throughout the shift, she completes a general walk through in the mornings as soon as she comes in and spot checks rooms as well to ensure call lights are within reach. <BR/>Interview on 07/30/24 at 03:48 PM DON stated that in-services on call lights and rounds are done at least once a month, with the last in-service done in June or end of May 2024. <BR/>Interview on 07/31/24 at 01:49 PM DON stated that every employee that works with the residents is responsible to ensure that call lights are within reach. DON stated that they do Guardian Angel or Interdisciplinary (IDT) rounds by department heads assigned to specific areas daily before morning meeting, before lunch and at the end of day to check for call light placement and any other issues in the resident rooms. He stated that they had in-serviced all staff over a month ago on call lights and customer service.<BR/>Record review of the facility policy titled Resident Rights provided by DON when asked for Call light or Call light system policy reflected it does not have information pertaining to call light. On 07/31/24 at 09:17 AM DON stated the facility does not have a policy specific for the call lights or call light system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman for two (Resident #82 and Resident 93) of two residents reviewed for transfer and discharge.<BR/>The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #82 was discharged home on 7/25/24.<BR/>The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #93 was discharged to another facility on 5/11/24.<BR/>This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. <BR/>Findings included:<BR/>1. Resident #82<BR/>Record Review of Resident #82's face sheet dated 7/31/2024 indicated she was a [AGE] year-old female admitted on [DATE] with the diagnosis of Cellulitis (a deep infection of the skin caused by bacteria), Muscle Wasting and Atrophy, Muscle Weakness, Type 2 Diabetes Mellitus, Essential Hypertension (high blood pressure), and Morbid Obesity (more than 80 to 100 pounds above their ideal body weight). Reviewed Discharge summary dated [DATE].<BR/>During an interview on 7/30/24 at 4:10pm with SW, stated that Resident #82's discharge was a planned discharge. The facility got a medical provider notice. She got a signed a NOMNC (a notice that indicates when Medicare coverage is about to end). She stated this medical provider sends them these notices for all WellMed patients. It tells her when the residents last day of therapy will be. This information was provided to Resident #82 and the resident's responsible party. She stated they both received a copy of the medical provider NOMNC, and both were made aware of Resident #82 was going to be discharged on 7/25/24. She was not aware that she needed to notify the Ombudsmen. She stated she did not notify Ombudsmen but will from here on out. <BR/>2. Resident #93<BR/>Record review of Resident #93's face sheet dated 7/30/24 reflected a [AGE] year-old male with an original admission date of 5/9/24. Diagnoses included cerebral infarction (type of stroke that occurs when a blood vessel that supplies blood to the brain is blocked) and diabetes type two (insufficient insulin production in the body). There was no discharge notice reviewed. <BR/>In an interview on 07/30/24 at 03:02 PM the SW stated Resident #93 was discharged to another facility due to resident needed to be in a memory care unit since Resident #93 was exit seeking. The SW stated the doctor made the referral for Resident #93 to be discharged to a memory unit. The SW sated a referral was discussed with Resident #93's family and the family agreed to the transfer. The SW stated she was not sure if a written notice was done and provided to Resident #93, Resident #93's responsible party, and local Ombudsman. The SW stated she was responsible for discharge procedures and notifying residents, resident's family, and the local Ombudsman. <BR/>In an interview on 07/31/24 at 09:30 AM the SW stated she felt the discharge process the facility conducted was appropriate due to Resident #93 was being immediately discharged because the family was in agreeance and the facility spoke with the other facility and they accepted Resident #93. The SW She stated Resident #93 was a certain insurance patient and that insurance company sends them the notices and information about transfers. The SW stated after talking with the facility team, they felt they completed the transfer appropriately. The SW stated with every discharge, the family and resident are aware of the discharge and discharge plan wither through a care plan meeting or through a 30-day discharge notice. The SW stated for Resident #93's transfer to another facility, written notice was not given to Resident #93, Resident #93's family, or the local Ombudsman but they were made aware of the transfer. <BR/>Record review of the facility's Transfer or Discharge, Facility-Initiated policy dated October 2022, revealed 3. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

**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, the comprehensive person-centered care plan, and the resident's goals and preferences for 5 of 6 (Resident #12, Resident #7, Resident#254, Resident#396, and Resident #36) residents reviewed for respiratory care.<BR/>1. The facility failed to ensure Resident #12 had the required emergency supplies at bedside including a suction machine, supply of suction catheters, sterile gloves and flush solution on 07/30/2024 at 10:08 AM.<BR/>2.The facility failed to ensure Resident #7's oxygen tubing was connected to the concentrator and the oxygen was administered at the correct setting of 2 liters per minute on Resident #7's oxygen concentrator was set at 3 liters per minute 7/29/24 at 9:05 AM. <BR/>3.The facility failed to ensure Resident #254's had the oxygen sign posted outside his room entrance door on 7/29/24 at 8:40 AM.<BR/>4.The facility failed to ensure Resident #254's oxygen was administered at the correct setting of 2 liters per minute on 7/29/24 at 8:40 AM.<BR/>5.The facility failed to ensure Resident #396's oxygen was administered at the correct setting of 3 liters per minute on 7/29/24 at 9:30 AM.<BR/>6.The facility failed to ensure Resident #36's oxygen was administered at the correct setting of 3 as per physician order and received oxygen at 2.5L/min. <BR/>This failure places residents who receive respiratory care at an increased risk of danger in a respiratory emergency due to a longer response time and at risk of developing respiratory complications, and a decreased quality of care. <BR/>The findings included:<BR/>1.Record review of Resident #12's face sheet dated 07/30/2024 reflected a [AGE] year-old male with an initial admission date of 10/22/2012 and a current admission date of 06/16/2020. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (chronic inflammatory lung disease that makes it difficult to breathe) and Tracheostomy Status.<BR/>Record review of Resident #12's annual MDS assessment section C, cognitive patterns, dated 06/04/2024 reflected a BIMS score of 15 (cognition intact). MDS assessment section O, Special Treatments, Procedures and Programs, reflected tracheostomy care has been performed while a resident of the facility within the last 14 days.<BR/>Record review of Resident #12's order summary report revealed an active order stating Trach care to include changing disposable inner cannula every Tuesday and Saturday (patient will do himself). Inner cannula size #8. Trach tube size 8. Resident does own trach care. Resident #12 had no active orders for emergency respiratory equipment.<BR/>Record review of Resident #12's care plan dated 06/21/2024 revealed there were no interventions mentioning keeping a suction machine, supply of suction catheters, sterile gloves and flush solution available at bedside in the case of a respiratory emergency.<BR/>In an interview with Resident #12 on 07/30/2024 at 10:08 AM, Resident #12 stated that he takes care of his own tracheostomy. Resident #12 stated that the nurses assist him sometimes if he needs help. Resident #12 stated that he did not know if there were emergency supplies in his room incase he developed a respiratory emergency. <BR/>During an observation of Resident #12's room on 07/30/2024 at 10:08 AM, no suction machine, supply of suction catheters, sterile gloves or flush solution could be located.<BR/>In an interview with CNA B on 07/30/2024 at 3:52 PM, CNA B stated that in a respiratory emergency involving a tracheostomy she would make sure the resident's head was elevated and then go and get the nurse to let them know there was an emergency. Afterwards, CNA B stated she would assist the nurse with whatever they needed in caring for the resident.<BR/>In an interview with LVN C on 07/30/2024 at 3:55 PM, LVN C stated that in a respiratory emergency involving a tracheostomy she would assess the air way and use a suction as needed to clear the airway. LVN C stated that Resident #12 handles his self-care for the most part. LVN C stated that Resident #12 is a full-code (medical directive that indicates a patient's wish for life saving measures in case of emergency) so she would bring the crash cart (wheeled container carrying medicine and equipment for use in emergency resuscitations) in as needed. LVN C stated she was unable to locate a suction machine, supply of suction catheters, sterile gloves or flush solution inside Resident #12's room. LVN C stated that she would have had to go get the crash cart during a respiratory emergency for Resident #12 to obtain the necessary supplies. LVN C stated that Resident #12 would receive care much quicker if the emergency supplies were by his bedside. LVN C stated that the nurses taking care of Resident #12 would be responsible for making sure the emergency supplies were in the room. <BR/>During an observation of the crash cart on 7/30/2024 at 4:08 PM, a suction machine, supply of suction catheters, sterile gloves and flush solution were available on the cart. The cart was located at the entrance to the 100 hall, approximately 54 steps away from Resident #12's door.<BR/>In an interview with the DON on 07/31/2024 at 3:15 PM, the DON stated the purpose of keeping emergency equipment by a resident with a tracheostomy is to provide a quick response time to the resident when they are experiencing a respiratory emergency. The DON stated that a resident could have worse outcomes with the emergency equipment not being in the room because it would take longer before emergency care could begin. The DON stated that it was the DON's responsibility to ensure emergency equipment was available in the room. <BR/>2.Record Review of Resident #7's face sheet dated 7/30/2024 indicated she was a [AGE] year old female initially admitted on [DATE], with the diagnoses of Chronic Obstructive Pulmonary disease (a common lung disease causing restrictive airflow and breathing problems), Hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), Hypertension (a condition in which the force of the blood against the artery walls is too high), Hypomagnesemia (an electrolyte disturbance caused by low levels of magnesium in the blood).<BR/>Record Review of Resident #7's comprehensive care plan dated 4/29/24 indicated Resident #7 has oxygen therapy related to ineffective gas exchange Diagnoses Chronic Obstructive Pulmonary D isease (lung disease), OXYGEN SETTINGS: OXYGEN at 2 liters per minute via Nasal cannula every shift for to relieve signs and symptoms of hypoxia related to shortness of breath, Date Initiated: 06/01/2022 and Revision on: 04/19/2023.<BR/>Record Review of Resident #7's significant change Minimum Data Set assessment dated [DATE] indicated she received oxygen therapy while a resident.<BR/>Record Review of Resident #7's July 2024 physician's orders indicated OXYGEN at 2 liters per minute via Nasal cannula every shift for to relieve signs and symptoms of hypoxia related to shortness of breath.<BR/>Observation of Resident #7 on 07/29/24 at 9:05 AM revealed her oxygen tubing was not connected to the concentrator. Resident #7's oxygen concentrator was set at 3 liters per minute. LVN A checked oxygen level before and after connecting tubing. LVN A checked Resident #7's oxygen saturation and received a reading of 88%. After LVN A connected the tubing to the oxygen concentrator, Resident #7's oxygen saturation increased to 91%.<BR/>Observation of Resident #7 on 07/31/24 at 09:44 AM revealed oxygen tubing was connected, oxygen setting was at 2 liters per minute, Resident #7 stated she was doing fine. No respiratory distress noted.<BR/>3.Record Review of Resident #254's face sheet dated 7/31/2024 indicated she was a [AGE] year-old female admitted on [DATE] with the diagnosis of Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease (a chronic lung disease that causes air flow limitation), Encephalopathy (damage or disease that affects the brain), Muscle Weakness, Chronic Kidney Disease Stage 3 (kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood), and Dementia.<BR/>Record Review of Resident #254's physician's orders dated 7/29/24 indicated O2@2L via nasal cannula continuous. To relieve s/s of Hypoxia r/t Chronic Obstructive Pulmonary Disease.<BR/>During an observation on 07/29/24 at 08:40 AM, Resident #254 was lying on a bed and had on a nasal cannula with the oxygen concentrator set at 3 liters per minute. Outside of the bedroom entrance door revealed there was not a sign indicating oxygen in use/no smoking. <BR/>During an interview with LVN A on 07/29/24 at 9:05 AM revealed she was Resident #7's and Resident #254's nurse. She stated she was responsible for checking the oxygen setting on the oxygen concentrator. She stated she usually checked every shift, but she has not checked Resident #7 or Resident #254. She was not aware Resident #7 was not receiving oxygen until told by the surveyor. It is important to check if the tubing was connected to the concentrator because if it was not connected the resident is not receiving oxygen. Resident #7's oxygen setting was at 3 liters per minute and physician order written for 2 liters per minute continuous. LVN A stated a negative outcome can be cyanosis (bluish or grayish color of the skin, nails, lips, or around the eyes), and the resident will not be well oxygenated. LVN A stated that Resident #7's oxygen level was low and that she was going to contact the physician to make them aware about the incident. LVN A stated she cannot recall about respiratory in-service or training. <BR/>4.Record Review of Resident #396's face sheet dated 7/31/2024 indicated she was an [AGE] year old female initially admitted on [DATE], with the diagnoses of Chronic Obstructive Pulmonary disease (a common lung disease causing restrictive airflow and breathing problems), unspecified systolic (congestive) heart failure (a specific type of heart failure that occurs in the heart's left ventricle), Paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow).<BR/>Record review of Resident #396's comprehensive care plan dated 7/25/24 indicated Resident #396 has oxygen therapy related to The resident has Emphysema/Chronic Obstructive Pulmonary Disease OXYGEN at 3 Liters per minute via NASAL CANNULA CONTINUOUS TO RELIEVE Signs and Symptoms OF HYPOXIA Date Initiated: 07/30/2024 Revision on: 07/30/2024<BR/>Record review of Resident #396's July 2024 physician's orders indicated OXYGEN at 3 liters per minute via Nasal cannula every shift continuously for to relieve signs and symptoms of hypoxia related to Chronic Obstructive Pulmonary Disease.<BR/>During an observation of Resident's #396 on 7/29/24 at 9:30am, her oxygen concentrator setting was at 5 Liters per minute via nasal cannula.<BR/>During an observation of Resident #396 on 7/31/24 at 10:08am her oxygen concentrator setting was at 2.5 liters per minute via nasal cannula. LVN B verified setting at 2.5 liters per minute and stated that she had just been in resident's room, and it was at the correct setting. At this time LVN B was observed to adjust the concentrator setting at 3 liters per minute.<BR/>During an interview with LVN B on 7/31/24 at 9:50 AM she stated the nurses are responsible to check oxygen tubing and settings once per shift. She stated she checked them this morning already except for one resident. She makes sure that the tubing was within date, oxygen level was correct and that there was water on concentrator for residents who are on continuous. She reconciled the physician order with the settings. LVN B said the CNAs are their extra eyes and ears so they would tell her if something was wrong with the resident or if the tubing was disconnected. LVN B said in December she had a skill check off on Respiratory care and it included how to use equipment. She said a negative outcome if the setting is low is that a resident can have hypoxia or if too high, LVN B stated the negative outcome will be that residents can be send out to the emergency room for evaluation. Skill check offs for oxygen use were done when she got hired. It was basically showing that they are competent on how to use equipment and check oxygen. LVN B stated the nurses are responsible for the oxygen signage on the outside of the room. If someone does not know the resident, they do not know where to look or how to identify the resident's needs for oxygen and it can cause a fire for example. The oxygen sign was an extra identifier.<BR/>During an interview with the ADON on 07/29/24 at 10:10 AM she stated that all staff are responsible for placing the oxygen sign outside the room. She stated that Resident #254 was previously on isolation. She was then moved, and the sign did not get moved with her. She stated that all staff are responsible for checking the oxygen when they do their rounds. This includes changing the oxygen tubing. <BR/>During an interview with the ADON on 7/31/24 at 09:37 AM she stated the nurses are the ones responsible for checking the settings on the concentrators every shift or periodically. The nurses are responsible to put the orders in the system. The negative outcome was over oxygenation or hypoxia, and the last skills check offs were done last December and they are done annually. The ADON said the nurse was responsible to check if tubing is connected appropriately and if a CNA sees it, they have to let the nurse know. If a resident was not receiving the oxygenation the negative outcome can be respiratory distress. <BR/>During an interview with the DON on 7/31/24 at 4:04 PM he stated the nurses, ADON, staffing educators, and himself are responsible for checking the settings on the concentrators. He stated the managers check oxygen on the hall in the morning before the morning meeting then again at the end of the day. They are checking the tubing, setting, and every week they change filters. DON stated the Tubing is changed on Sundays. Negative outcome of setting not being accurate, not much could happen since a resident can be up to 5 liters per minute and resident can tolerate depending on acuity level . DON stated the facility does skill check offs for oxygen upon hire and annually. <BR/>5.Record review of the admission record for Resident #36 reflected Resident #36 was readmitted to the facility on [DATE], was a [AGE] year-old female with diagnoses that included Chronic respiratory failure, Hypercapnia, chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), iron deficiency anemia(a condition in which blood lacks adequate healthy red blood cells.), sleep apnea(sleep disorder in which breathing repeatedly stops and starts) and other pulmonary embolism without acute cor pulmonale (blood clot that blocks and stops blood flow to an artery in the lung but does not cause sudden enlargement of the right ventricle of the heart) <BR/>Record review of Resident #36's Care Plan with admission date of 07/18/24 and last revised 03/14/24 stated the resident has congestive heart failure, at risk for activity intolerance, edema, fluid overload, OXYGEN SETTINGS: O2 prn as ordered. The care plan also stated the resident has oxygen therapy r/t CHF, ineffective gas exchange, respiratory illness, OXYGEN @3L/min via NC at HS and PRN at bedtime for the relieve[sic] of s&sx of hypoxia r/t SOB. AND as needed for relive[sic] of sign and symptoms of hypoxia. The care plan also noted that the resident has altered respiratory status/difficulty breathing r/t CHF, OXYGEN SETTINGS: O2 as ordered.<BR/>Record review of Resident #36's Quarterly MDS assessment dated [DATE] reflected she has a BIMS score of 15, indicating intact cognition. Section O Special Treatments, Procedures, and Programs: Respiratory Treatments has an X on C1 selecting Oxygen Therapy. <BR/>Record Review of Nurse's Note by LVN F for Resident # 36, dated 07/18/24 stated Resident readmit from [hospital] via [ambulance company] stretcher. Alert x 4. Was admitted pain/SOB and Rt arm pain. Resident states has a Fx Rt arm is wearing a wrapped cast, from voice pain with movement. Has multiple bruising to bi-lat arms/legs abd., yeast under ab and groin area. Remains on routine o2 at 3L per N/C with stats at 98%. Is on 1200 cc flu F/U appt. with cardiologist. Did not receive D/C med list from hospital sent [physician] for now pending fax.<BR/>Observation on 07/29/24 at 09:04 AM revealed Resident #36 was in bed with oxygen via NC at 2.5L/min. <BR/>Interview on 07/30/24 at 02:02 PM with Resident #36, she stated that she has always had oxygen on since return from hospital and prior to going to hospital. It was observed that resident# 36 had oxygen via NC at 2.5L/min. <BR/>Interview on 07/30/24 at 02:02 PM with CNA A, stated she thinks resident #36's oxygen rate is usually at 3L. <BR/>Interview on 07/30/24 at 02:11 PM with LVN B without reviewing chart stated Resident #36 is on oxygen at 3L via NC. When asked for order LVN B could not find an order for oxygen for Resident #36.<BR/>Interview on 07/31/24 at 01:46 PM DON stated that they will conduct rounds frequently and in-services on oxygen rates. DON stated they are getting all staff involved to ensure oxygen rates are as ordered. DON stated they assumed it was already at 3 yesterday. This morning it was adjusted to correct rate during morning rounds . DON stated he was working on a plan of correction to in-service nursing staff by DON and designee on random rounds to ensure accuracy of orders being carried out.<BR/>Record Review of Order Summary and order details on 07/30/24, noted physician order with start date 07/30/24 at 15:41 (3:41pm)Oxygen @ 3 L/pm via NC continuous to relieve s/s of hypoxia r/t COPD was noted in Resident #36's point click care (electronic health record) profile.<BR/>Observation on 07/30/24 at 03:54 PM revealed Resident #36 observed in bed with oxygen via NC still set at 2.5L/min.<BR/>Observation on 07/31/24 at 10:18 AM revealed Resident #36 observed in bed with oxygen via NC at 3L/min.<BR/>Record Review of the facility policy Tracheostomy Care last revised August 2013 stated: A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. <BR/>Record review of the facility's Oxygen Administration policy dated October 2010, revealed Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administrations. Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. General Guidelines: 1. Oxygen therapy is administered by way of an oxygen mask and nasal cannula. b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. Steps in the Procedure: 1.Place an Oxygen in Use sign on the outside of the room entrance door. Close the door. 3.Check the tubing connected to the oxygen cylinder to assure that is free of kinks. <BR/>Record Review of the facility's oxygen administration policy dated October 2010, reflected Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, documenting, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 5 residents (Residents #4, #2, and #3) reviewed for pharmacy services. <BR/>The facility failed to ensure LVN-A signed her MAR when she administered PRN narcotics to Residents #4, #2 and #3.<BR/>The facility failed to ensure LVN-A wasted her PRN narcotic medications with another licensed nurse. <BR/>These failures could place residents at risk for not receiving, or receiving more than intended amount of, PRN narcotic medications.<BR/>Findings included:<BR/>Record review of Resident #4's face sheet dated 03/26/25 revealed a [AGE] year-old female with an admission date of 08/25/2024, and a discharge date of 09/06/24. One of her diagnoses included Systemic Inflammatory Response Syndrome (an exaggerated defense response of the body to a harmful stressor, such as infection, trauma, or inflammation, and can cause intense pain).<BR/>Record review of Resident #4's admission MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. <BR/>Record review of Resident #4's physician orders dated 08/25/24 revealed an order for Hydrocodone-Acetaminophen (a narcotic pain medication) Oral Tablet 5-325 MG for pain.<BR/>Record review of Resident #4's MAR dated September 2024 revealed no signatures for the whole month of September 2024 for Hydrocodone-Acetaminophen 5-325 MG.<BR/>Record review of Resident #4's Controlled Substance Administration Record - Hydrocodone/APAP 5-325 MG dated 08/28/24 revealed the starting count was 30 tablets and the ending count was 18 tablets on 09/05/24 with 1 tablet documented as dropped with no witnessed waste on 09/04/24.<BR/>Record review of Resident #2's face sheet dated 03/26/25 revealed a [AGE] year-old male with an original admission date of 07/29/23, and a current admission date of 03/22/25. Resident #2 had a diagnosis of Pain Unspecified. <BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition.<BR/>Record review of Resident #2's physician orders started on 08/26/24 revealed an order for Hydrocodone-Acetaminophen 5-325 MG for pain. <BR/>Record review of Resident #2's MAR dated September 2024 revealed only two signatures for the whole month of September 2024 for Hydrocodone-Acetaminophen 5-325 MG.<BR/>Record review of Resident #2's Controlled Substance Administration Record - Hydrocodone/APAP 5-325 MG, dated 08/30/24, revealed the starting count was 30 tablets and the ending count was 8 tablets on 09/16/24 with 1 extra tablet pulled but no witnessed waste on 09/01/24.<BR/>Record review of Resident #3's face sheet dated 03/25/25 revealed an [AGE] year-old male with a current admission date of 07/30/24, and a discharge date of 02/07/25. Resident #3 had a diagnosis of Gout (a type of arthritis that includes sudden attacks of severe pain).<BR/>Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 10, indicating moderately impaired cognition.<BR/>Record review of Resident #3's physician orders started on 08/01/24 revealed an order for Hydrocodone-Acetaminophen 7.5-325 MG for pain.<BR/>Record review of Resident #3's MAR dated September 2024 revealed no signatures for the whole month of September 2024 for Hydrocodone-Acetaminophen 5-325 MG.<BR/>Record review of Resident #3's Controlled Substance Administration Record - Hydrocodone/APAP 7.5-325 MG, dated 08/31/24, revealed the starting count was 30 tablets and the ending count was 15 tablets on 09/16/24.<BR/>Interview with LVN-A attempted, but she no longer worked for the facility, and her phone number was disconnected.<BR/>Interview with Resident #4 attempted, but she is no longer living at this facility, and she refused to be interviewed by phone. <BR/>In an interview with the ADON on 03/25/25 at 9:30 AM, she stated she never realized the MAR was not being signed off accordingly because with PRN medications there was really no way to tell if they were signed or any type of alert since they were PRN medications and not scheduled. She denied that there was any sort of check or audit in place during that timeframe in which they were checking the MARs against the narcotic count sheets for signatures or accuracy. She stated she and the DON were trying to be more proactive and aware and follow-up on reviewing the PRN medications at the weekly meetings. She stated this could have been an issue because residents may or may not have been getting any or the appropriate amounts of pain medication, which could ultimately not relieve their pain at all or cause the resident harm if too much pain medication was administered. <BR/>In an interview with Resident #2 on 3/25/25 at 9:40 AM, he stated he remembered the nurse, and she was always nice to him. He stated he did not use much pain medication, but she was always good about bringing him his medication. <BR/>In an interview with the DON on 03/25/25 at 9:50 AM, she stated she was not here during this time frame, so she was not sure if any audits were being completed to verify that the MARs were being signed appropriately and checked or verified against the narcotic count logs, or if medications were being wasted appropriately, but she stated she felt like if there were any systems in place to check, this would not have happened, and it should have been noticed or caught by someone. She stated this could have been an issue because if the MARs were not signed appropriately residents may end up getting inappropriate amounts of pain medication, which could ultimately not relieve their pain at all or cause harm if too much pain medication was administered. She stated she was trying to be more proactive and aware and follow-up on reviewing the PRN medications at the weekly meetings. She also stated she and the facility were currently putting a system into place to perform random audits of the MARs of residents with narcotics and compare to the narcotic logs, as well as compare the MARs and logs to resident interviews.<BR/>In an interview with LVN-B on 3/25/25 at 1:37 PM, she stated she never paid attention to whether things were being signed off on the MARs or narcotic logs by other nurses, and she never paid attention to whether other nurses were wasting medications with or without a witness. She stated they had previously been in-serviced over documentation and passing medications so as to keep the residents safe from harm.<BR/> In an interview with the pharmacy director on 3/25/25 at 3:18 PM, he stated he did an audit around September 17th or 18th 2024 and sent the report to the interim DON at the time. He stated he provided dispensing information, but no further recommendations since there were no red flags or discrepancies with the areas that were observed during their audit. He stated they did an observational reconciliation to make sure there were not any discrepancies in medication counts. He stated they did not audit to check against MARS or nursing narcotic count logs because that was not something they performed in their audits, but they basically just checked to make sure the count was correct and that nothing seemed off, so their audits would not have noticed or recognized unsigned MARS or unsigned wasted narcotic medications.<BR/>In an interview with the Administrator on 3/26/25 at 2:30 PM, he stated he did not know what systems or checks were in place during the time frame between August and October to verify that MARs and narcotic logs were being checked for accuracy, but the DON and ADON had been discussing these areas in their weekly meetings in which they review from the previous Friday to the current Friday to look for any red flags with the residents who were on PRN medications. He stated that he did not understand how these things were missed before, and that could have caused harm to the residents if they had been given incorrect or inaccurate dosages of medications. He was unsure if any in-services since September of 2024 had been conducted regarding verification of signing MARS appropriately and wasting narcotics with another licensed nurse. <BR/>In an interview with the DON on 3/26/25 at 2:35 PM, she stated they had been doing spot checks here and there of MARs and Narcotic logs but not performing any actual audits. She stated during the weekly meetings they review pain, pain medications, and other areas of concern. She also stated she met with the nurses each morning went over any concerns with the residents, but she did not think any in-services since September of 2024 had been conducted regarding verification of signing MARS appropriately and wasting narcotics with another licensed nurse. The DON stated after consulting with her regional nurse, and as of today, she would be putting a system check or audit into place where she would look at three residents with a BIMS of 13 or greater on each hall weekly to ensure they received their PRN pain medication, and that it was signed out appropriately on the narcotic log and MAR.<BR/>Record review of the Controlled Substance Policy, 2001 Med-Pass revised November 2022, revealed 6. Unless otherwise instructed by the director of nursing services, when a resident refuses a dose (or it was not given), or a resident receives a partial dose (or it was not given) the medication was destroyed and may not be returned to the container. 7. Waste and/or disposal of controlled medication were done in the presence of the nurse and a witness who also signs the disposition sheet. <BR/>Record review of the Pharmacy Medication Administration Policy (no date listed on policy) revealed 9.4 Following resident medication administration, facility staff should appropriately document medication administration, dispose of unused medication per facility policy, discard used supplies per facility policy, and clean reusable equipment and supplies.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed.<BR/>There was expired chocolate milk in the refrigerator<BR/>There were dirty dishes on the clean rack<BR/>There were dented and scratched pans<BR/>This failure could place residents at serious risk for complications from food contamination.<BR/>Findings were:<BR/>Observation and initial tour of the kitchen on 04/18/23 at 09:30 AM revealed 8, 1/2 gallons of chocolate milk with expiration dates of 04/17/23 in the refrigerator with 2 other 1/2 gallons of unexpired chocolate milk. There were 4 full trays of dirty dessert cups on the clean rack mixed in with clean dessert cups. There were 4 Teflon-type pans that were badly scratched, flaking, and hanging on the rack of pans. A large colander that was badly dented was also hanging on the rack of pans. There were 8 small; size 4, 3 large; size 1/4-6, and 3 shallows; size 1/3-6 food-holding steam table pans, that were badly dented. <BR/>Observation of the clean rack of dishes on 04/20/23 at 01:40 PM revealed stained and/or scratched plastic glasses, coffee cups, and dessert cups on multiple trays.<BR/>An interview with the COOK on 04/18/23 at 09:45 AM stated the 4 full trays of dirty dessert cups on the clean rack were mixed in with clean dessert cups. The COOK stated the Teflon-type pans, and the large, dented colander were in use. The COOK stated the pans and colander should probably not be used in the state they were in because one of the pans was very rusty. The COOK stated whoever washed the dishes was responsible for checking if the dishes were clean.<BR/>Interview with the DM on 04/18/23 at 09:50 AM stated she had ordered new pans about 3 weeks ago but had not received them because of back-orders. The DM stated the dented and scratched pans should not be used because the Teflon could flake off and get in the food and it might cause cancer. The DM stated the entire kitchen staff was responsible for making sure the dishes were clean.<BR/>An interview with the DM and RD on 04/19/23 at 02:38 PM the RD stated the vendor came in weekly, removed expired goods, and credited the facility. The DM stated the expired chocolate milk was not separated from the unexpired chocolate milk or in any way marked for return. The DM stated expired goods could make residents sick if it was served and consumed by them.<BR/>An interview with the DM on 04/20/23 at 01:45 PM stated she had a whole bunch of new dishes that she had not yet put out. The DM stated the dirty dishes got thrown away whenever staff saw them because they were all adults in the kitchen. The DM stated the dirty dishes on the clean racks would have potentially been used.<BR/>An in-service dated 04/19/23 titled, Milk-Best by Dates, Credit, was provided by the DM on 04/19/23 at 2:55 PM. The in-service reflected the objective of the in-service was: if the milk date was prior to the current best-by date, do not use or throw it away. A vendor will arrive weekly on Thursdays to pick up any items and credit our account.<BR/>A record review of the restaurant supply invoice #CS90270 for 2 full sheet pans, 2 small; size 1/6-4, 3 large; size 1/4-6, and 2 shallows; size1/3-6 food-holding steam table pans, dated 04/18/23, documented a cash sale/customer picked up on 04/18/23. Invoice #219576 dated 04/18/23 for 1, 8-inch, 1, 10 inches, and 1, 12-inch aluminum fry pan, 1 saucepan, 1 large and 1 small colander documented customer picked up on 04/18/23. <BR/>The facility failed to produce a food storage policy.<BR/>8-101.10 Public Health Protection: (B) In enforcing the provisions of this Code, the REGULATORY AUTHORITY shall assess existing facilities or EQUIPMENT that were in use before the effective date of this Code based on the following considerations:<BR/>(1) Whether the facilities or EQUIPMENT are in good repair and capable of being maintained in a sanitary condition; (2) Whether FOOD-CONTACT SURFACES comply with Subpart 4-101; 4-101.11 Characteristics. Materials that are used in the construction of UTENSILS and FOOD CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: (A) Safe; (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. 4-101.18 Nonstick Coatings, Use Limitation. Multiuse KITCHENWARE such as frying pans, griddles, sauce pans, cookie sheets, and waffle bakers that have a perfluorocarbon resin coating shall be used with nonscoring or nonscratching UTENSILS and cleaning aids. Refrigeration prevents food from becoming a hazard by significantly slowing the growth of most microbes. The growth of some bacteria, such as Listeria monocytogenes, is significantly slowed but not stopped by refrigeration. Over a period of time, this and <BR/>similar organisms may increase their risk to public health in ready-to-eat foods. Based on a predictive growth curve modeling program for Listeria monocytogenes, ready-to-eat, time/temperature control for safety food may be kept at 5oC (41oF) a total <BR/>of 7 days. Food which is prepared and held, or prepared, frozen, and thawed must be controlled by date marking to ensure its safety based on the total amount of time it was held at refrigeration temperature, and the opportunity for Listeria monocytogenes to <BR/>multiply, before freezing and after thawing. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date <BR/>References: https://www.fda.gov/media/110822/download

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain clinical records in accordance with accepted professional standards of practice, that were complete and accurately documented, for one resident (Resident #1) of three residents reviewed for personal inventory log. When Resident #1 was admitted on [DATE], LVN A failed to complete an accurate inventory log for Resident #1's belongings. This failure could jeopardize a resident from having their valuables properly recorded, which in turn could result in a resident's valuables being misplaced and/or not returning home with the correct resident. The findings included: Record review of Resident #1's admission record dated 07/15/2025, revealed Resident #1 was a [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE] and later discharged [DATE] to home with hospice. Resident #1's primary stay was for Respite Hospice. Resident #1 had diagnoses of acute diastolic (congestive) heart failure, and type 2 diabetes (sugar irregularity). Record review of Resident #1's Discharge MDS dated [DATE] revealed Resident #1 had a BIMS score of 4 which meant she had severe cognitive impairment and additionally was independent for ADLs. Record review of Resident #1's Care Plan date initiated 06/15/2025 revealed the resident has an ADL self-care performance deficit. Goal: The resident will maintain current level of function through review date. Interventions: BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. DRESSING: Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self. Record review of the facility provider investigation report date of incident 06/18/2025 revealed On Wednesday 6/18/25 resident [Resident #1] was bathed by [hospice agency] C.N.A. Hospice C.N.A left [facility], later in the day [ADON A] received a phone call from [hospice agency], to inform us that the C.N.A who bathed [Resident #1] verbalized resident [Resident #1]'s gold chain with Crucifix pendant was not on her. [ADON A] and [Social Worker] went to speak to [Resident #1] about the jewelry in question. [Resident #1] verbalized she isn't sure what happened to it. [Social Worker] questioned [Resident #1] if resident recalls anyone taking it off of her or taking it in general. [Resident #1] verbalized No, no one took it off of me. [Social Worker] and [ADON A] looked in the resident room, around [facility] nursing facility and the assisted living side, since resident was noted going over to assisted living area and enjoying spending time there. The jewelry was unable to be located on the day it was noted to be missing. [Resident #1] 's [family member] was informed [facility] nursing staff were unable to locate jewelry, but staff will continue to look for it. At this time there were no allegations of theft and [facility] team members continued to look for jewelry in laundry and throughout the nursing home. During an interview on 07/12/2025 at 3:57PM, LVN A stated she recalled admitting Resident #1 into the facility on [DATE]. LVN A stated she recalled Resident #1 wearing a necklace, alongside a matching purple sweater, pants, and shoe attire. LVN A stated typically when admitting a resident, she would fill out all admission documents which included several types of assessments and a personal inventory log of all belongings. LVN A stated on the day of 06/15/2025 there were multiple residents being admitted and during the commotion of the day, she forgot to complete Resident #1's inventory log. LVN A reiterated she recalled seeing a necklace but could not recall the specific details of what the necklace looked like. LVN A stated although filling out the inventory log was a collaborative effort amongst the clinical staff, all personnel were busy on 06/15/2025 and therefore the inventory log was forgotten. LVN A stated filling out Resident #1's inventory was important, as it aided in ensuring Resident #1's belongings returned with her when she returned home. LVN A stated by not filling out Resident #1's inventory log, it jeopardized accurate monitoring of Resident #1's belongings and furthermore resulted in Resident #1 returning home without her sentimental valuables. LVN A stated she should have filled out Resident #1's inventory log but reiterated that day she had multiple admissions and forgot to complete Resident #1's inventory log. LVN A stated after the incident, she ensured to procedurally conduct the admission process which included filling out residents' inventory log of belongings. During an interview on 07/15/2025 at 5:15PM, the DON stated LVN A should have completed Resident #1's inventory log of personal belongings. The DON stated the importance of filling out an inventory log was to ensure a resident's belongings are itemized and accounted for during the resident's stay. Furthermore, once a resident is discharged the inventory log would ensure that the resident's belongings are all returned accurately. The DON reiterated LVN A should have completed Resident #1's inventory log but was not completed due to LVN A having multiple admissions on 06/15/2025. The DON stated Resident #1's well-being could have been negatively affected as the necklace held sentimental value. The DON stated if LVN A had completed Resident #1's inventory log, potentially, Resident #1's crucifix necklace could have been accurately monitored. The DON stated all clinical nurses were educated on admission requirements upon their hiring orientation. The DON stated the incident regarding Resident #1's crucifix necklace was an isolated event and accident. Record review of the facility's Admissions Checklist (Must be checked off by Documenting Nurse) undated revealed, Inventory Sheet Record review of the facility's Personal Property policy revised August 2022 revealed, 10. The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one Resident (Resident #44) of four residents observed for infection control practices during personal care, in that: <BR/>1.) The facility failed to ensure LVN D performed hand hygiene for 20 seconds or greater after wound care for Resident #44.<BR/>This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infection.<BR/>The Findings included:<BR/>Record review of Resident #44's face sheet dated 7/31/24 reflected a [AGE] year-old-male with an original admission date of 12/18/20. Diagnoses included type two diabetes (insufficient insulin production in the body), chronic obstructive pulmonary disease (chronic inflammatory lung diseases that causes obstructed air flow from the lungs), and dementia (general decline in cognitive abilities that affects a person's ability to perform everyday tasks). <BR/>During an observation on 07/31/24 08:21 AM LVN D performed wound care on Resident #44 as ordered. After wound care, LVN D removed her gloves and performed hand hygiene for 15 seconds. <BR/>Record review of Resident #44's MD orders dated 7/2/24 stated:<BR/>Apply Santyl External Ointment 250 UNIT/GM to left lateral (to side) lower leg topically one time a day for arterial ulcer. Clean with normal saline, pat dry with 4x4 gauze (fabric that allows fluids from the wound to be absorbed), apply Santyl (used to treat severe skin ulcers in adults) and moistened Hydrofera Blue (antibacterial foam that promotes healing), cover with dry dressing daily and as needed.<BR/>Record review of Resident #44's care plan with a revision date of 5/7/24 stated: <BR/>Resident #44 was at risk for pain r/t diabetes mellitus, Parkinson's, pressure ulcer, arterial ulcer, diabetic ulcers. <BR/>Interventions included:<BR/>Administer analgesia as per orders. Give half hour before treatments or care as needed prior to wound care.<BR/>-Monitor/record/report to nurse any s/s of non-verbal pain: Changes in breathing<BR/>-Notify physician if interventions are unsuccessful or if current complaint was a significant change from residents past experience of pain.<BR/>-Provide nonpharmacological interventions for pain<BR/>In an interview on 07/31/24 at 08:42 AM LVN D stated it was important to wash hands appropriately as to clean hands and to prevent the spread of infections to residents. LVN D sated she thought she counted to 20 seconds while lathering hands but thought she may have counted too fast. LVN D stated she was nervous and could not remember when the last handwashing in-service was conducted as she usually works nights and could have missed the in-services that were provided. <BR/>In an interview on 07/31/24 10:44 AM the DON sated all staff are expected to wash hands for 20 seconds or greater between glove changes and after removing gloves as it is part of the infection prevention process. The DON stated the wound care nurse should have lathered her hands for the allotted time of 20 seconds or greater. The DON stated by not washing hands as per CDC guidelines it could cause cross contamination and the goal of the facility is to stop the spread of germs and infections. The DON stated he could not recall when the last in-service was, but in-services are done annually and as needed. The DON stated an in-service on hand hygiene was going to be conducted immediately. <BR/>Record review of facility's Handwashing/Hand Hygiene policy dated revised 08/2019 documented: The facility considers hand hygiene the primary means to prevent the spread of infections . <BR/>-Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: <BR/>b. Before and after direct contact with residents<BR/>d. Before performing any non-surgical invasive procedures<BR/>g. Before handling clean or soiled dressings, gauze pads, etc.<BR/>j. After contact with blood or bodily fluids<BR/>k. After handling used dressings, contaminated equipment, etc.<BR/>m. After removing gloves.<BR/>www. cdc.gov guidelines states:<BR/>Washing your hands is easy, and it's one of the most effective ways to prevent the spread of germs. Follow these five steps every time.<BR/>Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap.<BR/>Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails.<BR/>Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 3 halls (Hall 200) reviewed for environment.<BR/>1) The facility failed to keep the soiled linen utility closet containing dirty linens locked when not in use.<BR/>2) The facility failed to keep the oxygen storage room containing empty and full oxygen canisters locked when not in use.<BR/>3) the facility failed to keep the central supply storage room containing approximately 40 individual shaving razors locked when not in use. <BR/>These failures could result in injury for residents who come into contact with sharp implements or hazardous materials.<BR/>The findings included:<BR/>During an observation on 07/29/2024 at 10:53 AM, the soiled linen utility closet on hall 200 across from resident room [ROOM NUMBER] was noted to be partially ajar. The sign on the door read Authorized Personnel Only. Inside the room was soiled linens and trash.<BR/>During an observation on 07/29/2024 at 3:03 PM, the oxygen storage room and central supply storage rooms at the end of hall 200 were unlocked. The signs on the oxygen storage room read Danger Flammable Gas and Danger Gas Cylinder Storage Area. Inside the oxygen storage room were approximately 50 oxygen canisters in racks. Half of them were in the section labeled O2 full and the other half were in the section labeled O2 empty. The door to central supply storage room had a locking mechanism with buttons for input, but the door could be opened without inputting any combination. Inside the central supply storage room were various hygiene supplies, including approximately 40 individual shaving razors in a basket on a shelf.<BR/>In an interview with CNA C on 07/31/2024 at 2:29 PM, CNA C stated that the locking mechanism on the door to the central supply storage room stopped working about a year ago. CNA C stated that she was not certain if the oxygen room had ever been locked because she had never been in that room. CNA C stated that she had never seen a resident by the storage rooms at the end of hall 200. CNA C stated that she did not think any residents on the 200 hall would grab a razor in the central supply storage room and hurt themselves or others. CNA C stated that she was not sure whether or not the oxygen storage room should be locked, but that the central supply storage room should probably be locked. CNA C stated that it should be the responsibility of whoever stocks the supply rooms to inform the DON or administrator that the doors are unlocked. <BR/>In an interview with LVN E on 07/31/2024 at 2:42 PM, LVN E stated that the oxygen storage room is usually locked at other facilities he has worked. LVN E stated that it was possible for a resident to go into the central supply storage room, grab a razor, and then hurt themselves or others. LVN E stated that if a resident walked into the central supply storage room and fell it could take a while before anyone would notice that the resident had fallen and injured themselves. <BR/>In an interview with the DON on 07/31/2024 at 3:15 PM, the DON stated whether or not storage rooms should be locked depends on what is being stored. The DON stated that the soiled linens closet should be secured when not in use. The DON stated that he was fine with the oxygen supply room being unlocked because they are in racks. The DON stated that he was fine with the central supply door being unlocked as long as nothing dangerous was in there. The DON stated that shaving razors do not belong in the central supply storage room at the end of hall 200. The DON stated that there was potential for residents to harm themselves or others with the razors in the room. The DON stated that it was possible, but not likely, that a resident could go into the central supply storage room and fall causing them to injure themselves. <BR/>On 07/31/2024 at 4:01 PM, a policy was requested from the DON and ADM covering the expectations for a safe, homelike environment but none could be located.

**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 was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 3 residents (Resident #2) reviewed for indwelling catheters. <BR/>The facility failed to prevent Resident #2's urinary catheter tubing from touching the floor. <BR/>This failure could place residents at risk for urinary tract infections. <BR/>Findings included: <BR/>Record review of Resident #2' admission record dated 11/30/23 reflected Resident #2 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #2 was a [AGE] year-old male with diagnosis which included end stage renal disease(kidney no longer work as they should), diabetes (high blood sugar levels), <BR/>cirrhosis of the liver (permanent damage to the liver), obstructive and reflux uropathy( functional hinderance of normal urine flow),benign prostatic hyperplasia without lower urinary tract symptoms (non-cancerous increase in size of the prostate gland), and extrarenal uremia (high levels of urea in the blood).<BR/>Record review of Resident #2's the physician orders dated 11/30/23, reflected orders for a foley catheter to be changed monthly one time, related to obstructive and reflux uropathy, start date 04/14/23. <BR/>Record review of the quarterly MDS dated [DATE] reflected Resident #2 was moderately cognitively impaired, (decisions poor) and had an indwelling catheter in place. <BR/>Record review of a care plan revised on 03/27/23 reflected Resident #2 had an indwelling urinary catheter. Interventions included to position catheter bag and tubing below the level of the bladder and away from the entrance of door, revised on 11/16/23. <BR/>Observation and interview on 11/30/23 at 9:05 am with Resident #2 revealed Resident #2 was in his bed, alert and wearing a urinary catheter was clipped to the bedside rail below his bladder level. The tubing did not have a plastic sleeve and was on the floor and attached to the urinary catheter. Resident #2 said he could not see that the catheter tubing was on the floor. <BR/>Interview on 11/30/23 at 9:18 am with CNA C revealed Resident #2's urinary catheter tubing was on the floor and did not have a plastic sleeve on the tubing. CNA C said CNAs and nurses were responsible to make sure the catheter bag and tubing were not not on floor the because the urinary catheter could get contaminated and lead to infections. CNA C said she was in-serviced on infection control and proper placement of urinary catheter bag and tubing. CAN C said she would go tell the nurse to come and replace the tubing since it was already contaminated while on the floor. <BR/>Interview on 11/30/23 at 9:33 am with CNA D revealed she had gone into Resident #2's room earlier in the morning and she and another CNA had to reposition Resident #2 up for his breakfast and she removed the urinary catheter bag and tubing. CNA D said she clipped the urinary catheter bag on the bedside rail and forgot to place the tubing where it would not touch the floor. CNA D said the urinary catheter could get contaminated if it touched the floor. The urinary tubing should have had a plastic sleeve in case the tubing touched the floor. CNA D said the CNAs and nurses were responsible to ensure the urinary catheter tubing had a plastic tubing and did not touch the floor. <BR/>Interview on 11/30/23 at 9:37 am with LVN B revealed Resident #2's urinary catheter bag and tubing should not be on the floor. The urinary catheter tubing should have a plastic sleeve to prevent contamination if the tubing touched the floor. LVN B said the CNAs and nurses were responsible to ensure the urinary catheter tubing had a plastic sleeve to prevent the tubing from contamination if it touched the floor. <BR/> Interview on 11/30/23 at 9:54 am with the DON revealed the urinary catheter tubing should not be on the floor because the catheter could get contaminated. The DON said she and the charges nurses and CNAs were responsible to ensure the urinary catheter tubing had a plastic sleeve to prevent contamination. <BR/>Record review of the facility policy's titled Catheter Care, Urinary dated September 2014 reflected under Infection Control Use standard precautions when handling or manipulating the drainage system. Be sure the catheter tubing and drainage bag are kept off the floor.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 3 halls (Hall 200) reviewed for environment.<BR/>1) The facility failed to keep the soiled linen utility closet containing dirty linens locked when not in use.<BR/>2) The facility failed to keep the oxygen storage room containing empty and full oxygen canisters locked when not in use.<BR/>3) the facility failed to keep the central supply storage room containing approximately 40 individual shaving razors locked when not in use. <BR/>These failures could result in injury for residents who come into contact with sharp implements or hazardous materials.<BR/>The findings included:<BR/>During an observation on 07/29/2024 at 10:53 AM, the soiled linen utility closet on hall 200 across from resident room [ROOM NUMBER] was noted to be partially ajar. The sign on the door read Authorized Personnel Only. Inside the room was soiled linens and trash.<BR/>During an observation on 07/29/2024 at 3:03 PM, the oxygen storage room and central supply storage rooms at the end of hall 200 were unlocked. The signs on the oxygen storage room read Danger Flammable Gas and Danger Gas Cylinder Storage Area. Inside the oxygen storage room were approximately 50 oxygen canisters in racks. Half of them were in the section labeled O2 full and the other half were in the section labeled O2 empty. The door to central supply storage room had a locking mechanism with buttons for input, but the door could be opened without inputting any combination. Inside the central supply storage room were various hygiene supplies, including approximately 40 individual shaving razors in a basket on a shelf.<BR/>In an interview with CNA C on 07/31/2024 at 2:29 PM, CNA C stated that the locking mechanism on the door to the central supply storage room stopped working about a year ago. CNA C stated that she was not certain if the oxygen room had ever been locked because she had never been in that room. CNA C stated that she had never seen a resident by the storage rooms at the end of hall 200. CNA C stated that she did not think any residents on the 200 hall would grab a razor in the central supply storage room and hurt themselves or others. CNA C stated that she was not sure whether or not the oxygen storage room should be locked, but that the central supply storage room should probably be locked. CNA C stated that it should be the responsibility of whoever stocks the supply rooms to inform the DON or administrator that the doors are unlocked. <BR/>In an interview with LVN E on 07/31/2024 at 2:42 PM, LVN E stated that the oxygen storage room is usually locked at other facilities he has worked. LVN E stated that it was possible for a resident to go into the central supply storage room, grab a razor, and then hurt themselves or others. LVN E stated that if a resident walked into the central supply storage room and fell it could take a while before anyone would notice that the resident had fallen and injured themselves. <BR/>In an interview with the DON on 07/31/2024 at 3:15 PM, the DON stated whether or not storage rooms should be locked depends on what is being stored. The DON stated that the soiled linens closet should be secured when not in use. The DON stated that he was fine with the oxygen supply room being unlocked because they are in racks. The DON stated that he was fine with the central supply door being unlocked as long as nothing dangerous was in there. The DON stated that shaving razors do not belong in the central supply storage room at the end of hall 200. The DON stated that there was potential for residents to harm themselves or others with the razors in the room. The DON stated that it was possible, but not likely, that a resident could go into the central supply storage room and fall causing them to injure themselves. <BR/>On 07/31/2024 at 4:01 PM, a policy was requested from the DON and ADM covering the expectations for a safe, homelike environment but none could be located.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately to the administrator of the facility and to the State Survey Agency, for one (R#1) of 18 residents reviewed for abuse/neglect. <BR/>The facility staff did not report an incident of injury when R#1 was observed bleeding from eyebrow during perineal care. <BR/>This failure could place residents at risk for neglect. <BR/>The findings included:<BR/>Record review of R #1's Face Sheet dated 08/07/2023 documented a [AGE] year-old female resident admitted to the facility on [DATE]. Her diagnoses were: muscle wasting, mobility abnormalities, dysphagia (swallowing difficulty), right knee contracture, and left knee contracture. <BR/>Record review of R#1's Annual Minimum Data Set, dated [DATE] noted the following: Brief interview of mental status summary score of 99- (resident was unable to complete the interview). MDS coded R#1 to need total dependence for toilet use, transfers, and bed mobility. Functional Status: required extensive assistance with two-person physical assist/support for toileting, transfers, and bed mobility, as well as one-person physical assist with eating. <BR/>R#1's Care Plan dated 05/27/2023 is has an ADL self-care performance deficit r/t Impaired balance, contracture BIL hips, knees, hx shoulder dislocation, cognitive impairments. Interventions: Position with pillows for comfort d/t contractures. ROM with adls as tolerated. Bathing/showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Bathing/showering: The resident is totally dependent on 1 staff to provide shower. Bed mobility: The resident requires Total assistance by 1 staff to turn and reposition in bed. Dressing: The resident requires total assist by staff to dress. Eating: The resident requires Total assist by staff to eat. Personal hygiene: The resident requires (total assistance) by 1 staff with personal hygiene and oral care. Skin inspection: The resident requires SKIN inspection (daily with adls Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse. Toilet use: The resident requires (Total assistance) by one staff for toileting. <BR/>Record review of R #1's Nurses Note date 08/03/2023 at 8:30 a.m. documented by LVN B, writer received report during change of shift 08/02/2023 6p-6a that resident had small area of discoloration to Lt eye. Upon assessment of resident, she was observed with discoloration to under Lt eye coming up around eye and small [NAME] to Lt eyebrow. Writer spoke to CNA A morning of 08/03/2023 who stated resident had band aid over eyebrow at start of shift morning 08/02/2023. CNA B also stated it was noted 08/02/2023 at beginning of shift. Writer reported findings to DON morning 08/03/2023.<BR/>Record Review of additional progress notes for R#1's, and assessments on 08/04/2023, had no additional mention of R#1's injuries. <BR/>During an observation and interview on 08/04/2023 at 5:45PM, R#1 was in a wheelchair, sitting at a dining room table, being assisted to eat by staff. R#1 was observed to have dark purple discoloration with light green on the left eye, in the eye-ball socket area. Attempted interview with R#1, but R#1 was non-verbal to the questions asked. <BR/>During an interview on 08/04/02023 at 5:16PM, the Administrator stated injury of unknown origin, especially bruises are reportable injury to state. The administrator stated every morning the ADONs and DON, will discuss events that transpired during the previous 24hr. day before, during their morning clinical meeting. The Administrator stated during the morning meetings, any incident and accidents will also be discussed during the morning clinical meeting. with the 24hrs. The Administrator stated if an event transpired during the weekend, the event will be discussed during Monday morning meeting. The Administrator stated he was not aware of event regarding R#1 and would report the incident to state. The Administrator stated he needed to be notified of any injury small or large, to begin an investigation to determine how the injury happened, not just guess. The Administrator stated he was not made aware of any scratch, or bruise for R#1 from 08/02/2023-08/04/2023. The Administrator stated, had the DON known about R#1's injury, the DON should have begun internal investigation to rule out abuse, and should have instructed managerial staff to continue the investigation, while the DON was off. The Administrator stated no definitive answer as to why the internal investigation had not been done. The Administrator verbalized his dismay for his staff not reporting and investigating R#1's injury. <BR/>During an interview on 08/04/2023 at 6:04pm, ADON A stated any time an unexplainable injury was observed, the charge nurse will notify the DON and fill out incident report. The ADON A stated if there was a large or small bruise or injury of unknown origin, there needs to be an incident report and the physician needs to be notified to attain recommendations. ADON A stated bruises are reportable to state. ADON A stated an investigation will begin by the DON to ensure the safety of resident and to rule out abuse. ADON A stated she was aware of the event with R#1, but does not know what transpired, and was not given directions to continue any investigation regarding R#1's bruise. ADON A stated she did not know if the DON had begun the internal investigation for R#1. ADON A stated the event with R#1 was not discussed at morning meeting on 08/03/2023. ADON A stated if the DON could not definitively state what happened, it should be investigated, and reported to state.<BR/>During an interview on 08/04/2023 at 6:18PM ADON B stated she was in the room on 08/03/2023 at 8:30-8:45AM when the charge nurse notified the DON that she had noticed discoloration on R#1's left eye. ADON B stated, the charge nurse notified the DON, there was no documentation nor progress note on R#1's injury. ADON B stated she heard the charge nurse notify the DON, that LVN A had stated in report that R#1 had some slight red discoloration and upon the charge nurse's observation, there was dark purple bruising to R#1's left eye. ADON B stated the DON told the LVN B that she would investigate the injury and get with LVN A. ADON B stated during the morning meeting on 08/03/2023, the topic of R#1's bruising was not brought up and stated the bruising topic should have been discussed due to the injury's unknown origin. ADON B stated she was not given any direction to continue any internal investigations. ADON B stated both nurses LVN A and charge nurse should have filled out an incident report. ADON B stated she conducted an in-service regarding abuse/neglect and reporting criteria given about a month ago to all clinical staff. The ADON B stated the DON should have followed up on R#1's injury and should have begun an internal investigation to rule out abuse, especially due to not knowing of definitive origin of R#1's injury and should have been reported to state. ADON B stated when she was looking at R#1's electronic medical record , no was not incident report for R#1.<BR/>During an interview on 08/04/2023 at 6:55pm, LVN A stated she went into work on 08/01/2023 6:00AM- 6:00PM, no redness or bruising were observed through her shift. On 08/02/2023 LVN A again went to work from 6:00AM- 6:00PM shift. LVN A stated that she was in R#1's room when two CNAs were getting R#1 up. LVN A stated she was notified while in R#1's room, that R#1 had red discoloration to left eye. LVN A stated she assessed the left eye and observed red discoloration on eye but did not feel a cause for concern. LVN A stated R#1 will at times curl hand near her left eye and utilized her previous experience with R#1 to determine the cause of the red discoloration was R#1 rubbing her left eye. LVN A stated there was no bruising on either of R#1's eyes or nose. LVN A allowed the CNAs to place R#1 in wheelchair and take to the dining area for breakfast and then back to bed. LVN A stated she checked and monitored the red discolored eye area throughout her shift on 08/02/2023 and did not fill out an incident report due to her previous experience with R#1 rubbing her eyes. LVN A stated she did not notify the DON nor Administrator about eye discoloration, due to her previous experience with R#1 self-inflicted red discoloration on left eye by scratching and rubbing eyes. LVN A stated she notified the incoming LVN B on 08/02/2023 at 6:00PM to keep an eye on red eye discoloration. LVN A stated when she left work on 08/02/2023 at 6:00PM R#1's left eye had slight red discoloration but nothing big like a black eye. LVN A stated she felt she acted and advocated appropriately for R#1. LVN A was asked if she witnessed R#1 rubbing and scratching her eye during her shift, to which she replied no and was asked how she then definitively ruled out abuse, given that she did not witness R#1 scratching her eyes, LVN A gave no definitive answer. LVN A stated she was last in-serviced about abuse and neglect early August 2023. <BR/>During an interview on 08/11/2023 at 12:53PM the DON stated the expectation of the facility, when dealing with injuries was for the charge nurse to be notified, and for the charge nurse to assess the resident, file an incident report, notify family, doctor and according to injury will report according to the HHSC Guidelines. The DON stated on Thursday 8/3/2023 around 8:30AM in the morning, the night charge nurse notified the DON that she needed to speak with her. The DON stated the charge nurse told her that R#1 had a bruise to her left eye, and that nobody had done anything about it. The DON stated she had not heard anything about R#1's injury and stated she would investigate. The DON stated the injury was not brought up in morning clinical meeting because no incident report was done, no risk management report/incident report was done, and because she did not know extent of bruise. The DON stated on 08/03/2023 she observed R#1 to which she saw R#1 with light purple discoloration on left eye. The DON stated she interviewed LVN A on 08/03/2023, and was told by LVN A, that R#1 had self-inflicted injury with her hands. The DON stated R#1 had tendency to rub her eyes and rest her hands by face. The DON stated upon interviewing LVN A, LVN A stated she saw red discoloration during her 6:00AM- 6:00PM shift on 08/02/2023 but did not see a cause for concern or need for incident report. The DON stated, on 08/03/2023 she told LVN A to complete an incident report and dismissed because she knew R#1 rubbed her eyes. The DON stated she was off on 08/04/2023. The DON continued by stating she started her investigation on 08/03/2023, and assessed for safety hazards, spoke to all clinical staff, and on 08/05/2023 CNA A stated while she was changing R#1, CNA A observed R#1 rubbing her eye with hand on face, and when she turned R#1 back to supine position a little bit of blood was visualized. The DON stated, the CNA A stated she reported the injury to LVN A, and that LVN A forgot to do an incident report. The DON was asked how she ruled out abuse, the DON stated she did recall discussing R#1's injury in the clinical morning meeting on 08/03/2023 and notified the ADONs to continue the internal investigation while she was off on 08/04/2023. The DON stated she continued her investigation on Saturday 08/05/2023 as well as conducted an in-service regarding documenting/abuse/neglect on the same day. The DON stated has attempted to rectify situation by writing a formal write up for LVN A. <BR/>During an interview on 08/11/2023 at 5:17 PM, CNA A stated on 08/01/2023 she went to R#1's room to perform perineal care on R#1 and when she turned R#1 to her left side, she visualized R#1 scratching her eye with her nails. CNA A stated when she turned R#1 back to supine position, she saw that R#1 had blood on the left eyebrow. The CNA A stated she notified LVN A of R#1's bloody eyebrow while LVN A was in the hallway, to which LVN A went into R#1's room and cleaned up R#1's eyebrow, then instructed CNA A to assist R#1 to wheelchair. The CNA A stated R#1's face just had a little bleeding in eyebrow and that was it. The CNA A stated the DON did not ask about the incident until 08/05/2023. The CNA A stated she attended in-service regarding documenting/abuse/neglect on 08/05/2023. <BR/>Attempted interview with LVN B and was told she was not available for interview. <BR/>Record review of facility's Documenting/Abuse/Neglect dated, 08/04/2023, did not have LVN A in attendance, but did have CNA A in attendance. <BR/>Record review of facility's incident/accident reports on 08/04/2023, no report documented for R#1. <BR/>Record review of facility's Accident and Incident-Investigating and Reporting Policy revised July 2020 stated, <BR/>1. <BR/>The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. <BR/>2. <BR/>The following data, as applicable, shall be included in the Risk Management report;<BR/>a. <BR/>The date and time the accident or incident took place;<BR/>b. <BR/>The nature of the injury/illness (e.g. bruise, fall, nausea, etc.); <BR/>c. <BR/>Where the accident or incident took place;<BR/>d. <BR/>The name(s) of witnesses and their account of the accident or incident<BR/>Record review of facility's Charting and Documentation Policy revised July 2017 stated,<BR/>1. <BR/>All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be report by the facility Administrator, or his/her designee, to the following persons or agencies:<BR/>a. <BR/>The State licensing/certification agency responsible for surveying/licensing the facility;<BR/>2. <BR/>An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:<BR/>a. <BR/>Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or <BR/>b. <BR/>Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately to the administrator of the facility and to the State Survey Agency, for one (R#1) of 18 residents reviewed for abuse/neglect. <BR/>The facility staff did not report an incident of injury when R#1 was observed bleeding from eyebrow during perineal care. <BR/>This failure could place residents at risk for neglect. <BR/>The findings included:<BR/>Record review of R #1's Face Sheet dated 08/07/2023 documented a [AGE] year-old female resident admitted to the facility on [DATE]. Her diagnoses were: muscle wasting, mobility abnormalities, dysphagia (swallowing difficulty), right knee contracture, and left knee contracture. <BR/>Record review of R#1's Annual Minimum Data Set, dated [DATE] noted the following: Brief interview of mental status summary score of 99- (resident was unable to complete the interview). MDS coded R#1 to need total dependence for toilet use, transfers, and bed mobility. Functional Status: required extensive assistance with two-person physical assist/support for toileting, transfers, and bed mobility, as well as one-person physical assist with eating. <BR/>R#1's Care Plan dated 05/27/2023 is has an ADL self-care performance deficit r/t Impaired balance, contracture BIL hips, knees, hx shoulder dislocation, cognitive impairments. Interventions: Position with pillows for comfort d/t contractures. ROM with adls as tolerated. Bathing/showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Bathing/showering: The resident is totally dependent on 1 staff to provide shower. Bed mobility: The resident requires Total assistance by 1 staff to turn and reposition in bed. Dressing: The resident requires total assist by staff to dress. Eating: The resident requires Total assist by staff to eat. Personal hygiene: The resident requires (total assistance) by 1 staff with personal hygiene and oral care. Skin inspection: The resident requires SKIN inspection (daily with adls Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse. Toilet use: The resident requires (Total assistance) by one staff for toileting. <BR/>Record review of R #1's Nurses Note date 08/03/2023 at 8:30 a.m. documented by LVN B, writer received report during change of shift 08/02/2023 6p-6a that resident had small area of discoloration to Lt eye. Upon assessment of resident, she was observed with discoloration to under Lt eye coming up around eye and small [NAME] to Lt eyebrow. Writer spoke to CNA A morning of 08/03/2023 who stated resident had band aid over eyebrow at start of shift morning 08/02/2023. CNA B also stated it was noted 08/02/2023 at beginning of shift. Writer reported findings to DON morning 08/03/2023.<BR/>Record Review of additional progress notes for R#1's, and assessments on 08/04/2023, had no additional mention of R#1's injuries. <BR/>During an observation and interview on 08/04/2023 at 5:45PM, R#1 was in a wheelchair, sitting at a dining room table, being assisted to eat by staff. R#1 was observed to have dark purple discoloration with light green on the left eye, in the eye-ball socket area. Attempted interview with R#1, but R#1 was non-verbal to the questions asked. <BR/>During an interview on 08/04/02023 at 5:16PM, the Administrator stated injury of unknown origin, especially bruises are reportable injury to state. The administrator stated every morning the ADONs and DON, will discuss events that transpired during the previous 24hr. day before, during their morning clinical meeting. The Administrator stated during the morning meetings, any incident and accidents will also be discussed during the morning clinical meeting. with the 24hrs. The Administrator stated if an event transpired during the weekend, the event will be discussed during Monday morning meeting. The Administrator stated he was not aware of event regarding R#1 and would report the incident to state. The Administrator stated he needed to be notified of any injury small or large, to begin an investigation to determine how the injury happened, not just guess. The Administrator stated he was not made aware of any scratch, or bruise for R#1 from 08/02/2023-08/04/2023. The Administrator stated, had the DON known about R#1's injury, the DON should have begun internal investigation to rule out abuse, and should have instructed managerial staff to continue the investigation, while the DON was off. The Administrator stated no definitive answer as to why the internal investigation had not been done. The Administrator verbalized his dismay for his staff not reporting and investigating R#1's injury. <BR/>During an interview on 08/04/2023 at 6:04pm, ADON A stated any time an unexplainable injury was observed, the charge nurse will notify the DON and fill out incident report. The ADON A stated if there was a large or small bruise or injury of unknown origin, there needs to be an incident report and the physician needs to be notified to attain recommendations. ADON A stated bruises are reportable to state. ADON A stated an investigation will begin by the DON to ensure the safety of resident and to rule out abuse. ADON A stated she was aware of the event with R#1, but does not know what transpired, and was not given directions to continue any investigation regarding R#1's bruise. ADON A stated she did not know if the DON had begun the internal investigation for R#1. ADON A stated the event with R#1 was not discussed at morning meeting on 08/03/2023. ADON A stated if the DON could not definitively state what happened, it should be investigated, and reported to state.<BR/>During an interview on 08/04/2023 at 6:18PM ADON B stated she was in the room on 08/03/2023 at 8:30-8:45AM when the charge nurse notified the DON that she had noticed discoloration on R#1's left eye. ADON B stated, the charge nurse notified the DON, there was no documentation nor progress note on R#1's injury. ADON B stated she heard the charge nurse notify the DON, that LVN A had stated in report that R#1 had some slight red discoloration and upon the charge nurse's observation, there was dark purple bruising to R#1's left eye. ADON B stated the DON told the LVN B that she would investigate the injury and get with LVN A. ADON B stated during the morning meeting on 08/03/2023, the topic of R#1's bruising was not brought up and stated the bruising topic should have been discussed due to the injury's unknown origin. ADON B stated she was not given any direction to continue any internal investigations. ADON B stated both nurses LVN A and charge nurse should have filled out an incident report. ADON B stated she conducted an in-service regarding abuse/neglect and reporting criteria given about a month ago to all clinical staff. The ADON B stated the DON should have followed up on R#1's injury and should have begun an internal investigation to rule out abuse, especially due to not knowing of definitive origin of R#1's injury and should have been reported to state. ADON B stated when she was looking at R#1's electronic medical record , no was not incident report for R#1.<BR/>During an interview on 08/04/2023 at 6:55pm, LVN A stated she went into work on 08/01/2023 6:00AM- 6:00PM, no redness or bruising were observed through her shift. On 08/02/2023 LVN A again went to work from 6:00AM- 6:00PM shift. LVN A stated that she was in R#1's room when two CNAs were getting R#1 up. LVN A stated she was notified while in R#1's room, that R#1 had red discoloration to left eye. LVN A stated she assessed the left eye and observed red discoloration on eye but did not feel a cause for concern. LVN A stated R#1 will at times curl hand near her left eye and utilized her previous experience with R#1 to determine the cause of the red discoloration was R#1 rubbing her left eye. LVN A stated there was no bruising on either of R#1's eyes or nose. LVN A allowed the CNAs to place R#1 in wheelchair and take to the dining area for breakfast and then back to bed. LVN A stated she checked and monitored the red discolored eye area throughout her shift on 08/02/2023 and did not fill out an incident report due to her previous experience with R#1 rubbing her eyes. LVN A stated she did not notify the DON nor Administrator about eye discoloration, due to her previous experience with R#1 self-inflicted red discoloration on left eye by scratching and rubbing eyes. LVN A stated she notified the incoming LVN B on 08/02/2023 at 6:00PM to keep an eye on red eye discoloration. LVN A stated when she left work on 08/02/2023 at 6:00PM R#1's left eye had slight red discoloration but nothing big like a black eye. LVN A stated she felt she acted and advocated appropriately for R#1. LVN A was asked if she witnessed R#1 rubbing and scratching her eye during her shift, to which she replied no and was asked how she then definitively ruled out abuse, given that she did not witness R#1 scratching her eyes, LVN A gave no definitive answer. LVN A stated she was last in-serviced about abuse and neglect early August 2023. <BR/>During an interview on 08/11/2023 at 12:53PM the DON stated the expectation of the facility, when dealing with injuries was for the charge nurse to be notified, and for the charge nurse to assess the resident, file an incident report, notify family, doctor and according to injury will report according to the HHSC Guidelines. The DON stated on Thursday 8/3/2023 around 8:30AM in the morning, the night charge nurse notified the DON that she needed to speak with her. The DON stated the charge nurse told her that R#1 had a bruise to her left eye, and that nobody had done anything about it. The DON stated she had not heard anything about R#1's injury and stated she would investigate. The DON stated the injury was not brought up in morning clinical meeting because no incident report was done, no risk management report/incident report was done, and because she did not know extent of bruise. The DON stated on 08/03/2023 she observed R#1 to which she saw R#1 with light purple discoloration on left eye. The DON stated she interviewed LVN A on 08/03/2023, and was told by LVN A, that R#1 had self-inflicted injury with her hands. The DON stated R#1 had tendency to rub her eyes and rest her hands by face. The DON stated upon interviewing LVN A, LVN A stated she saw red discoloration during her 6:00AM- 6:00PM shift on 08/02/2023 but did not see a cause for concern or need for incident report. The DON stated, on 08/03/2023 she told LVN A to complete an incident report and dismissed because she knew R#1 rubbed her eyes. The DON stated she was off on 08/04/2023. The DON continued by stating she started her investigation on 08/03/2023, and assessed for safety hazards, spoke to all clinical staff, and on 08/05/2023 CNA A stated while she was changing R#1, CNA A observed R#1 rubbing her eye with hand on face, and when she turned R#1 back to supine position a little bit of blood was visualized. The DON stated, the CNA A stated she reported the injury to LVN A, and that LVN A forgot to do an incident report. The DON was asked how she ruled out abuse, the DON stated she did recall discussing R#1's injury in the clinical morning meeting on 08/03/2023 and notified the ADONs to continue the internal investigation while she was off on 08/04/2023. The DON stated she continued her investigation on Saturday 08/05/2023 as well as conducted an in-service regarding documenting/abuse/neglect on the same day. The DON stated has attempted to rectify situation by writing a formal write up for LVN A. <BR/>During an interview on 08/11/2023 at 5:17 PM, CNA A stated on 08/01/2023 she went to R#1's room to perform perineal care on R#1 and when she turned R#1 to her left side, she visualized R#1 scratching her eye with her nails. CNA A stated when she turned R#1 back to supine position, she saw that R#1 had blood on the left eyebrow. The CNA A stated she notified LVN A of R#1's bloody eyebrow while LVN A was in the hallway, to which LVN A went into R#1's room and cleaned up R#1's eyebrow, then instructed CNA A to assist R#1 to wheelchair. The CNA A stated R#1's face just had a little bleeding in eyebrow and that was it. The CNA A stated the DON did not ask about the incident until 08/05/2023. The CNA A stated she attended in-service regarding documenting/abuse/neglect on 08/05/2023. <BR/>Attempted interview with LVN B and was told she was not available for interview. <BR/>Record review of facility's Documenting/Abuse/Neglect dated, 08/04/2023, did not have LVN A in attendance, but did have CNA A in attendance. <BR/>Record review of facility's incident/accident reports on 08/04/2023, no report documented for R#1. <BR/>Record review of facility's Accident and Incident-Investigating and Reporting Policy revised July 2020 stated, <BR/>1. <BR/>The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. <BR/>2. <BR/>The following data, as applicable, shall be included in the Risk Management report;<BR/>a. <BR/>The date and time the accident or incident took place;<BR/>b. <BR/>The nature of the injury/illness (e.g. bruise, fall, nausea, etc.); <BR/>c. <BR/>Where the accident or incident took place;<BR/>d. <BR/>The name(s) of witnesses and their account of the accident or incident<BR/>Record review of facility's Charting and Documentation Policy revised July 2017 stated,<BR/>1. <BR/>All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be report by the facility Administrator, or his/her designee, to the following persons or agencies:<BR/>a. <BR/>The State licensing/certification agency responsible for surveying/licensing the facility;<BR/>2. <BR/>An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:<BR/>a. <BR/>Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or <BR/>b. <BR/>Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed.<BR/>There was expired chocolate milk in the refrigerator<BR/>There were dirty dishes on the clean rack<BR/>There were dented and scratched pans<BR/>This failure could place residents at serious risk for complications from food contamination.<BR/>Findings were:<BR/>Observation and initial tour of the kitchen on 04/18/23 at 09:30 AM revealed 8, 1/2 gallons of chocolate milk with expiration dates of 04/17/23 in the refrigerator with 2 other 1/2 gallons of unexpired chocolate milk. There were 4 full trays of dirty dessert cups on the clean rack mixed in with clean dessert cups. There were 4 Teflon-type pans that were badly scratched, flaking, and hanging on the rack of pans. A large colander that was badly dented was also hanging on the rack of pans. There were 8 small; size 4, 3 large; size 1/4-6, and 3 shallows; size 1/3-6 food-holding steam table pans, that were badly dented. <BR/>Observation of the clean rack of dishes on 04/20/23 at 01:40 PM revealed stained and/or scratched plastic glasses, coffee cups, and dessert cups on multiple trays.<BR/>An interview with the COOK on 04/18/23 at 09:45 AM stated the 4 full trays of dirty dessert cups on the clean rack were mixed in with clean dessert cups. The COOK stated the Teflon-type pans, and the large, dented colander were in use. The COOK stated the pans and colander should probably not be used in the state they were in because one of the pans was very rusty. The COOK stated whoever washed the dishes was responsible for checking if the dishes were clean.<BR/>Interview with the DM on 04/18/23 at 09:50 AM stated she had ordered new pans about 3 weeks ago but had not received them because of back-orders. The DM stated the dented and scratched pans should not be used because the Teflon could flake off and get in the food and it might cause cancer. The DM stated the entire kitchen staff was responsible for making sure the dishes were clean.<BR/>An interview with the DM and RD on 04/19/23 at 02:38 PM the RD stated the vendor came in weekly, removed expired goods, and credited the facility. The DM stated the expired chocolate milk was not separated from the unexpired chocolate milk or in any way marked for return. The DM stated expired goods could make residents sick if it was served and consumed by them.<BR/>An interview with the DM on 04/20/23 at 01:45 PM stated she had a whole bunch of new dishes that she had not yet put out. The DM stated the dirty dishes got thrown away whenever staff saw them because they were all adults in the kitchen. The DM stated the dirty dishes on the clean racks would have potentially been used.<BR/>An in-service dated 04/19/23 titled, Milk-Best by Dates, Credit, was provided by the DM on 04/19/23 at 2:55 PM. The in-service reflected the objective of the in-service was: if the milk date was prior to the current best-by date, do not use or throw it away. A vendor will arrive weekly on Thursdays to pick up any items and credit our account.<BR/>A record review of the restaurant supply invoice #CS90270 for 2 full sheet pans, 2 small; size 1/6-4, 3 large; size 1/4-6, and 2 shallows; size1/3-6 food-holding steam table pans, dated 04/18/23, documented a cash sale/customer picked up on 04/18/23. Invoice #219576 dated 04/18/23 for 1, 8-inch, 1, 10 inches, and 1, 12-inch aluminum fry pan, 1 saucepan, 1 large and 1 small colander documented customer picked up on 04/18/23. <BR/>The facility failed to produce a food storage policy.<BR/>8-101.10 Public Health Protection: (B) In enforcing the provisions of this Code, the REGULATORY AUTHORITY shall assess existing facilities or EQUIPMENT that were in use before the effective date of this Code based on the following considerations:<BR/>(1) Whether the facilities or EQUIPMENT are in good repair and capable of being maintained in a sanitary condition; (2) Whether FOOD-CONTACT SURFACES comply with Subpart 4-101; 4-101.11 Characteristics. Materials that are used in the construction of UTENSILS and FOOD CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: (A) Safe; (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. 4-101.18 Nonstick Coatings, Use Limitation. Multiuse KITCHENWARE such as frying pans, griddles, sauce pans, cookie sheets, and waffle bakers that have a perfluorocarbon resin coating shall be used with nonscoring or nonscratching UTENSILS and cleaning aids. Refrigeration prevents food from becoming a hazard by significantly slowing the growth of most microbes. The growth of some bacteria, such as Listeria monocytogenes, is significantly slowed but not stopped by refrigeration. Over a period of time, this and <BR/>similar organisms may increase their risk to public health in ready-to-eat foods. Based on a predictive growth curve modeling program for Listeria monocytogenes, ready-to-eat, time/temperature control for safety food may be kept at 5oC (41oF) a total <BR/>of 7 days. Food which is prepared and held, or prepared, frozen, and thawed must be controlled by date marking to ensure its safety based on the total amount of time it was held at refrigeration temperature, and the opportunity for Listeria monocytogenes to <BR/>multiply, before freezing and after thawing. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date <BR/>References: https://www.fda.gov/media/110822/download

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, comfortable, and homelike environment for 3 (RM# 304, RM#112 and RM#216) rooms observed for maintenance. <BR/>The facility failed to maintain resident occupied RM#304, RM# 112 and RM#216: <BR/>-RM# 304 had unaligned and broken floor tiles.<BR/>-RM#112 had part of the ceiling texture was falling.<BR/>-RM#216 had an unsecured door.<BR/>These failures could place residents in rooms at risk for injury or a declined sense of worth. <BR/>Findings were: <BR/>On 2/15/2024 at 11:45 a.m. observation of RM#216 revealed an upside-down door propped up against the closet in the room. The door was unsecure. <BR/>On 2/15/2024 at 12:01 p.m. observation of room [ROOM NUMBER] revealed popcorn ceiling texture peeling away from the rest of the ceiling. The ceiling area was above the television area across from the resident's bed.<BR/>On 2/15/2024 at 12:15 p.m. observation of room [ROOM NUMBER] revealed uneven and disarray of tiles upon entrance to room [ROOM NUMBER]. The tiles were loose with uneven lines and portions of the tiles were missing.<BR/>During an interview on 2/15/2024 at 11:00 a.m., Resident #1, residing in room [ROOM NUMBER], stated the floor is messed up and needs to be fixed. <BR/>During an interview on 2/15/2024 at 12:02 p.m., Resident #2, residing in room [ROOM NUMBER], stated the ceiling does bother me. <BR/>During an interview on 2/16/2024 at 1:26 p.m., the Maintenance Director stated, I know when things need repair by rounding (walking the halls and entering rooms) at the beginning of each day and through the work orders entered into the computer system by staff. He also stated he was unaware of the maintenance concerns in room [ROOM NUMBER], 216, and 304 until 2/15/2024 when it was brought to his attention by this Investigator. <BR/>Record review of the printed maintenance record request dated 2/16/2024 revealed rooms [ROOM NUMBER] were not listed as needing repairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, comfortable, and homelike environment for 3 (RM# 304, RM#112 and RM#216) rooms observed for maintenance. <BR/>The facility failed to maintain resident occupied RM#304, RM# 112 and RM#216: <BR/>-RM# 304 had unaligned and broken floor tiles.<BR/>-RM#112 had part of the ceiling texture was falling.<BR/>-RM#216 had an unsecured door.<BR/>These failures could place residents in rooms at risk for injury or a declined sense of worth. <BR/>Findings were: <BR/>On 2/15/2024 at 11:45 a.m. observation of RM#216 revealed an upside-down door propped up against the closet in the room. The door was unsecure. <BR/>On 2/15/2024 at 12:01 p.m. observation of room [ROOM NUMBER] revealed popcorn ceiling texture peeling away from the rest of the ceiling. The ceiling area was above the television area across from the resident's bed.<BR/>On 2/15/2024 at 12:15 p.m. observation of room [ROOM NUMBER] revealed uneven and disarray of tiles upon entrance to room [ROOM NUMBER]. The tiles were loose with uneven lines and portions of the tiles were missing.<BR/>During an interview on 2/15/2024 at 11:00 a.m., Resident #1, residing in room [ROOM NUMBER], stated the floor is messed up and needs to be fixed. <BR/>During an interview on 2/15/2024 at 12:02 p.m., Resident #2, residing in room [ROOM NUMBER], stated the ceiling does bother me. <BR/>During an interview on 2/16/2024 at 1:26 p.m., the Maintenance Director stated, I know when things need repair by rounding (walking the halls and entering rooms) at the beginning of each day and through the work orders entered into the computer system by staff. He also stated he was unaware of the maintenance concerns in room [ROOM NUMBER], 216, and 304 until 2/15/2024 when it was brought to his attention by this Investigator. <BR/>Record review of the printed maintenance record request dated 2/16/2024 revealed rooms [ROOM NUMBER] were not listed as needing repairs.

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 one of one kitchen reviewed for pests.<BR/>1. There were multiple live flies and gnats in the kitchen.<BR/>2. There were multiple live flies in the dining room.<BR/>These failures could put residents who consumed food from the kitchen and who ate in the dining room at risk for infection and/or food contamination. <BR/>The findings included:<BR/>Observation of the facility's kitchen dry storage area on 07/29/24 at 09:10am revealed 2 flies and approimately 10 gnats that were flying around in the area.<BR/>Observation of the facility's kitchen food preparation and cooking area on 07/29/24 at 09:45am revealed multiple flies were flying around in the kitchen area and had landed on multiple food preparation surfaces. <BR/>Observation on 07/29/24 at 11:45am of the facility's dining room revealed multiple flies in the dining room. One resident was noted to have a fly swatter on the dining room table that she was sitting at. <BR/>In an interview on 07/30/24 at 1:43pm, the DM stated that they had ordered and received an air curtain for the dining room door to help keep the flies and gnats outside and they were waiting on an electrician to fix the electrical issue so that it could be installed. The DM stated the electrician should be out next week. <BR/>In an interview on 07/31/24 at 10:36am, the ADM stated that the MS was out of the facility to get foggers to spray outside. The ADM stated they would be spraying outside at least weekly during peak seasons to help control the flies. The ADM stated the MS was also looking for fly traps for the kitchen. The ADM stated pest control was contracted for 2 times a month; one time to spray the inside and the next time outside, but that they could call them anytime to come in for additional treatment if needed. The ADM stated that pest control should be coming out today (07/31/24).<BR/>In an interview on 07/31/24 at 11:24am, MS stated pest control came out 2 times a month and as needed. MS stated pest control had been out on 7/25/24 and 7/20/24. MS stated pest control should be out by about 1:00 pm today and that he was going to discuss how to control the flies in the facility and what recommendations or remedies the pest control company had.<BR/>Record review of the facility's pest control request log on 7/31/24 at 10:50am revealed 13 entries dated 6/26/24 through 7/29/24. 12 of 13 entries were related to roaches and 1 of 13 entries was related to ants. There were no entries related to flies or gnats for any area of the facility.<BR/>Record review of the facility's pest control invoices on 7/31/24 at 11:26am revealed the pest control company had been out on 7/20/24 and 7/25/24 and had treated for roaches and ants, but there was no mention of treating for flies inside or outside the facility.<BR/>