THE LEV AT SAN ANTONIO

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents drug regiment was free from unecessary drugs (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 14 (Resident #1) residents reviewed for pharmacy services. <BR/>The facility failed to monitor Resident #1's side effects and behaviors regarding the resident's olanzapine (antipsychotic medication) for schizoaffective disorder, busPIRone (antianxiety medication) for anxiety disorder, and Sertraline (antidepressant) for depression related to schizoaffective disorder from 11/17/2023 to 08/08/2024. <BR/>This failure placed the residents at risk of side effects and adverse reactions to the medications as ordered by the physician and a delay in treatment and worsening of their condition. <BR/>Findings included: <BR/>Record review of Resident #1's electronic face sheet, dated 08/08/2024, reflected the resident was admitted to the facility on [DATE]. Resident #1's diagnoses included: end stage renal disease (the kidneys lose the ability to remove waste and balance fluids), type 2 diabetes mellitus (the body has trouble controlling blood sugar and using it for energy), schizoaffective disorder (mental disorder with mood disorder such as depression), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). <BR/>Record review of Resident #1's quarterly MDS assessment with an ARD of 05/08/2024 reflected the resident scored an 13/15 on her BIMS which signified the resident was cognitively intact, and Resident #1 was taking antipsychotic, antianxiety, and antidepressant as ordered. <BR/>Record review of Resident #1's comprehensive care plan, revised on 11/09/2023, reflected [Resident #1] uses anti-anxiety medications for anxiety disorder, antidepressant, and antipsychotic medications for schizoaffective disorder and intervention: administer these medications as ordered, monitor side effects every shift, and monitor behaviors.<BR/>Record review of Resident #1's physician order, dated 11/17/23, reflected the resident had the orders of busPIRone HCL oral tablet 10 mg give 1 tablet by mouth two times a day related to anxiety disorder, olanzapine tablet 5 mg give 1 tablet by mouth two times a day for schizoaffective disorder, and sertraline HCL oral tablet 100 mg give 1 tablet by mouth one time a day for depression related to schizoaffective disorder. <BR/>Record review of Resident #1's medication administration record, dated from 08/01/2024 to 08/31/2024, reflected sertraline was scheduled to the morning time, busPIRone was scheduled to 9 am and 5 pm, and olanzapine was scheduled to 7 am and 3 pm. Further record review of Resident #1's medication administration record reflected there were no sections for monitoring side effects and behaviors regarding using an antipsychotic medication, antianxiety medication, and antidepressant. <BR/>Observation on 08/08/2024 at 2:12 p.m. revealed Resident #1 was on the bed in her room and Resident #1 did not reveal any side effects related to antipsychotic medication, antianxiety medication, and antidepressant such as tremors, shuffling gait, rigid muscles, and vomiting. <BR/>Interview on 08/08/2024 at 2:12 p.m. with Resident #1 stated she denied difficulty swallowing, dry mouth, social isolation, loss of appetite, and fatigue. <BR/>Interview on 08/08/2024 at 2:00 p.m. with LVN B stated Resident #1 did not have side effects and adverse behaviors related to antipsychotic medication, antianxiety medication, and antidepressant, such as tremors, shuffling gait, rigid muscles, vomiting, difficulty swallowing, dry mouth, social isolation, loss of appetite, and weight loss. <BR/>Interview on 08/08/2024 at 2:13 p.m. with DON stated Resident #1 was taking olanzapine (antipsychotic medication) for schizoaffective disorder, busPIRone (antianxiety medication) for anxiety disorder, and Sertraline (antidepressant) for depression related to schizoaffective disorder, but the facility did not monitor the side effects and behaviors related to these medications as evidence by no monitoring sections on Resident #1's medication administration record. The facility nurses should have monitored side effects and behaviors everyday regarding Resident #1's antipsychotic medication, antianxiety medication, and antidepressant as a plan of care. Further interview with the DON revealed she did not know what reason the facility did not monitor, and the potential harm was the facility nurses could not notice side effects or adverse behaviors related to Resident #1's antipsychotic medication, antianxiety medication, and antidepressant. <BR/>Record review of the facility policy, titled Use of psychotic medications, revised 11/2017, reflected . 10. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis such as in accordance with nurse assessment and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident's right to be treated with respect and dignity and to care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for 1 of 2 residents (Resident # 4) reviewed for dignity.<BR/>The facility failed to ensure Resident #1's catheter bag was covered in a privacy bag.<BR/>This deficiency could affect residents with an indwelling catheter; and could lead to a diminished quality of life and psychosocial harm.<BR/>The findings were:<BR/>Record review of Resident#4's face sheet, dated 05/03/23, and EMR (electronic medical record) revealed, the resident was re-admitted on [DATE] with diagnoses that included: acute respiratory failure, pulmonary edema (fluid in the lungs), and obstructive and reflex uropathy (blockage of the urinary tract). Resident was a female; age [AGE]. RP (responsible party) was listed as: the resident. <BR/>Record review of Resident#4's quarterly MDS (minimum data set), dated 01/20/23, revealed: <BR/>o <BR/>BIMS (brief interview of mental status) Score was 12 (moderate impairment). <BR/>o <BR/>ADLs (activities of daily living): B/B (bowel and bladder) listed bowel was incontinent. Bladder was indwelling catheter. Transfer was extensive one person Bed Mobility extensive two persons assistance. ROM (range of motion): resident had no impairment<BR/>Record review of Resident #4's CP, dated 03/14/23, listed the goal/ intervention for an indwelling catheter read: Ensure Foley bag is in privacy bag while in bed or W/C.<BR/>Record review of Resident#4's Physician' Orders, dated 03/14/23 read: privacy bag while in bed or w/c<BR/>Record review of Resident #4 's TAR (treatment administration record), (dated May 2023,revealed the resident received treatment for indwelling catheter which included: monitor for infection, ensure catheter strap in place, and ensure privacy bag was present. <BR/>Observation and interview on 05/03/23 at 11:24 AM , Resident #4 was in bed, alert and oriented. Catheter bag present [located on the bottom rail of the bed] without privacy bag (roommate present); urine exposed in the bag and the door was opened; and the bag was visible to people outside the room. The Resident stated, .they check on the catheter every day .when I get up the catheter bag goes with me on the wheel chair .it is never covered .I feel embarrassed because staff and residents can see my urine .I brought it up in the past .I go to the doctor once per month .the bag is not covered .I go out of the room about one or two times per month . <BR/>During an interview on 05/03/23 at 11:55 AM, LVN A stated that catheter care was done on the resident in the morning on 05/03/23 and LVN A forgot to check on the placement of the privacy bag; and checking of the privacy bag was part of catheter care. [ as stated above the resident felt embarrassed because people could see the urine in the bag when the door was opened]. <BR/>During a telephone interview on 05/03/23 at 1:36 PM, LVN D stated they (LVN D) provided catheter care to Resident #4 on 05/03/23 morning and did not noticed that the catheter bag was not covered in a privacy bag and checking of the privacy bag was part of catheter care<BR/>During an interview on 05/03/23 at 11:49 AM, the DON stated; the catheter bag was exposed with urine and it was a dignity issue The DON stated that nursing staff was responsible to check on the privacy bag and the catheter. The DON did not offer an explanation as to why Resident #4's catheter bag was not covered in a privacy bag.<BR/>Record review of facility's Catheter Care policy dated 2021 read: .6. Leg bags will be attached to the resident's thigh or calf making sure to have slack on the tubing to minimize pressure and tension. Ensure straps are snug but not tight .2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use .<BR/>Record review of the facility's Abuse, Neglect and Exploitation policy, dated 2022, read: .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .<BR/>Record review of Resident #4's admission Packet, dated 09/09/21, Statement of Resident Rights, signed by resident read: be treated with courtesy, consideration, and respect . <BR/>Record review of facility's Resident Rights policy dated, 2022, read: The resident has a right to be treated with respect and dignity .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that the resident's needs and choices for how he spends time outside the facility, were not supported and accommodated, including making transportation arrangements, for 1 of 8 resident (Resident #54) whose care was reviewed, in that: <BR/>Resident #54's requested help with transportation for a non-medical appointment to explore benefits he may qualify for due to his diagnoses of blindness, including help with medical appointments. <BR/>This deficient practice could place residents with the ability to make choices at risk of having their rights violated, diminished quality of life and unmet needs. <BR/>The findings were: <BR/>Record Review of Resident #54's admission Record, dated 08/28/24, reflected a [AGE] year-old male admitted [DATE] with diagnoses to include blindness in one eye, low vision in the other eye, and glaucoma (group of eye conditions that damage the optic nerve) in right eye.<BR/>Record Review of Resident #54's quarterly MDS assessment, dated 06/26/24, reflected Resident #54 had a BIMS score of 15 out of 15, indicating intact cognition. <BR/>Record Review of Resident #54's care plan, dated 08/26/24, reflected, [Resident #54] is dependent on staff for meeting emotional, intellectual, physical, and social needs, dated 03/16/23.<BR/>Record Review of Resident #54's doctor's orders, dated 08/26/24, reflected May go out on pass with meds, dated 11/22/23. <BR/>Record Review of the Facility Assessment, dated 08/02/24, reflected they had a transportation van as a physical resource for the facility.<BR/>During an interview on 08/26/24 at 09:04 AM, Resident #54 revealed a [non-profit organization] set him up with the blind division of [organization #2] to explore more benefits Resident #54 could qualify for due to his diagnosis of blindness, to include medical benefits. Resident #54 revealed he missed about 3 appointments with [organization #2] because the facility would cancel or not set up his transportation accommodations due to this appointment not being considered a medical appointment. <BR/>During an interview on 08/28/24 at 10:08 AM, Receptionist N revealed the facility only made transportation arrangements for medical or health appointments. She further revealed they did not make any other transportation arrangements. She further revealed some residents used [transportation company] for themselves. She further revealed the facility had a transportation van but the facility was not using it. <BR/>During an interview on 08/28/24 at 10:35 AM, the Administrator revealed they did not use the facility's transportation van because it was titled in another state. They did, however, coordinate with [transportation companies]. She further revealed they would accommodate transportation for other appointments and the residents would schedule appointments through the receptionist. <BR/>During an interview on 08/28/24 at 02:20 PM, the BOM revealed the facility only scheduled residents to attend medical appointments through [transportation companies]. She revealed the facility can make transportation arrangements for residents to pay for. She revealed Resident #54 wanted transportation to [organization #2] because he wanted to work in the community . She revealed they didn't offer transportation for this.<BR/>During an interview on 08/28/24 at 02:34 PM, confidential staff member revealed she was told she could not make any transportation arrangements for Resident #54. When the confidential staff member was told she couldn't make transportation arrangements for Resident #54, she was not asked why Resident #54 needed transportation for others to decide if he needed transportation for health or not . The confidential staff member stated this appointment seemed necessary for Resident #54 to attend as it would benefit his quality of life and health. She further revealed she was not aware if the facility tried to only schedule transportation with Resident #54 and have Resident #54 pay for it. <BR/>During an interview on 08/30/24 at 03:08PM, staff member from [organization #2] revealed she had to visit the facility because Resident #54 was not able to attend appointments with her. She revealed Resident #54 said he could not go to the appointments because it was not a medical appointment, however, she revealed their organization helps with medical appointments like helping Resident #54 see an eye specialist. She further revealed the facility told her they couldn't help Resident #54 with transportation because Resident #54's insurance would not cover his transportation to this appointment. She further revealed this was concerning to her but she knew that insurance was complicated. <BR/>Record Review of Statement of Resident Rights in the residents' admission agreement, undated, reflected The facility must encourage and assist you to fully exercise your rights .You have the right to: 1. All care necessary for you to have the highest possible level of health; 4. Be treated with courtesy, consideration, and respect .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment reviewed for safe water temperatures and homelike environment, in that; <BR/>1. <BR/>Water temperatures at hand sinks and showers were out of safe parameters (100-110 degrees Fahrenheit) in public restrooms, resident restrooms and shower stalls, and in the communal shower room.<BR/>2. <BR/>Cardboard screwed into air conditioning vent to prevent air flow in room [ROOM NUMBER]. <BR/>3. <BR/>Rooms 409, shower water was 76.5/85.5 Degrees Fahrenheit, room [ROOM NUMBER] shower temperature was 85.5 <BR/>Degrees Fahrenheit, and the 200 main shower water temperature was 75.7 Degrees Fahrenheit.<BR/>This deficient practice could affect all residents, staff and visitors by placing them at risk for injury related to water temperatures exceeding safe parameters , or diminished quality of life by exposure to an uncomfortably low water temperatures during hand washing or showers and a non-homelike environment. <BR/>The findings included:<BR/>1.Record review of the quarterly MDS assessment, dated 4/05/2023, reveal Resident #28 was a [AGE] year-old male admitted [DATE]. Primary medical condition for admission was medically complex conditions related to schizophrenia. Other active diagnoses included cerebrovascular accident, transient ischemic attack, or stroke. Functional status coded as total dependence for set up only. Formal, clinical skin assessment revealed Resident #28 was not at risk for developing pressure ulcers. <BR/>Record review of the admission record revealed Resident #42 was a [AGE] year-old female admitted on [DATE]. <BR/>Record review of the quarterly MDS assessment dated [DATE], revealed Resident #42's primary medical condition category for admission was medically complex conditions related to COVID-19. Resident #42 had a summary BIMS score of 13, indicative of intact cognition. Resident #42 required physical help limited to transfer only by one staff member for bathing. Resident #42 had a formal, clinical assessment that indicated she was at risk of developing pressure injuries. <BR/>In an interview on 6/20/2023 at 12:31 PM, Resident #28 stated the water gets too hot in the [communal] shower room. Resident #28 stated, It's surprising no one has gotten hurt, it's so hot! Resident #28 stated there were frequently times when there was no hot water at all. Resident # 28 stated, he had skipped showers because there was no hot water available before he wanted to go to bed. <BR/>In an interview on 6/21/2023 at 2:16 PM Resident #42 stated she usually get showers on the evening shift [2p-10p] on Tuesdays/Thursdays/Saturdays. Resident #42 stated she did receive a shower on Monday [6/19/2022] just prior to her therapy session. Resident #42 stated halfway through the shower, they ran out of hot water. Resident #42 could not recall the name of the female aide assisting her. Resident #42 stated the aid had to go get a basin of warm water to rinse all the soap off her. Resident #42 stated that today she felt itchy but was not sure if it was because of the shower she received on Monday (6/19/2023) or she might be sensitive to the material [wool blend] her sweater was made of. <BR/>In an observation on 6/21/2023 at 6:16 PM, the hand sink water temperature was 138 degrees Fahrenheit, and the shower stall water temperature was 156 degrees Fahrenheit in room [ROOM NUMBER]. <BR/>In an observation and interview on 6/21/2023 at 6:30 PM, with ADON present, the hand sink water temperature was 136 degrees Fahrenheit, and the shower stall water temperature was 154 degrees Fahrenheit in the communal shower room . The ADON stated no residents or staff have voiced any concerns; and there were no reports of scalding of any resident, staff or visitor. In room [ROOM NUMBER], the hand sink water temperature was 132 degrees Fahrenheit, and the shower temperature was 154 degrees Fahrenheit. <BR/>In an interview on 6/21/2023 at 6:45 PM, with Resident #68 stated the water temperatures have been fine. Resident #68 did not think there had been any problems with the water temperature or pressure. Resident #68 stated sometimes the facility runs out of hot water. Resident #68 stated he had never gotten halfway through a shower and then had no hot water. Resident #68 stated, it's an all or nothing situation, you can tell immediately if there is no hot water. Resident #68 stated he like to take extra hot showers. Resident #68 stated he was independent with showering, as long as staff brought him the necessary supplies. Resident #68 stated he had to wait an hour or two only once or twice to take a shower due to lack of hot water. <BR/>In an interview on 6/21/2023 at 7:05 PM with the ADON present, the MTN stated three days prior the maintenance assistant had been sent unsupervised to adjust the boiler thermostat higher in response to resident complaints that the water temperatures at the furthest point from the boiler were too cool. The MNT stated the maintenance assistant was not available for interview The MNT stated he checked the water temperatures twice weekly and none of the temperatures had been above 120 degrees Fahrenheit. The MNT stated he did not realize the boiler thermostat had been set to 145 to 150 degrees Fahrenheit. The MNT stated the water temperatures closer to the boiler would be higher than the water temperatures at the furthest point in the building. The MNT stated the communal shower is the furthest point from the boiler. The MNT stated the 300 hall rooms would be the closest to the boiler. The MNT stated he checked the water temperatures at multiple locations daily since the assistant had adjusted the boiler thermostat, and those temperatures ranged between 114 to 120 degrees Fahrenheit at the furthest point from the boiler. The MNT stated he would turn the thermostat down, but it would probably take all night for a noticeable temperature decrease.<BR/>In an interview on 6/22/2023 at 7:39 AM, the MNT stated he was able to get the water temperatures down significantly. The MNT stated the showers were now temping at 111 degrees Fahrenheit and the hand sinks were temping at 108 degrees Fahrenheit. <BR/>In an observation on 6/22/2023 at 12:26 PM the communal shower room water temperature in the shower stall was 125 degrees Fahrenheit. <BR/>In an observation on 6/22/2023 at 12:31 PM, in room [ROOM NUMBER], the hand sink and shower stall water temperatures did not rise above 75 degrees Fahrenheit after 5 minutes of running hot water simultaneously at the hand sink and the shower stall.<BR/>In an observation and interview on 6/22/2023 at 4:50 PM, with MNT present, the communal shower room hand sink water temperature was 76.5 degrees Fahrenheit, and the shower stall water temperature was 78.5 degrees Fahrenheit. The MNT stated it would probably be an hour to an hour and half before there is hot water again. The MNT did not have an explanation as to why the water temperature was 125 degrees Fahrenheit at the communal shower room which was the farthest point from the boiler but in room [ROOM NUMBER], which was closer to the boiler, there was no hot water just after lunch. <BR/>In an interview on 6/22/2023 at 5:02 PM, CNA D stated that she provided a shower to Resident #42 on Monday [6/19/2023] but did not recall running out of hot water before completing the shower for Resident #42. CNA D stated that if the hot water stopped prior to completing the shower for any resident, she would obtain a basin of warm water to finish the task. CNA D stated she could not recall that happening recently. <BR/>In an interview on 6/22/2023 at 5:20 PM, RA C stated on there are approximately 2 to 4 showers scheduled on the Monday/Wednesday/Friday 2p-10p shift per aide, with 8 to 10 showers scheduled on the Tuesday/Thursday/Saturday 2p-10p shift per aide. RA C stated frequently there is not enough hot water to complete all the scheduled showers in one block of time on the 2p-10p shift. RA C stated when this happens, residents are advised to wait approximately one hour for the hot water to be adequate for the rest of the showers. RA C stated that right as of this moment, 10 of the scheduled 19 showers for this shift (2p-10p) were completed, with 9 showers still to be provided. RA C stated, if we wait until after dinner, or in about an hour, there should be enough hot water to complete the rest of the residents' showers for the day. RA C stated no resident had missed getting a shower because of a lack of hot water, although they may have had to wait for the hot water [tank] to fill back up.<BR/>In an observation on 6/22/2023 at 5:24 PM the shower stall water temperature was 126.4 degrees Fahrenheit in room [ROOM NUMBER]. <BR/>In an observation on 6/23/2023 at 8:34 AM, the water temperature in the communal shower room shower stall read 78 degrees Fahrenheit. <BR/>In an observation on 6/23/2023 between 4:36 PM and 5:22 PM, The MNT obtained water temperatures at the hand sink and shower stall at 13 different locations (communal shower room, rooms 209, 208, 304, 305, 308, 309, 313, 315, 503, 515, 409, and 417) with temperatures ranging from 76.8 to 127 degrees Fahrenheit. <BR/>Record review of the Grievance Form dated 2/13/2023, revealed the following statement, Maintenance is working to rectify all water issues and a plumbing company has been hired to handle any repairs. Resident (unnamed) has been offered alternate shower options while awaiting repairs. Grievance Form dated 3/29/2023 revealed under explanation of concern: Complaint of no hot water . Handwritten on the back of this form, House Keeping and maintenance were notified and are rectifying the issues of concern with a date of 3/29/2023; Further, with a date of 4/18/2023, Maintenance has been diligently attempting to correct all plumbing issues. Repairs are being made daily. Resident (unnamed) was offered another room without issues and declined to accept. Offer extended on several occasions. <BR/>Review of Maintenance Water Temperatures logbook revealed no readings out of the safe parameters of 100-110 degrees Fahrenheit on any of the entries. There were omitted or missed entries. The log was up to current date (6/22/2023) and contained 5 or more years of data. <BR/>2.In an observation, and interview on 6/20/2023 at 12:46 PM, a section of brown cardboard could be observed secured with screws into the air conditioning vent in the ceiling over Resident #42's recliner. [See P1, photograph.] Resident #42 stated the cardboard had been in place since she moved into the facility. Resident #42 stated the cardboard was the only way the MNT could keep the cold air from blowing so hard on her. Resident #42 stated she is always cold and dressed for warmth every day. Resident #42 was observed to be wearing dress slacks, a long-sleeved blouse and a long sleeved, thick sweater. Resident #42 stated she thought the cardboard was ugly but stated she would rather live with ugly than be miserably cold all the time. Observations of ambient room temperatures throughout the facility between 6/19/2023 and 6/23/2023 revealed temperatures between 71-81 degrees Fahrenheit. Local area under heat advisory during this time frame, with environmental temperature highs above 100 degrees Fahrenheit, with heat index over 110 degrees Fahrenheit. [Accessed 6/22/2023 via https://forecast.weather.gov/]<BR/>3. Observation on 6/20/2023 at 3:35 PM in resident room [ROOM NUMBER] shower temperature was 85.5 Degrees Fahrenheit.<BR/>Observation on 6/21/2023 at 3:18 PM in resident room [ROOM NUMBER] revealed the shower room was 85.5 Degrees Fahrenheit. <BR/>Observation on 6/22/2023 at 4:36 PM in the 200 main shower with the Maintenance Supervisor took shower water temperature was 75.7 Degrees Fahrenheit.<BR/>Observation on 6/22/2023 at 4:50 PM in resident room [ROOM NUMBER] with MNT revealed the shower room was 76.2 Degrees Fahrenheit. <BR/>Observation on 6/22/2023 at 4:51 PM with the MNT took the water temperature with his thermometer, Resident #6's shower water was 76.2 Degrees Fahrenheit. <BR/>In an interview on 6/21/2023 at 2:02 PM, MNT stated that one thermostat controlled a block of 3 rooms. MNT stated Resident #42 is cold natured, but residents in the other rooms on her thermostat were not. MNT stated Resident #42 complained about being able to feel and hear the air conditioning blowing on her harder with the just the vent set in the closed position. MNT stated the vent was in the closed or off position. MNT stated he screwed a section of brown cardboard into the vent to appease Resident #42. MNT stated he had only recently screwed the cardboard into the air conditioning vent but could not recall exactly when that was done. MNT stated he would move the brown cardboard section to the inside of the air conditioning vent, so it would not be visible. <BR/>Review of undated Safe and Homelike Environment policy revealed statement, . facility will provide a safe, clean, comfortable and homelike environment, . and does not pose a safety risk. Under the heading Policy Explanation and Compliance Guidelines: 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Under definitions, homelike environment should include the resident's opinion of the living environment. <BR/>Review of undated Safe Water Temperatures policy revealed statement, .facility to maintain appropriate water temperatures in resident care areas. Under the heading Policy Explanation and Compliance Guidelines: 5. Water temperatures will be set to a temperature of no more than 110 degrees Fahrenheit. 6. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents' rights to voice grievances to the facility or other agencies or entities that heard grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 8 residents (Resident #16) reviewed for grievances:<BR/>1. <BR/>The facility failed to ensure Licensed Vocational Nurse A (LVN A) initiated a grievance report on behalf of Resident #16's grievance on 08/23/2024.<BR/>2. <BR/>The facility failed to ensure Medication Aide O (MA O) and the ADON initiated a grievance report on behalf of Resident #16's grievance on 08/25/2024.<BR/>This failure could place residents at risk by denying their right to make and have grievances heard and contributed to ill feelings of not being heard and unresolved issues. <BR/>The findings included:<BR/>1. <BR/>Resident #16<BR/>A record review of Resident #16's admission record dated 08/27/2024 revealed an admission date of 05/26/2024 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitations), anxiety, and mood disorder. <BR/>A record review of Resident #16's admission MDS assessment, dated 06/29/2024, revealed Resident #16 was a [AGE] year-old female admitted for long term care and was assessed with a BIMS score of 12 out of a possible 15 which indicated no cognitive impairment. <BR/>A record review of Resident #16's care plan dated 08/28/2024, revealed, Resident #16 is dependent on staff for meeting emotional, intellectual, physical, and social needs . All staff to converse with resident while providing care . Resident #16 has a potential communication problem r/t bilateral tinnitus (ringing in the ears) . COMMUNICATION: Allow adequate time to respond, repeat as necessary, Do not CNA rush , Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed <BR/>A record review of Resident #16's physicians' orders revealed the Medical Director gave an order on August 9th, 2024, for Resident #16 to be seen by an oncology physician.<BR/>A record review of the facility's grievance binder for the period of January 2024 through August 25, 2024, revealed no grievances for Resident #16. <BR/>During an interview on 08/25/2024 at 12:00 PM Resident #16 stated she was diagnosed on [DATE]th, 2024, with kidney cancer. Resident #16 stated her physician had ordered for her to see a cancer specialist and she has not received any information on an appointment. Resident #16 stated she had asked many staff for details of an appointment to see the specialist without success, no one will give me an answer. Resident #16 stated she recently told LVN A early this morning, (LVN A) works overnight and last night / early this morning, I told her I was upset no one would tell me when my appointment with the cancer specialist is, can you look into this? <BR/>During an interview and observation on 8/25/24 at 12:10 PM revealed MA O entered the room to administer medications to Resident #16. Resident #16 stated to MA O she had a complaint and would like to have information on her cancer specialist appointment. MA O was observed to leave Resident #16's room. MA O stated to the surveyor Resident #16 had just now made a complaint regarding her cancer specialist appointment. MA O stated she would report the complaint to the nurse. <BR/>During an interview on 08/27/24 at 05:13 PM the ADON stated in the afternoon of 08/25/2024 MA O asked her to research an oncology appointment on behalf of Resident #16. The ADON stated MA O did not report Resident #16 had a complaint. The ADON stated if she had she would have had MA O generate a grievance report and would have followed the investigation of the report. <BR/>During an interview on 08/30/24 at 01:10 PM, LVN A stated she was Resident #16's nurse on the 08/23/2024 from 10:00 PM to 8/24/2024 at 06:00 AM. LVN A stated, during the shift, Resident #16 reported to her that she was concerned no one had given her any information regarding an oncology appointment she needed. LVN A stated she had not generated a grievance regarding Resident #16's concerns for information regarding the oncology appointment. LVN A stated Resident #16 was not complaining but rather just had a concern. LVN A stated an example of a complaint would include more emotions and or Pain. LVN A stated she had relayed the concern to the hospice RN but had not reported the concern to the ADON and or the DON. <BR/>A record review of Resident #16's medical record revealed a note dated 08/23/2024 at 02:31 AM authored by LVN A, . relayed to Hospice nurse, Resident #16 wanting to be seen by oncology <BR/>During an interview on 08/29/24 at 05:40 PM the DON stated the expectation for all staff who heard a complaint were to report the complaint on a grievance form and report the grievance to a supervisor and or the administrator or herself (the DON). The DON stated the risk for harm to residents was varied and at a minimum could lead to unresolved needs and or concerns. <BR/>A record review of the facility's undated Resident and Family Grievances policy revealed, . A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC facility stay. <BR/>The facility will not prohibit or in any way discourage a resident from communicating with external entities including federal and state surveyors or other federal or state health department employees . Grievances may be voiced in the following forums: Verbal complaint to a staff member or Grievance Official . The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. Take any immediate actions needed to prevent further potential violations of any resident's right. Report any allegations involving neglect, abuse, injuries of unknown source, and or misappropriation of resident property immediately to the administrator and follow procedures for those allegations. Forward the grievance form to the grievance official as soon as practicable. The grievance official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident for 1 of 8 residents (Resident # 47) reviewed for pharmacy services. LVN H did not document an SBAR to Resident #47's physician in which Resident #47 had dislodged her intravenous access and had not received her 1 dose of the prescribed antibiotic. LVN H administered Resident #47's physician ordered antibiotic without documenting the physician's order. This failure could place residents at risk for harm due to not receiving pharmacy services as ordered. The findings included: A record review of Resident #47's admission record dated 9/10/2025 revealed an admission date of 1/4/2022 with diagnoses which included schizophrenia (a chronic mental health condition characterized by a persistent disruption in thoughts, perceptions, and behaviors), dementia (a general term for a group of conditions that cause a gradual decline in cognitive abilities, such as memory, thinking, reasoning, and language), and heart failure. A record review of Resident #47's quarterly MDS assessment dated [DATE] revealed Resident #47 was a [AGE] year-old female admitted for LTC and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #47's care plan dated 9/10/2025 revealed, (Resident #47) is at risk for adverse reactions related to polypharmacy . if resident has more than one prescribing medical doctor ensure that each physician has the full list of meds available including over the counter and as needed medications while ordering. A record review of Resident #47's physicians orders dated 9/8/2025 revealed the Physician prescribed for Resident #47 to receive ceftriaxone (a powerful, broad-spectrum antibiotic that works by killing bacteria) 2 grams once a day intravenously at midnight for 5 days for pneumonia starting on 9/9/2025. A record review of Resident #47's nursing progress notes dated 9/9/2025 at 1:52 AM revealed LVN I documented, Patient pulled out IV tubing. pending (intravenous access contractor) to replace iv. A record review of Resident #47's Nursing Progress notes dated 9/9/2025 at 7:57 AM revealed LVN H documented, IV Ceftriaxone 2mg/100ml started and running well. IV placed to right forearm- posterior. A record review of Resident #47's physicians orders and medication administration record for September 2025 revealed no order for a 1-time administration of ceftriaxone 2 grams intravenously at 7:57 AM on 9/10/2025. During an interview on 9/9/2025 at 7:41 PM LVN I stated Resident #47 was diagnosed with pneumonia and was prescribed Ceftriaxone intravenously daily at midnight with the first dose scheduled for 9/9/2025 at midnight. LVN I stated she was the nurse on duty at that time but had not given the medication because Resident #47 had pulled out her IV access earlier in the day and could not administer the medication. LVN I stated she worked 9/8/2025 from 2:00 PM to 9/9/2025 at 6:00 AM. LVN I stated she organized the intravenous contractor to arrive early 9/9/2025 to re-establish the intravenous access for Resident #47. LVN I stated she gave report to LVN H at 6:00 AM 9/9/2025. During an interview on 9/10/2025 at 1:39 PM LVN H stated she had received report from LVN I on 9/9/2025 at 6:00 AM which included Resident #47 had removed her IV access and had not received her first dose of her antibiotic. LVN H stated the intravenous access contractor had arrived shortly after 6:00 AM on 9/9/2025 and re-established her intravenous access. LVN H stated she had SBAR'ed (a report of situation, background, and recommendation) the physician and received a 1-time order to administer Resident #47 antibiotic now and continue with the scheduled antibiotic daily at midnight. LVN H stated she had not documented the report to the physician and had not entered the order into the physician's order summary nor the medication administration record. LVN H stated she administered the antibiotic on 9/9/2025 at 7:57AM and had not documented the administration on Resident #47's medication administration record. During an interview on 9/11/2025 at 4:30 PM the DON stated the expectation for nurses who reported a change of condition to a physician was for the nurse to accurately and timely document the report to include any new orders. The DON stated the documentation could be but not limited to the physicians' orders, the medication administration record, and the progress notes. The DON stated she received a report that LVN H had not documented the physicians new order for a 1-time medication administration of Resident #47's antibiotic nor had LVN H documented the change of condition SBAR for Resident #47's loss of intravenous access and missed first dose of her antibiotic. The DON stated LVN H also had not documented Resident #47's antibiotic administration on 9/9/2025 at 7:57 AM in Resident #47's medication administration record. The DON stated the potential negative outcome could be lack of documentation for Resident #47's medication administration. During an interview on 9/11/2025 at 5:00 PM the administrator stated she agreed with the DON's findings regarding LVN H and Resident #47's intravenous antibiotic administration. A record review of the facility's undated policy titled Medication Administration revealed, medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, any manner to prevent contamination or infection. policy explanation and compliance guidelines; . review MAR to identify medication to be administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 28 medication administration opportunities with 2 errors resulting in a 7.14% medication error rate, for 1 of 8 residents (Resident #57) reviewed for medication administration errors. Medication Aide J administered to Resident #57 his prescribed:Metoclopramide (a prescription medication used to treat and prevent nausea and vomiting, and to manage certain gastrointestinal issues.)Gabapentin (a prescription medication used to treat nerve pain and epilepsy.)Late by 51 minutes. These failures could place residents at risk for not receiving the therapeutic effects of their medications. The findings included: A record review of Resident #57's admission record dated 9/10/2025 revealed an admission date of 6/26/2025 with diagnoses which included diabetes mellitus with diabetic neuropathy (nerve damage related to high blood sugar levels) and gastro-esophageal reflux (a condition where stomach contents flow back up into the esophagus, causing irritation and inflammation.) A record review of Resident #57'a quarterly MDS assessment dated [DATE] revealed Resident #57 was a [AGE] year-old male admitted for LTC and assessed with a BIMS score of 12 out of a possible 15 which indicated intact cognition. A record review of Resident #57's care plan dated 9/10/2025 revealed, (Resident #57) has diabetes mellitus . diabetes medication as ordered by doctor . (Resident #57) had GERD related to hyperacidity . give medications as ordered . A record review of Resident #57's physicians orders dated 9/10/2025 revealed the physician prescribed for Resident #57 to receive:- Metoclopramide oral tablet 5mg give 1 tablet by mouth three times a day at 9:00 AM, 3:00 PM, and at 9:00 PM, related to GERD.- Gabapentin oral capsule 100mg give 2 capsules by mouth two times a day at 7:00 AM and at 3:00 PM related to diabetic neuropathy. During an observation and interview on 9/9/2025 at 4:51 PM revealed Medication Aide J prepared and administered to Resident #57 his metoclopramide 5mg and his gabapentin 100mg 2 capsules 51 minutes past the prescribed 3:00 PM to 4:00 PM time frame. Medication Aide J stated she had administered Resident #57's medications 51 minutes past the prescribed 3:00 PM to 4:00 PM time frame because when she attempted to administer the medications around 3:00 PM Resident #57 was receiving a bath and she made the decision to re-attempt later in the afternoon. Medication Aide J stated she had not alerted the charge Nurse to the potential late medication administration. During an interview on 9/11/2025 at 4:30 PM the DON stated the expectation was for medication aides and nurses to administer residents' medications at the time the prescriber intended with a time frame of 1 hour prior and 1 hour past the prescribed time. The DON stated a medication ordered for administration at 3:00 PM and administered at 4:51 PM would be 51 minutes past the acceptable time frame. The DON stated the potential negative outcome could be residents would not receive the intended therapeutic effects of their prescribed medications. A record review of the facility's undated policy titled Medication Errors revealed, this is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. definitions; medication error means the observed or identified preparation or administration of medications 4 biologicals which is not in accordance with prescribers' order . medication error rate is determined by calculating the percentage of errors observed during a medication observation. The numerator is the total number of errors that is observed, both significant and non-significant. The denominator consists of the total number of observations or opportunities of error it includes all the doses observed being administered plus the doses ordered but not administered. The equation for calculating the visionary is as follows: medication error rate = number of errors observed divided by the opportunities for errors. the facility shall insure medications will be administered as follows: according to physicians' orders. 5% or as well as their events.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .<BR/>Based on observation, interview, and record review the facility failed to establish and maintain <BR/>an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility, reviewed for infection control in that:<BR/>1.The DON exited a designated droplet transmission-based precautions room after doffing her N95 mask in the room. <BR/>2.The facility failed to ensure CNA F utilized appropriate infection control practices when entering a designated droplet transmission-based precautions room. <BR/>3.MA E did not sanitize bp cuff between residents. <BR/>4. CMA L did not have eye protection when entered a COVID positive room. <BR/>This deficient practice could affect all residents, staff and visitors at risk for infection.<BR/>Findings include:<BR/>1. In an observation and interview on 6/20/2023 at 5:45 PM, the DON was observed exiting room [ROOM NUMBER], a room designated droplet transmission-based precautions, without an N95 mask in place. The DON stated she doffed all her Personal Protective Equipment (PPE) in the room just prior to exiting the room. The DON stated the trash receptacle is just inside and behind the door. The DON stated staff are expected to doff their PPE in the room designated droplet transmission-based precautions perform hand hygiene, exit the room and immediately obtain a new mask from the isolation supply cart placed just outside of the room if they will be continuing with care in either warm zone or hot zone rooms. The DON stated she would review the policy and make any necessary changes to procedures. <BR/>Further observations between 6/21/2023 8:00 AM and 6/23/2023 8:00 PM revealed a roll of small clear trash bags on top of each isolation cart outside a designated droplet transmission-based precaution room. Staff were observed to exit the room with only their N95 mask in place, upon exiting the room, the staff members opened a trash bag, doffed their N95 masks directly into the trash bag, and tied it securely closed. The staff members performed hand hygiene and discarded the sealed trash bag with the used N95 mask(s) in an appropriate receptacle. <BR/>2.In an observation and interview on 6/20/2023 at 5:20 PM, CNA F entered room [ROOM NUMBER], designated droplet, transmission-based precautions without wearing an appropriate N95 mask. CNA F donned PPE gown, gloves and face shield appropriately. CNA F exited the room at 5:37 PM, with only a face shield in place. CNA F stated she had worn an N95 mask to enter the room but doffed all other PPE prior to exiting. CNA F stated the face shield could be sanitized between uses. CNA F took the face shield off, set it on the isolation cart outside of the room, and used disinfecting wipes to clean the mask. <BR/>3.In an observation, and interview on 6/23/2023 between 9:00 AM and 9:36 AM, MA E did not sanitize the blood pressure cuff between residents during observation of medication administration. MA E stated she forgot to sanitize the blood pressure cuff between each use due to being observed. MA E stated that she understood infection control principles, and that the blood pressure cuff should be sanitize between each resident to prevent possible cross-contamination. MA E stated residents on isolation precautions have dedicated equipment for their use. MA E stated none of the residents she had used the blood pressure cuff on were on transmission-based precautions at this time. MA E stated in the worse possible scenario would be if the first resident had an undisclosed infectious condition, it would be possible the next residents that used the dirty blood pressure cuff could get it through cross contamination. <BR/>4.Observation on 6/2023 at 11:58 PM revealed CNA L entered a COVID positive room with no eye protection.<BR/>Observation on 6/2023 at 11:59 PM in the front of the COVID positive room was a PPE cart with gloves, N95 mask, gowns and eye protections. Observation in front of all COVID rooms where posted PPE droplet precautions and what to wear in a resident COVID positive room, included eye protection. Observation of another posting in front of all COVID positive room Hot Zone room must have appropriate PPE.<BR/>During an interview on 6/20/2023 at 12 PM with LVN M confirmed CNA L entered resident room with no eye protection and handed her eye protections from outside the door. LVN M provided CNA L with eye protection from the PPE drawer in front of the COVID room. <BR/>During an interview on 6/20/2023 at 2:02 PM with CNA L confirmed she was not wearing eye protection in positive COVID room because she could not find in the PPE cart. <BR/>During an interview on 6/21/2023 at 6 PM with the Administrator discussed concerns and she only listened and did no reply further. <BR/>Review of undated Transmission-Based (Isolation) Precautions policy revealed, under the heading Policy Explanation and Compliance Guidelines: 7. f. The facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions. g. If sharing noncritical equipment between residents, the equipment will be cleaned and disinfected following manufacturer's instructions with an EPA-registered disinfectant after use. 9. Droplet Precautions- Healthcare personnel will wear a facemask for close contact with an infectious resident.<BR/>Review of undated infographic entitled Doffing (taking off the gear) placed on the door of each room designated droplet transmission-based precautions revealed the following order for removing PPE: 1. Remove gloves. 2. Remove gown. 3. Health Care Personnel may now exit patient room. 4. Perform hand hygiene. 5. Remove face shield or googles. 6. Remove and discard respirator [N95 mask]. 7. Perform hand hygiene after removing respirator.

Based on observation, interview and record review the facility failed to ensure to maintain all mechanical and electrical equipment in safe operating condition in 1 of 1 kitchen reviewed for equipment. The facility failed to ensure the temperature gauge on the dishwasher was working properly and the sanitation level was reaching between 50 PPM and 100 PPM to properly disinfect the dishware. 2. The DS failed to provide an updated water temperature and sanitation log for the dishwasher for documenting readings to ensure the equipment was working properly. These deficient practices could place residents at risk of not having equipment working in safe conditions. The findings were: A record review of the chemical temperature log for the month of September 2025 revealed there was not a log for the month of September 2025. A record review of the chemical temperature log for the month of August 2025 revealed 93 opportunities to document the water temperature and sanitation level with 21 of the 93 opportunities documented were below 50 PPM for the sanitation level and there were 8 missing opportunities for documentation. They were blank. Observation and interview on 09/07/2025 at 9:19 AM revealed DA A running the dishwasher and taking a reading of the level of sanitation in the dishwasher. Interview with DA A revealed the temperature gauge was not reading higher than 103 degrees. She stated the gauge was not working but mentioned it was working last Thursday (9/4/25), on the last day she worked before her days off. Further observation revealed she tested the sanitation level by dipping test strip and inserted into the reservoir on the outside of the dishwasher. She stated it was barely reaching 25 PPM and noted the color on the test strip did not match the color designating 50PPM. DA A stated she noted the sanitation level was reading low for at least the past three weeks and had brought it up to the DS's attention. She stated last Thursday, 9/4/25, she checked the sanitization level twice and the results were also low that day. She stated it should read at least 50 PPM. for it to kill all the bacteria otherwise it could make the residents sick. DA A further stated she was not documenting the water temperature or the sanitation level because there was not an updated log for September 2025. During an observation and interview on 9/7/2025 at 10:18 AM revealed DA A in the kitchen plating desserts in dishware she had previously washed in the morning. DA A presented the chemical / temperature logs for August 2025 which were kept on a clipboard by the DS's office. DA A stated she tested the water chemical sanitizer level prior to using the dishwasher. DA A stated the chemical level was obtained by using a chemical test strip dipped in the dishwasher water while in operation and comparing the test strip to the color scale on the side of the test strip container / bottle. DA A stated for days in August and September the test strip was below the required 50 PPM level and she had reported the finding to the DS. DA A stated she had measured the dishwasher chemical sanitizer water level this morning and the finding was below 50 PPM somewhere around 25 PPM. DA A stated she did not document the findings because there was no log for September 2025. DA A stated she recalled on 9/4/2025 the dishwasher chemical sanitization water level was below 50 PPM. Interview on 09/07/2025 at 10:21 AM with the DS revealed dietary aides were assigned dishwashing duties to include checking the dishwasher for proper sanitization chemical levels and water temperature three times a day before using the dishwasher to wash and sanitize dishes, utensils, pots pans etc. The DS stated the chemical sanitizer would be checked by using a chemical litmus paper strip and placing the test strip in the chemically infused water while the dishwasher was washing dishes and the test strip would be held against the color palette on the side of the litmus paper strip bottle. The DS stated the color reading should match the color palette to indicate 50 PPM of chemical sanitizer in the water and the minimum water temperature should reach 120 F. The DS stated both the chemical level of 50 PPM and the 120 F temperature were required for the dishwasher to effectively sanitize the dishes. The DS stated she would have the dietary aides do a demonstration to ensure they were doing it correctly. The DS stated 10 minutes ago she was informed by Dietary Aide A that Dietary Aide A had exchanged the chemical sanitizer because the chemical sanitizer was not reaching 50 PPM water saturation. The DS stated the lack of documentation and chemical sanitizer levels below 50 PPM could have a negative potential for germs and un-sanitized dishes and utensils. Interview on 9/7/25 at 3:35 PM with the DS revealed she did not know the sanitation levels for the dishwasher were reading 45 PPM before today, 9/7/25. She stated no one had said anything to her. She stated they received the new dishwasher a couple of months ago. She stated if not in the facility, dietary staff was to call her when there was a problem with any of the equipment. She stated she had in-serviced staff related to operating procedures for the dishwasher, temperature levels which should be between 120 and 140 degrees and in reading the sanitation levels in the water which should read between 50 and 100 PPM. She stated she would call the service company if the water temperatures or sanitation levels were outside of required parameters. She stated she called the service provider some time back because the temperature gauge was not working but never because the sanitation levels were reading low. Interview on 9/8/25 at 10:13 AM with DA A revealed she would run the dishwasher twice before washing the dishes and as stated in a previous interview, she noted the sanitation was under 50 PPM for the last 3 weeks. She stated it was right under 50 PPM so she documented it as being 45 PPM. She stated she let one of the Cooks know that there was not a current log for September 2025 for documenting the water temperature and sanitation level for the dishwasher. She stated the Cooks were in charge when the DS was not available. Interview on 9/825 at 10:43 AM with DA P revealed she would operate the dishwasher and would document the temperature and sanitation level on a piece of paper and leave it on the DS's desk because there was not a log for September 2025. She stated she did not remember the readings. Interview on 9/8/25 at 10:58 AM with DA Q revealed he had worked the dishwasher a couple of weeks ago but did not document the temperature or sanitation level because there was not a log for September 2025. During an interview on 9/8/2025 at 11:00 AM the DON revealed the opportunities when the dishwasher was operated below the effective water chemical sanitization levels could have potentially exposed residents to food borne illness. The DON stated the census on 9/7/2025 was 76 residents with a potential to affect 90% of the residents who received foods / meals from the kitchen. The DON stated no one had reported the kitchen's dishwasher had been operating below the chemical sanitizer level of 50 PPM. The DON stated if she had been aware of the situation she would have called for immediate action to include the correction of the chemical sanitizer to effectively sanitize dishware and an assessment of all potentially affected residents. Interview on 9/8/25 at 3:06 PM with the service provider for the facility dishwasher revealed he serviced the dishwasher on 9/7/25 because the DS reported the temperature gauge was not working and the sanitation level was reading low. He stated upon testing the dishwasher he noted the temperature gauge was not working properly and he replaced it. He also tested the sanitation level which was reading 10 PPM and stated it should reach between 50 and 100 PPM. He stated the sanitation level should reach the required parameters and the water temperature should reach 120 degrees during the wash cycle and 140 degrees during the rinse cycle in order for the dishware to properly sanitize and disinfect the dishware removing any bacteria. The service provider stated the DS manager had not reported any problems with the dishwasher before 9/7/25. Interview on 9/8/25 at 4:47 PM with the ADM revealed she was the DS immediate supervisor and expected the DS to ensure all the equipment was running properly, that the temperature logs for all appliances including the dishwasher were updated and that she ensured dietary staff completed the tasks assigned to them. The ADM stated she expected the DS to let her know of any problems and if not able to resolve the issues she would assist as needed. She stated she learned that on 9/7/25 the sanitation level in the dishwasher was reading 45 PPM and the temperature gauge was not working properly. She stated the DS had not reported any problems prior to 9/7/25. The ADM stated the DS should have noted the temperature logs for all appliances including the dishwasher had not been updated while rounding. In addition, the DS should have known the sanitation levels were low and reading 45 PPM during August 2025 and she should have addressed the problem at that time. The ADM stated that not properly sanitizing the dishware could lead to foodborne illness and the residents could get sick as a result. Review of facility policy, Dishwasher Temperature, undated, read in relevant part It is the policy of this facility that the dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. Policy Explanation and Guidance: 1. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. 2. Manufacturer's instructions shall be followed for machine washing and sanitizing. 4. For low temperature dishwashers (chemical sanitation): a. The wash temperature shall be 120 degrees Fahrenheit. b. The sanitizing solution shall be 50 PPM (parts per million) hypochlorite (chlorine) on dish surface in final rinse. 5. Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that the resident's needs and choices for how he spends time outside the facility, were not supported and accommodated, including making transportation arrangements, for 1 of 8 resident (Resident #54) whose care was reviewed, in that: <BR/>Resident #54's requested help with transportation for a non-medical appointment to explore benefits he may qualify for due to his diagnoses of blindness, including help with medical appointments. <BR/>This deficient practice could place residents with the ability to make choices at risk of having their rights violated, diminished quality of life and unmet needs. <BR/>The findings were: <BR/>Record Review of Resident #54's admission Record, dated 08/28/24, reflected a [AGE] year-old male admitted [DATE] with diagnoses to include blindness in one eye, low vision in the other eye, and glaucoma (group of eye conditions that damage the optic nerve) in right eye.<BR/>Record Review of Resident #54's quarterly MDS assessment, dated 06/26/24, reflected Resident #54 had a BIMS score of 15 out of 15, indicating intact cognition. <BR/>Record Review of Resident #54's care plan, dated 08/26/24, reflected, [Resident #54] is dependent on staff for meeting emotional, intellectual, physical, and social needs, dated 03/16/23.<BR/>Record Review of Resident #54's doctor's orders, dated 08/26/24, reflected May go out on pass with meds, dated 11/22/23. <BR/>Record Review of the Facility Assessment, dated 08/02/24, reflected they had a transportation van as a physical resource for the facility.<BR/>During an interview on 08/26/24 at 09:04 AM, Resident #54 revealed a [non-profit organization] set him up with the blind division of [organization #2] to explore more benefits Resident #54 could qualify for due to his diagnosis of blindness, to include medical benefits. Resident #54 revealed he missed about 3 appointments with [organization #2] because the facility would cancel or not set up his transportation accommodations due to this appointment not being considered a medical appointment. <BR/>During an interview on 08/28/24 at 10:08 AM, Receptionist N revealed the facility only made transportation arrangements for medical or health appointments. She further revealed they did not make any other transportation arrangements. She further revealed some residents used [transportation company] for themselves. She further revealed the facility had a transportation van but the facility was not using it. <BR/>During an interview on 08/28/24 at 10:35 AM, the Administrator revealed they did not use the facility's transportation van because it was titled in another state. They did, however, coordinate with [transportation companies]. She further revealed they would accommodate transportation for other appointments and the residents would schedule appointments through the receptionist. <BR/>During an interview on 08/28/24 at 02:20 PM, the BOM revealed the facility only scheduled residents to attend medical appointments through [transportation companies]. She revealed the facility can make transportation arrangements for residents to pay for. She revealed Resident #54 wanted transportation to [organization #2] because he wanted to work in the community . She revealed they didn't offer transportation for this.<BR/>During an interview on 08/28/24 at 02:34 PM, confidential staff member revealed she was told she could not make any transportation arrangements for Resident #54. When the confidential staff member was told she couldn't make transportation arrangements for Resident #54, she was not asked why Resident #54 needed transportation for others to decide if he needed transportation for health or not . The confidential staff member stated this appointment seemed necessary for Resident #54 to attend as it would benefit his quality of life and health. She further revealed she was not aware if the facility tried to only schedule transportation with Resident #54 and have Resident #54 pay for it. <BR/>During an interview on 08/30/24 at 03:08PM, staff member from [organization #2] revealed she had to visit the facility because Resident #54 was not able to attend appointments with her. She revealed Resident #54 said he could not go to the appointments because it was not a medical appointment, however, she revealed their organization helps with medical appointments like helping Resident #54 see an eye specialist. She further revealed the facility told her they couldn't help Resident #54 with transportation because Resident #54's insurance would not cover his transportation to this appointment. She further revealed this was concerning to her but she knew that insurance was complicated. <BR/>Record Review of Statement of Resident Rights in the residents' admission agreement, undated, reflected The facility must encourage and assist you to fully exercise your rights .You have the right to: 1. All care necessary for you to have the highest possible level of health; 4. Be treated with courtesy, consideration, and respect .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents' rights to voice grievances to the facility or other agencies or entities that heard grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 8 residents (Resident #16) reviewed for grievances:<BR/>1. <BR/>The facility failed to ensure Licensed Vocational Nurse A (LVN A) initiated a grievance report on behalf of Resident #16's grievance on 08/23/2024.<BR/>2. <BR/>The facility failed to ensure Medication Aide O (MA O) and the ADON initiated a grievance report on behalf of Resident #16's grievance on 08/25/2024.<BR/>This failure could place residents at risk by denying their right to make and have grievances heard and contributed to ill feelings of not being heard and unresolved issues. <BR/>The findings included:<BR/>1. <BR/>Resident #16<BR/>A record review of Resident #16's admission record dated 08/27/2024 revealed an admission date of 05/26/2024 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitations), anxiety, and mood disorder. <BR/>A record review of Resident #16's admission MDS assessment, dated 06/29/2024, revealed Resident #16 was a [AGE] year-old female admitted for long term care and was assessed with a BIMS score of 12 out of a possible 15 which indicated no cognitive impairment. <BR/>A record review of Resident #16's care plan dated 08/28/2024, revealed, Resident #16 is dependent on staff for meeting emotional, intellectual, physical, and social needs . All staff to converse with resident while providing care . Resident #16 has a potential communication problem r/t bilateral tinnitus (ringing in the ears) . COMMUNICATION: Allow adequate time to respond, repeat as necessary, Do not CNA rush , Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed <BR/>A record review of Resident #16's physicians' orders revealed the Medical Director gave an order on August 9th, 2024, for Resident #16 to be seen by an oncology physician.<BR/>A record review of the facility's grievance binder for the period of January 2024 through August 25, 2024, revealed no grievances for Resident #16. <BR/>During an interview on 08/25/2024 at 12:00 PM Resident #16 stated she was diagnosed on [DATE]th, 2024, with kidney cancer. Resident #16 stated her physician had ordered for her to see a cancer specialist and she has not received any information on an appointment. Resident #16 stated she had asked many staff for details of an appointment to see the specialist without success, no one will give me an answer. Resident #16 stated she recently told LVN A early this morning, (LVN A) works overnight and last night / early this morning, I told her I was upset no one would tell me when my appointment with the cancer specialist is, can you look into this? <BR/>During an interview and observation on 8/25/24 at 12:10 PM revealed MA O entered the room to administer medications to Resident #16. Resident #16 stated to MA O she had a complaint and would like to have information on her cancer specialist appointment. MA O was observed to leave Resident #16's room. MA O stated to the surveyor Resident #16 had just now made a complaint regarding her cancer specialist appointment. MA O stated she would report the complaint to the nurse. <BR/>During an interview on 08/27/24 at 05:13 PM the ADON stated in the afternoon of 08/25/2024 MA O asked her to research an oncology appointment on behalf of Resident #16. The ADON stated MA O did not report Resident #16 had a complaint. The ADON stated if she had she would have had MA O generate a grievance report and would have followed the investigation of the report. <BR/>During an interview on 08/30/24 at 01:10 PM, LVN A stated she was Resident #16's nurse on the 08/23/2024 from 10:00 PM to 8/24/2024 at 06:00 AM. LVN A stated, during the shift, Resident #16 reported to her that she was concerned no one had given her any information regarding an oncology appointment she needed. LVN A stated she had not generated a grievance regarding Resident #16's concerns for information regarding the oncology appointment. LVN A stated Resident #16 was not complaining but rather just had a concern. LVN A stated an example of a complaint would include more emotions and or Pain. LVN A stated she had relayed the concern to the hospice RN but had not reported the concern to the ADON and or the DON. <BR/>A record review of Resident #16's medical record revealed a note dated 08/23/2024 at 02:31 AM authored by LVN A, . relayed to Hospice nurse, Resident #16 wanting to be seen by oncology <BR/>During an interview on 08/29/24 at 05:40 PM the DON stated the expectation for all staff who heard a complaint were to report the complaint on a grievance form and report the grievance to a supervisor and or the administrator or herself (the DON). The DON stated the risk for harm to residents was varied and at a minimum could lead to unresolved needs and or concerns. <BR/>A record review of the facility's undated Resident and Family Grievances policy revealed, . A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC facility stay. <BR/>The facility will not prohibit or in any way discourage a resident from communicating with external entities including federal and state surveyors or other federal or state health department employees . Grievances may be voiced in the following forums: Verbal complaint to a staff member or Grievance Official . The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. Take any immediate actions needed to prevent further potential violations of any resident's right. Report any allegations involving neglect, abuse, injuries of unknown source, and or misappropriation of resident property immediately to the administrator and follow procedures for those allegations. Forward the grievance form to the grievance official as soon as practicable. The grievance official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to develop policies and procedures to ensure that before offering the influenza immunization, each resident or the resident's representative received education regarding the benefits and potential side effects of the immunization and each resident was offered an influenza immunization during October 1 through March 31 annually, for 3 of 70 residents (Resident #10, #22, and #28) reviewed for the influenza vaccine offered. <BR/>The facility failed to provide education to Residents #10, #22, and #28 regarding the benefits and potential side effects of the influenza immunization.<BR/>The facility failed to offer an influenza immunization to Residents #10, #22, and #28, during October 1, 2023, through March 31, 2024. <BR/>These deficient practices could place residents at risk for harm, by contracting and spreading influenza.<BR/>The findings included:<BR/>Resident #10:<BR/>A record review of Resident #10's admission record dated 08/25/2024 revealed an admission date of 10/19/2021 with diagnoses which included dementia (a general decline in cognitive abilities that affects a person's ability to perform everyday activities. This typically involves problems with memory, thinking, behavior, and motor control), personal history of covid-19 (a contagious virus), and type II diabetes (a chronic disease characterized by high blood sugar levels). <BR/>A record review of Resident #10s annual MDS assessment dated [DATE] revealed Resident #10 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 00 out of a possible 15 which indicated severe impaired cognition. <BR/>A record review of Resident #10's physicians orders dated 08/25/2024 revealed no order for Resident #10 to receive the influenza vaccine yearly. <BR/>A record review of Resident #10's immunization record dated 08/25/2024 revealed no influenza vaccine was offered and or declined. <BR/>Resident #22<BR/>A record review of Resident #22's admission record dated 08/28/2024 revealed an admission date of 01/29/2024 with diagnoses which included adult failure to thrive, chronic kidney disease with need for dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), and type II diabetes (a chronic disease characterized by high blood sugar levels). <BR/>A record review of Resident #22's quarterly MDS assessment dated [DATE] revealed Resident #22 was an [AGE] year-old male admitted for long term care and assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. <BR/>A record review of Resident #22's physicians orders dated 08/25/2024 revealed an order for Resident #22 to receive the influenza vaccine yearly. <BR/>A record review of Resident #22's immunization record dated 08/25/2024 revealed no influenza vaccine was offered and or declined. <BR/>Resident #28<BR/>A record review of Resident #28's admission record dated 08/28/2024 revealed an admission date of 01/20/2024 with diagnoses which included chronic kidney disease with need for dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), and type II diabetes (a chronic disease characterized by high blood sugar levels). <BR/>A record review of Resident #28's quarterly MDS assessment dated [DATE] revealed Resident #28 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. <BR/>A record review of Resident #28's physicians orders dated 08/25/2024 revealed an order for Resident #22 to receive the influenza vaccine yearly. <BR/>A record review of Resident #28's immunization record dated 08/25/2024 revealed no influenza vaccine was offered and or declined. <BR/>During an interview on 08/27/24 at 05:13 PM the ADON stated residents #10, #22, and #28 were not offered education on the benefits and potential side effects of the influenza immunization and the facility did not offer an influenza immunization to Residents #10, #22, and #28, during October 1, 2023, through March 31, 2024. The ADON stated the risk for harm to the residents was potential exposure to the influenza virus and infection by the virus. <BR/>During an interview on 08/29/24 at 04:15 PM the DON stated the facility's policy was to offer all residents the influenza immunization annually from October 1 through March 31. The DON stated some how residents #10, #22, and #28 were not offered the influenza virus. The DON stated the risk for harm to the residents was potential exposure to the influenza virus and infection by the virus.<BR/>A record review of the facility's undated Influenza Vaccination policy revealed, It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza . Influenza vaccinations will be routinely offered annually from October 1st, through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine. Additionally, influenza vaccinations will be offered to residents upon availability of the seasonal vaccine until influenza is no longer circulating in the facility's geographic area. Following assessment for potential medical contraindications, influenza vaccinations may be administered in accordance with physician-approved standing orders. Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of CDC's current vaccine information statement relative to the influenza vaccination. The vaccine information statements (VIS) will, as appropriate, be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding the benefits and potential side effects of the influenza vaccine

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all alleged violations which involved abuse, neglect, exploitation or mistreatment which included injuries of unknown source and misappropriation of resident property immediately but not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included to the State Survey Agency in accordance with State law through established procedures for 1 of 4 halls (200 hall), reviewed for abuse and neglect.<BR/>The facility failed to notify the State Survey Agency that the 200-hall air conditioner was not working from [DATE] to [DATE].<BR/>This failure could place residents at risk of neglect, dehydration, heat exhaustion, medical complications, and poor quality of life.<BR/>The findings were:<BR/>Observation on [DATE] at 11:10 a.m. revealed the facility felt slightly warm in the lobby area and conference room hallway. The AC thermostat outside of the conference room was set at 76 degrees Fahrenheit with the current temperature noted at 76 degrees Fahrenheit. The lobby temperature was 77.8 degrees Fahrenheit at the sitting chair level, the vent in the lobby was 67 degrees Fahrenheit.<BR/>Observation on [DATE] at 11:20 a.m. revealed the vent in the hallway leading to 200-hall (between the conference room and 200-hall was 80.2 degrees Fahrenheit, and the vent in front of room [ROOM NUMBER] in the hallway was 82 degrees Fahrenheit, the vent in hallway in front of room [ROOM NUMBER] was 82 degrees Fahrenheit.<BR/>Observation and interview on [DATE] at 11:25 a.m. revealed room [ROOM NUMBER]B Resident #1 was sitting in a wheelchair in her room watching television, the resident was in a half sleeve thin shirt and pants, the resident stated it was warm in her room and the vent in the room temperature was 85 degrees Fahrenheit. Resident #1 stated she was okay and not sweating but it was warm.<BR/>Observation on [DATE] at 11:28 a.m. 200-hall nursing station vent temperature was 86 degrees Fahrenheit. A tower fan was being used at the nurses station.<BR/>Observation and interview on [DATE] at 11:40 a.m. revealed Resident #1 was at the nursing station telling the nurse it was too warm in her room. The nurse stated he would notify maintenance. Resident #1 stated she was fine and not sweating but stated her room had been warm for a while but was not sure exactly how long. Resident #1 stated she was offered by facility staff to move to a room with air conditioning and she refused as she did not want a semi-private room.<BR/>Observation and interview on [DATE] at 11:43 a.m. revealed room [ROOM NUMBER] Resident #2 was sitting up in his bed with a sheet covering his private and thigh areas and was uncovered from the knee down. Resident #2 had 2 fans pointed at him and he stated it was warm but the facility had given him fans and they were definitely working. Resident #2 stated he was offered another room until the AC was fixed but it would not be a private room so he did not want to go. The thermostat on the wall in the room was set at 68 degrees Fahrenheit but the temperature reading was 81 degrees Fahrenheit. The vent in the room was 84 degrees Fahrenheit.<BR/>Observation and interview on [DATE] at 11:48 a.m. revealed room [ROOM NUMBER], Resident #3 was in bed, multiple family members (10 or more were inside the room and outside the room), the resident had expired early this morning. The family reported the resident was hot this past week as were the family members that visited. The vent in the room was 83.1 degrees Fahrenheit, the wall temperature at sitting level was 82.2 degrees Fahrenheit. The facility offered to move the resident to a room with air conditioning previously but the family had declined. <BR/>Observation and interview on [DATE] at 11:53 a.m. revealed room [ROOM NUMBER], Resident #4 was sitting in her room directly in front of a fan on her nightstand and drinking a glass of water . Resident's hair appeared slightly damp but the resident denied sweating and stated she was fine and to leave her alone. The vent in the room measured 90.1 degrees Fahrenheit, and the wall at sitting level was 85 degrees Fahrenheit.<BR/>Observation and interview on [DATE] at 11:54 a.m. revealed room [ROOM NUMBER] was cool and the vent was 66.3 degrees Fahrenheit. Resident #5 was in bed under the covers and stated she was cold. <BR/>Observation and interview on [DATE] at 3:22 p.m. revealed the MD took temperatures and temperatures were as follows: The vent between the conference room and 200-hall was 87 degrees Fahrenheit, the vent in the hallway on 200-hall outside the breakroom was 85.1 degrees Fahrenheit, the vent in the hallway outside room [ROOM NUMBER] was 86.9 degrees Fahrenheit, room [ROOM NUMBER]'s vent was 86.7 degrees Fahrenheit, room [ROOM NUMBER]'s vent was 87 degrees Fahrenheit, and the nursing station vent was 93 degrees Fahrenheit. The dialysis room felt cool and there was a large portable AC set up that was not currently on. The MD stated some residents got hot and some cold so the AC was used normally per resident preference during dialysis. The MD stated the contractor was able to move the AC install up to [DATE] and he would be going to rent a portable air conditioner for 200 hall as a resident agreed to move and he now was able to use that room for the exhaust hose.<BR/>During all observations, residents were observed with glasses of water and were observed drinking water.<BR/>In an anonymous interview it was stated the facility had been warm for at least a week and the residents and visitors had been sweating. The facility provided fans to the residents and offered all the resident's on 200-hall to move to another room with air conditioning but the residents refused room changes for different reasons. <BR/>In an interview on [DATE] at 12:00 p.m. with the Administrator and the DON, the Administrator stated the AC broke on [DATE] and a new one was ordered. The Administrator stated she did not notify HHSC or the program manager for the facility AC being broken. The Administrator stated she did not think it needed to be reported to HHSC as the residents were fine and had been offered room changes to rooms with air conditioning and only one resident had opted to move. The Administrator further stated the residents all had more than one fan and had refused the offered room changes but they would ask the resident's again. The DON stated her office was on the 200-hall and was warm but she was comfortable and at times even wore her sweater. The DON stated she checked on the residents several times throughout the day to ensure there were no health issues. The DON further stated the families complained about being warm but the residents had not.<BR/>Record review of the invoice revealed a new 10-ton rooftop unit was ordered on [DATE] to be delivered on [DATE] and installed on [DATE]. A down payment had been paid to secure the crane and equipment needed. <BR/>Record review of the facility's, undated, policy titled Abuse, Neglect, and Exploitation revealed .Reporting /Response 1. Reporting of all alleged violations to the Administrator, state agency .within specified timeframes .b not later than 24 hours if the events that cause the allegation do not involve abuse and do not result 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 alleged violations which involved abuse, neglect, exploitation or mistreatment which included injuries of unknown source and misappropriation of resident property immediately but not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included to the State Survey Agency in accordance with State law through established procedures for 1 of 4 halls (200 hall), reviewed for abuse and neglect.<BR/>The facility failed to notify the State Survey Agency that the 200-hall air conditioner was not working from [DATE] to [DATE].<BR/>This failure could place residents at risk of neglect, dehydration, heat exhaustion, medical complications, and poor quality of life.<BR/>The findings were:<BR/>Observation on [DATE] at 11:10 a.m. revealed the facility felt slightly warm in the lobby area and conference room hallway. The AC thermostat outside of the conference room was set at 76 degrees Fahrenheit with the current temperature noted at 76 degrees Fahrenheit. The lobby temperature was 77.8 degrees Fahrenheit at the sitting chair level, the vent in the lobby was 67 degrees Fahrenheit.<BR/>Observation on [DATE] at 11:20 a.m. revealed the vent in the hallway leading to 200-hall (between the conference room and 200-hall was 80.2 degrees Fahrenheit, and the vent in front of room [ROOM NUMBER] in the hallway was 82 degrees Fahrenheit, the vent in hallway in front of room [ROOM NUMBER] was 82 degrees Fahrenheit.<BR/>Observation and interview on [DATE] at 11:25 a.m. revealed room [ROOM NUMBER]B Resident #1 was sitting in a wheelchair in her room watching television, the resident was in a half sleeve thin shirt and pants, the resident stated it was warm in her room and the vent in the room temperature was 85 degrees Fahrenheit. Resident #1 stated she was okay and not sweating but it was warm.<BR/>Observation on [DATE] at 11:28 a.m. 200-hall nursing station vent temperature was 86 degrees Fahrenheit. A tower fan was being used at the nurses station.<BR/>Observation and interview on [DATE] at 11:40 a.m. revealed Resident #1 was at the nursing station telling the nurse it was too warm in her room. The nurse stated he would notify maintenance. Resident #1 stated she was fine and not sweating but stated her room had been warm for a while but was not sure exactly how long. Resident #1 stated she was offered by facility staff to move to a room with air conditioning and she refused as she did not want a semi-private room.<BR/>Observation and interview on [DATE] at 11:43 a.m. revealed room [ROOM NUMBER] Resident #2 was sitting up in his bed with a sheet covering his private and thigh areas and was uncovered from the knee down. Resident #2 had 2 fans pointed at him and he stated it was warm but the facility had given him fans and they were definitely working. Resident #2 stated he was offered another room until the AC was fixed but it would not be a private room so he did not want to go. The thermostat on the wall in the room was set at 68 degrees Fahrenheit but the temperature reading was 81 degrees Fahrenheit. The vent in the room was 84 degrees Fahrenheit.<BR/>Observation and interview on [DATE] at 11:48 a.m. revealed room [ROOM NUMBER], Resident #3 was in bed, multiple family members (10 or more were inside the room and outside the room), the resident had expired early this morning. The family reported the resident was hot this past week as were the family members that visited. The vent in the room was 83.1 degrees Fahrenheit, the wall temperature at sitting level was 82.2 degrees Fahrenheit. The facility offered to move the resident to a room with air conditioning previously but the family had declined. <BR/>Observation and interview on [DATE] at 11:53 a.m. revealed room [ROOM NUMBER], Resident #4 was sitting in her room directly in front of a fan on her nightstand and drinking a glass of water . Resident's hair appeared slightly damp but the resident denied sweating and stated she was fine and to leave her alone. The vent in the room measured 90.1 degrees Fahrenheit, and the wall at sitting level was 85 degrees Fahrenheit.<BR/>Observation and interview on [DATE] at 11:54 a.m. revealed room [ROOM NUMBER] was cool and the vent was 66.3 degrees Fahrenheit. Resident #5 was in bed under the covers and stated she was cold. <BR/>Observation and interview on [DATE] at 3:22 p.m. revealed the MD took temperatures and temperatures were as follows: The vent between the conference room and 200-hall was 87 degrees Fahrenheit, the vent in the hallway on 200-hall outside the breakroom was 85.1 degrees Fahrenheit, the vent in the hallway outside room [ROOM NUMBER] was 86.9 degrees Fahrenheit, room [ROOM NUMBER]'s vent was 86.7 degrees Fahrenheit, room [ROOM NUMBER]'s vent was 87 degrees Fahrenheit, and the nursing station vent was 93 degrees Fahrenheit. The dialysis room felt cool and there was a large portable AC set up that was not currently on. The MD stated some residents got hot and some cold so the AC was used normally per resident preference during dialysis. The MD stated the contractor was able to move the AC install up to [DATE] and he would be going to rent a portable air conditioner for 200 hall as a resident agreed to move and he now was able to use that room for the exhaust hose.<BR/>During all observations, residents were observed with glasses of water and were observed drinking water.<BR/>In an anonymous interview it was stated the facility had been warm for at least a week and the residents and visitors had been sweating. The facility provided fans to the residents and offered all the resident's on 200-hall to move to another room with air conditioning but the residents refused room changes for different reasons. <BR/>In an interview on [DATE] at 12:00 p.m. with the Administrator and the DON, the Administrator stated the AC broke on [DATE] and a new one was ordered. The Administrator stated she did not notify HHSC or the program manager for the facility AC being broken. The Administrator stated she did not think it needed to be reported to HHSC as the residents were fine and had been offered room changes to rooms with air conditioning and only one resident had opted to move. The Administrator further stated the residents all had more than one fan and had refused the offered room changes but they would ask the resident's again. The DON stated her office was on the 200-hall and was warm but she was comfortable and at times even wore her sweater. The DON stated she checked on the residents several times throughout the day to ensure there were no health issues. The DON further stated the families complained about being warm but the residents had not.<BR/>Record review of the invoice revealed a new 10-ton rooftop unit was ordered on [DATE] to be delivered on [DATE] and installed on [DATE]. A down payment had been paid to secure the crane and equipment needed. <BR/>Record review of the facility's, undated, policy titled Abuse, Neglect, and Exploitation revealed .Reporting /Response 1. Reporting of all alleged violations to the Administrator, state agency .within specified timeframes .b not later than 24 hours if the events that cause the allegation do not involve abuse and do not result 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 protect a resident's right to be treated with respect and dignity and to care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for 1 of 2 residents (Resident # 4) reviewed for dignity.<BR/>The facility failed to ensure Resident #1's catheter bag was covered in a privacy bag.<BR/>This deficiency could affect residents with an indwelling catheter; and could lead to a diminished quality of life and psychosocial harm.<BR/>The findings were:<BR/>Record review of Resident#4's face sheet, dated 05/03/23, and EMR (electronic medical record) revealed, the resident was re-admitted on [DATE] with diagnoses that included: acute respiratory failure, pulmonary edema (fluid in the lungs), and obstructive and reflex uropathy (blockage of the urinary tract). Resident was a female; age [AGE]. RP (responsible party) was listed as: the resident. <BR/>Record review of Resident#4's quarterly MDS (minimum data set), dated 01/20/23, revealed: <BR/>o <BR/>BIMS (brief interview of mental status) Score was 12 (moderate impairment). <BR/>o <BR/>ADLs (activities of daily living): B/B (bowel and bladder) listed bowel was incontinent. Bladder was indwelling catheter. Transfer was extensive one person Bed Mobility extensive two persons assistance. ROM (range of motion): resident had no impairment<BR/>Record review of Resident #4's CP, dated 03/14/23, listed the goal/ intervention for an indwelling catheter read: Ensure Foley bag is in privacy bag while in bed or W/C.<BR/>Record review of Resident#4's Physician' Orders, dated 03/14/23 read: privacy bag while in bed or w/c<BR/>Record review of Resident #4 's TAR (treatment administration record), (dated May 2023,revealed the resident received treatment for indwelling catheter which included: monitor for infection, ensure catheter strap in place, and ensure privacy bag was present. <BR/>Observation and interview on 05/03/23 at 11:24 AM , Resident #4 was in bed, alert and oriented. Catheter bag present [located on the bottom rail of the bed] without privacy bag (roommate present); urine exposed in the bag and the door was opened; and the bag was visible to people outside the room. The Resident stated, .they check on the catheter every day .when I get up the catheter bag goes with me on the wheel chair .it is never covered .I feel embarrassed because staff and residents can see my urine .I brought it up in the past .I go to the doctor once per month .the bag is not covered .I go out of the room about one or two times per month . <BR/>During an interview on 05/03/23 at 11:55 AM, LVN A stated that catheter care was done on the resident in the morning on 05/03/23 and LVN A forgot to check on the placement of the privacy bag; and checking of the privacy bag was part of catheter care. [ as stated above the resident felt embarrassed because people could see the urine in the bag when the door was opened]. <BR/>During a telephone interview on 05/03/23 at 1:36 PM, LVN D stated they (LVN D) provided catheter care to Resident #4 on 05/03/23 morning and did not noticed that the catheter bag was not covered in a privacy bag and checking of the privacy bag was part of catheter care<BR/>During an interview on 05/03/23 at 11:49 AM, the DON stated; the catheter bag was exposed with urine and it was a dignity issue The DON stated that nursing staff was responsible to check on the privacy bag and the catheter. The DON did not offer an explanation as to why Resident #4's catheter bag was not covered in a privacy bag.<BR/>Record review of facility's Catheter Care policy dated 2021 read: .6. Leg bags will be attached to the resident's thigh or calf making sure to have slack on the tubing to minimize pressure and tension. Ensure straps are snug but not tight .2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use .<BR/>Record review of the facility's Abuse, Neglect and Exploitation policy, dated 2022, read: .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .<BR/>Record review of Resident #4's admission Packet, dated 09/09/21, Statement of Resident Rights, signed by resident read: be treated with courtesy, consideration, and respect . <BR/>Record review of facility's Resident Rights policy dated, 2022, read: The resident has a right to be treated with respect and dignity .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident's right to be treated with respect and dignity and to care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for 1 of 2 residents (Resident # 4) reviewed for dignity.<BR/>The facility failed to ensure Resident #1's catheter bag was covered in a privacy bag.<BR/>This deficiency could affect residents with an indwelling catheter; and could lead to a diminished quality of life and psychosocial harm.<BR/>The findings were:<BR/>Record review of Resident#4's face sheet, dated 05/03/23, and EMR (electronic medical record) revealed, the resident was re-admitted on [DATE] with diagnoses that included: acute respiratory failure, pulmonary edema (fluid in the lungs), and obstructive and reflex uropathy (blockage of the urinary tract). Resident was a female; age [AGE]. RP (responsible party) was listed as: the resident. <BR/>Record review of Resident#4's quarterly MDS (minimum data set), dated 01/20/23, revealed: <BR/>o <BR/>BIMS (brief interview of mental status) Score was 12 (moderate impairment). <BR/>o <BR/>ADLs (activities of daily living): B/B (bowel and bladder) listed bowel was incontinent. Bladder was indwelling catheter. Transfer was extensive one person Bed Mobility extensive two persons assistance. ROM (range of motion): resident had no impairment<BR/>Record review of Resident #4's CP, dated 03/14/23, listed the goal/ intervention for an indwelling catheter read: Ensure Foley bag is in privacy bag while in bed or W/C.<BR/>Record review of Resident#4's Physician' Orders, dated 03/14/23 read: privacy bag while in bed or w/c<BR/>Record review of Resident #4 's TAR (treatment administration record), (dated May 2023,revealed the resident received treatment for indwelling catheter which included: monitor for infection, ensure catheter strap in place, and ensure privacy bag was present. <BR/>Observation and interview on 05/03/23 at 11:24 AM , Resident #4 was in bed, alert and oriented. Catheter bag present [located on the bottom rail of the bed] without privacy bag (roommate present); urine exposed in the bag and the door was opened; and the bag was visible to people outside the room. The Resident stated, .they check on the catheter every day .when I get up the catheter bag goes with me on the wheel chair .it is never covered .I feel embarrassed because staff and residents can see my urine .I brought it up in the past .I go to the doctor once per month .the bag is not covered .I go out of the room about one or two times per month . <BR/>During an interview on 05/03/23 at 11:55 AM, LVN A stated that catheter care was done on the resident in the morning on 05/03/23 and LVN A forgot to check on the placement of the privacy bag; and checking of the privacy bag was part of catheter care. [ as stated above the resident felt embarrassed because people could see the urine in the bag when the door was opened]. <BR/>During a telephone interview on 05/03/23 at 1:36 PM, LVN D stated they (LVN D) provided catheter care to Resident #4 on 05/03/23 morning and did not noticed that the catheter bag was not covered in a privacy bag and checking of the privacy bag was part of catheter care<BR/>During an interview on 05/03/23 at 11:49 AM, the DON stated; the catheter bag was exposed with urine and it was a dignity issue The DON stated that nursing staff was responsible to check on the privacy bag and the catheter. The DON did not offer an explanation as to why Resident #4's catheter bag was not covered in a privacy bag.<BR/>Record review of facility's Catheter Care policy dated 2021 read: .6. Leg bags will be attached to the resident's thigh or calf making sure to have slack on the tubing to minimize pressure and tension. Ensure straps are snug but not tight .2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use .<BR/>Record review of the facility's Abuse, Neglect and Exploitation policy, dated 2022, read: .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .<BR/>Record review of Resident #4's admission Packet, dated 09/09/21, Statement of Resident Rights, signed by resident read: be treated with courtesy, consideration, and respect . <BR/>Record review of facility's Resident Rights policy dated, 2022, read: The resident has a right to be treated with respect and dignity .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment reviewed for safe water temperatures and homelike environment, in that; <BR/>1. <BR/>Water temperatures at hand sinks and showers were out of safe parameters (100-110 degrees Fahrenheit) in public restrooms, resident restrooms and shower stalls, and in the communal shower room.<BR/>2. <BR/>Cardboard screwed into air conditioning vent to prevent air flow in room [ROOM NUMBER]. <BR/>3. <BR/>Rooms 409, shower water was 76.5/85.5 Degrees Fahrenheit, room [ROOM NUMBER] shower temperature was 85.5 <BR/>Degrees Fahrenheit, and the 200 main shower water temperature was 75.7 Degrees Fahrenheit.<BR/>This deficient practice could affect all residents, staff and visitors by placing them at risk for injury related to water temperatures exceeding safe parameters , or diminished quality of life by exposure to an uncomfortably low water temperatures during hand washing or showers and a non-homelike environment. <BR/>The findings included:<BR/>1.Record review of the quarterly MDS assessment, dated 4/05/2023, reveal Resident #28 was a [AGE] year-old male admitted [DATE]. Primary medical condition for admission was medically complex conditions related to schizophrenia. Other active diagnoses included cerebrovascular accident, transient ischemic attack, or stroke. Functional status coded as total dependence for set up only. Formal, clinical skin assessment revealed Resident #28 was not at risk for developing pressure ulcers. <BR/>Record review of the admission record revealed Resident #42 was a [AGE] year-old female admitted on [DATE]. <BR/>Record review of the quarterly MDS assessment dated [DATE], revealed Resident #42's primary medical condition category for admission was medically complex conditions related to COVID-19. Resident #42 had a summary BIMS score of 13, indicative of intact cognition. Resident #42 required physical help limited to transfer only by one staff member for bathing. Resident #42 had a formal, clinical assessment that indicated she was at risk of developing pressure injuries. <BR/>In an interview on 6/20/2023 at 12:31 PM, Resident #28 stated the water gets too hot in the [communal] shower room. Resident #28 stated, It's surprising no one has gotten hurt, it's so hot! Resident #28 stated there were frequently times when there was no hot water at all. Resident # 28 stated, he had skipped showers because there was no hot water available before he wanted to go to bed. <BR/>In an interview on 6/21/2023 at 2:16 PM Resident #42 stated she usually get showers on the evening shift [2p-10p] on Tuesdays/Thursdays/Saturdays. Resident #42 stated she did receive a shower on Monday [6/19/2022] just prior to her therapy session. Resident #42 stated halfway through the shower, they ran out of hot water. Resident #42 could not recall the name of the female aide assisting her. Resident #42 stated the aid had to go get a basin of warm water to rinse all the soap off her. Resident #42 stated that today she felt itchy but was not sure if it was because of the shower she received on Monday (6/19/2023) or she might be sensitive to the material [wool blend] her sweater was made of. <BR/>In an observation on 6/21/2023 at 6:16 PM, the hand sink water temperature was 138 degrees Fahrenheit, and the shower stall water temperature was 156 degrees Fahrenheit in room [ROOM NUMBER]. <BR/>In an observation and interview on 6/21/2023 at 6:30 PM, with ADON present, the hand sink water temperature was 136 degrees Fahrenheit, and the shower stall water temperature was 154 degrees Fahrenheit in the communal shower room . The ADON stated no residents or staff have voiced any concerns; and there were no reports of scalding of any resident, staff or visitor. In room [ROOM NUMBER], the hand sink water temperature was 132 degrees Fahrenheit, and the shower temperature was 154 degrees Fahrenheit. <BR/>In an interview on 6/21/2023 at 6:45 PM, with Resident #68 stated the water temperatures have been fine. Resident #68 did not think there had been any problems with the water temperature or pressure. Resident #68 stated sometimes the facility runs out of hot water. Resident #68 stated he had never gotten halfway through a shower and then had no hot water. Resident #68 stated, it's an all or nothing situation, you can tell immediately if there is no hot water. Resident #68 stated he like to take extra hot showers. Resident #68 stated he was independent with showering, as long as staff brought him the necessary supplies. Resident #68 stated he had to wait an hour or two only once or twice to take a shower due to lack of hot water. <BR/>In an interview on 6/21/2023 at 7:05 PM with the ADON present, the MTN stated three days prior the maintenance assistant had been sent unsupervised to adjust the boiler thermostat higher in response to resident complaints that the water temperatures at the furthest point from the boiler were too cool. The MNT stated the maintenance assistant was not available for interview The MNT stated he checked the water temperatures twice weekly and none of the temperatures had been above 120 degrees Fahrenheit. The MNT stated he did not realize the boiler thermostat had been set to 145 to 150 degrees Fahrenheit. The MNT stated the water temperatures closer to the boiler would be higher than the water temperatures at the furthest point in the building. The MNT stated the communal shower is the furthest point from the boiler. The MNT stated the 300 hall rooms would be the closest to the boiler. The MNT stated he checked the water temperatures at multiple locations daily since the assistant had adjusted the boiler thermostat, and those temperatures ranged between 114 to 120 degrees Fahrenheit at the furthest point from the boiler. The MNT stated he would turn the thermostat down, but it would probably take all night for a noticeable temperature decrease.<BR/>In an interview on 6/22/2023 at 7:39 AM, the MNT stated he was able to get the water temperatures down significantly. The MNT stated the showers were now temping at 111 degrees Fahrenheit and the hand sinks were temping at 108 degrees Fahrenheit. <BR/>In an observation on 6/22/2023 at 12:26 PM the communal shower room water temperature in the shower stall was 125 degrees Fahrenheit. <BR/>In an observation on 6/22/2023 at 12:31 PM, in room [ROOM NUMBER], the hand sink and shower stall water temperatures did not rise above 75 degrees Fahrenheit after 5 minutes of running hot water simultaneously at the hand sink and the shower stall.<BR/>In an observation and interview on 6/22/2023 at 4:50 PM, with MNT present, the communal shower room hand sink water temperature was 76.5 degrees Fahrenheit, and the shower stall water temperature was 78.5 degrees Fahrenheit. The MNT stated it would probably be an hour to an hour and half before there is hot water again. The MNT did not have an explanation as to why the water temperature was 125 degrees Fahrenheit at the communal shower room which was the farthest point from the boiler but in room [ROOM NUMBER], which was closer to the boiler, there was no hot water just after lunch. <BR/>In an interview on 6/22/2023 at 5:02 PM, CNA D stated that she provided a shower to Resident #42 on Monday [6/19/2023] but did not recall running out of hot water before completing the shower for Resident #42. CNA D stated that if the hot water stopped prior to completing the shower for any resident, she would obtain a basin of warm water to finish the task. CNA D stated she could not recall that happening recently. <BR/>In an interview on 6/22/2023 at 5:20 PM, RA C stated on there are approximately 2 to 4 showers scheduled on the Monday/Wednesday/Friday 2p-10p shift per aide, with 8 to 10 showers scheduled on the Tuesday/Thursday/Saturday 2p-10p shift per aide. RA C stated frequently there is not enough hot water to complete all the scheduled showers in one block of time on the 2p-10p shift. RA C stated when this happens, residents are advised to wait approximately one hour for the hot water to be adequate for the rest of the showers. RA C stated that right as of this moment, 10 of the scheduled 19 showers for this shift (2p-10p) were completed, with 9 showers still to be provided. RA C stated, if we wait until after dinner, or in about an hour, there should be enough hot water to complete the rest of the residents' showers for the day. RA C stated no resident had missed getting a shower because of a lack of hot water, although they may have had to wait for the hot water [tank] to fill back up.<BR/>In an observation on 6/22/2023 at 5:24 PM the shower stall water temperature was 126.4 degrees Fahrenheit in room [ROOM NUMBER]. <BR/>In an observation on 6/23/2023 at 8:34 AM, the water temperature in the communal shower room shower stall read 78 degrees Fahrenheit. <BR/>In an observation on 6/23/2023 between 4:36 PM and 5:22 PM, The MNT obtained water temperatures at the hand sink and shower stall at 13 different locations (communal shower room, rooms 209, 208, 304, 305, 308, 309, 313, 315, 503, 515, 409, and 417) with temperatures ranging from 76.8 to 127 degrees Fahrenheit. <BR/>Record review of the Grievance Form dated 2/13/2023, revealed the following statement, Maintenance is working to rectify all water issues and a plumbing company has been hired to handle any repairs. Resident (unnamed) has been offered alternate shower options while awaiting repairs. Grievance Form dated 3/29/2023 revealed under explanation of concern: Complaint of no hot water . Handwritten on the back of this form, House Keeping and maintenance were notified and are rectifying the issues of concern with a date of 3/29/2023; Further, with a date of 4/18/2023, Maintenance has been diligently attempting to correct all plumbing issues. Repairs are being made daily. Resident (unnamed) was offered another room without issues and declined to accept. Offer extended on several occasions. <BR/>Review of Maintenance Water Temperatures logbook revealed no readings out of the safe parameters of 100-110 degrees Fahrenheit on any of the entries. There were omitted or missed entries. The log was up to current date (6/22/2023) and contained 5 or more years of data. <BR/>2.In an observation, and interview on 6/20/2023 at 12:46 PM, a section of brown cardboard could be observed secured with screws into the air conditioning vent in the ceiling over Resident #42's recliner. [See P1, photograph.] Resident #42 stated the cardboard had been in place since she moved into the facility. Resident #42 stated the cardboard was the only way the MNT could keep the cold air from blowing so hard on her. Resident #42 stated she is always cold and dressed for warmth every day. Resident #42 was observed to be wearing dress slacks, a long-sleeved blouse and a long sleeved, thick sweater. Resident #42 stated she thought the cardboard was ugly but stated she would rather live with ugly than be miserably cold all the time. Observations of ambient room temperatures throughout the facility between 6/19/2023 and 6/23/2023 revealed temperatures between 71-81 degrees Fahrenheit. Local area under heat advisory during this time frame, with environmental temperature highs above 100 degrees Fahrenheit, with heat index over 110 degrees Fahrenheit. [Accessed 6/22/2023 via https://forecast.weather.gov/]<BR/>3. Observation on 6/20/2023 at 3:35 PM in resident room [ROOM NUMBER] shower temperature was 85.5 Degrees Fahrenheit.<BR/>Observation on 6/21/2023 at 3:18 PM in resident room [ROOM NUMBER] revealed the shower room was 85.5 Degrees Fahrenheit. <BR/>Observation on 6/22/2023 at 4:36 PM in the 200 main shower with the Maintenance Supervisor took shower water temperature was 75.7 Degrees Fahrenheit.<BR/>Observation on 6/22/2023 at 4:50 PM in resident room [ROOM NUMBER] with MNT revealed the shower room was 76.2 Degrees Fahrenheit. <BR/>Observation on 6/22/2023 at 4:51 PM with the MNT took the water temperature with his thermometer, Resident #6's shower water was 76.2 Degrees Fahrenheit. <BR/>In an interview on 6/21/2023 at 2:02 PM, MNT stated that one thermostat controlled a block of 3 rooms. MNT stated Resident #42 is cold natured, but residents in the other rooms on her thermostat were not. MNT stated Resident #42 complained about being able to feel and hear the air conditioning blowing on her harder with the just the vent set in the closed position. MNT stated the vent was in the closed or off position. MNT stated he screwed a section of brown cardboard into the vent to appease Resident #42. MNT stated he had only recently screwed the cardboard into the air conditioning vent but could not recall exactly when that was done. MNT stated he would move the brown cardboard section to the inside of the air conditioning vent, so it would not be visible. <BR/>Review of undated Safe and Homelike Environment policy revealed statement, . facility will provide a safe, clean, comfortable and homelike environment, . and does not pose a safety risk. Under the heading Policy Explanation and Compliance Guidelines: 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Under definitions, homelike environment should include the resident's opinion of the living environment. <BR/>Review of undated Safe Water Temperatures policy revealed statement, .facility to maintain appropriate water temperatures in resident care areas. Under the heading Policy Explanation and Compliance Guidelines: 5. Water temperatures will be set to a temperature of no more than 110 degrees Fahrenheit. 6. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for 1 of 10 Residents (Resident #123) reviewed for care plans, in that: <BR/>a. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #123 to address code status information, details of care provided and coordination of services.<BR/>b. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #123 to address Dialysis Service and Treatment, details of care provided and coordination of services.<BR/>These failures could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs. <BR/>The findings were:<BR/>a. Record Review of Resident #123's admission Record dated [DATE] revealed she was admitted to facility on [DATE] with diagnoses of end stage renal disease, dependence on renal dialysis and acute respiratory failure with hypoxia (deficiency of oxygen reaching the tissues). Record of Resident #123's admission Record was documented for Advanced Directive section-Resident is a full code perform CPR.<BR/>Record Review of Resident #123's admission MDS dated [DATE] revealed Section C -Cognitive Patterns, BIMS score was 13/15 (cognitively intact). <BR/>Record Review of Resident #123's Care plan dated [DATE] revealed Resident #123 had no care plan for code status.<BR/>Record Review of Resident #123's consolidated physician orders for [DATE] revealed code status of full code.<BR/>Observation on [DATE] at 1:29 PM with Resident #123 revealed she was not in bed in her room, other visits she was sleeping in bed and at other times she was not making sense. <BR/>During an interview on [DATE] at 4 PM with the Social Worker (SW) stated for her record Resident # 123 was a full code. The SW stated the care plan coordinator made sure residents care was placed in the care plan. SW stated she did not have anything to do with the resident's care plan. SW stated <BR/>b. Record Review of Resident #123's admission MDS dated [DATE] revealed Section C -Cognitive Patterns, BIMS score was 13/15 (cognitively intact), and Section O Special Treatments, Procedures and programs, under other was J. Dialysis services was marked. <BR/>Record Review of Resident #123's Care plan dated [DATE] revealed Resident #123 did not have a care plan for Dialysis services with interventions. <BR/>Record Review of Resident #123's consolidated physician orders for [DATE] revealed no Dialysis Services and Treatment was ordered. <BR/>During an interview on [DATE] at 4:23 PM with the MDS coordinator confirmed she did not have Resident #123 code status or Dialysis Services in her care plan. The MDS coordinator stated she was not sure why it was not in the care plan since she did receive Dialysis services/treatment. MDS coordinator stated she was still training and was a work in progress. The MDS coordinator stated she was responsible for making sure all resident care plans reflect their care. Interview with MDS coordinator stated she was not sure why Resident #123 did not have an order for Dialysis, so there was no care plan.<BR/>During an interview on [DATE] at 5 PM with the Administrator discussed concerns and she only listened and did no reply further. <BR/>Record review of policy Communication of Code Status dated [DATE] revealed Policy: It is the policy of this facility to adhere to residents' tights to formulate advance directives. In accordance with these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. Policy Explanation and Compliance Guidelines: 3. The nurse who notates the physician order was responsible for documenting the direction in all relevant sections of the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 10 (Resident #4) residents in that:<BR/>Resident #4 requested his beard be shaved and staff did not respond to him. <BR/>This could result and could place risk for not receiving necessary care to maintain grooming. <BR/>The Findings were: <BR/>Record review of Resident #4's admission Record dated 6/23/2023 revealed he was admitted on [DATE], re-admitted on [DATE] with diagnoses of repeated falls, chronic kidney disease, cognitive communication deficit, lack of coordination and muscle weakness. Resident #4's picture on his admission Record revealed he had a mustache and no beard.<BR/>Record review of Resident #4's quarterly MDS dated [DATE] was documented section C Cognitive Pattern, BIMS score was 10/15 (moderately impaired), Section G functional Status for transfers were required total dependence with two-person assistance, personal hygiene (shaving) he required extensive assistance with one person assistance, he had impairments on one side in upper extremity, he had impairments on both sides to lower extremity and mobilized with an electric wheelchair.<BR/>Record review of Resident #4's Care Plan dated 6/2/2023 revealed under personal hygiene Resident #4 required total dependence from staff.<BR/>Observation on 6/22/2023 at 5:42 PM in Resident #4's room revealed he had a mustache and facial hair around chin and cheeks (about 2 inches long).<BR/>Interview on 6/22/2023 at 5:43 PM with Resident #4 he stated he had asked staff (unknown) to shave him and they had not responded. Interview with Resident #4 stated he liked to be shaved and he touched his chin and beard with his hand and said shave. Resident #4 did not touch his mustache. <BR/>Interview on 6/23/2023 at 11:26 AM with CNA P stated Resident #4 was assisted by CNAs on a daily basis on grooming, to include shaving his beard. CNA P stated Resident #4 CNAs were to offer grooming to resident during daily grooming. CNA P stated Resident #4 liked his mustache but did not like to have a beard and likes to be well kept. CNA P stated he had not cared for Resident #4 and in that hall for weeks. <BR/>Interview on 6/23/2023 at 3:58 PM with MDS coordinator, stated she had been working on resident MDS's for 1 month and was in training. The MDS coordinator stated care plan for personal hygiene for Resident #4 required total dependence and staff would need to shave him to shave him if he requested. <BR/>Review of Policy Activities of Daily Living (ADLs) dated November 2017 was documented Policy: The facility will, based on residents' comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Policy Explanation and Compliance Guidelines: 3. A resident who is unable to carry out activities of daily living will receive the necessary series to maintain good grooming and personal hygiene. <BR/>Record review of policy dated November 2017 revealed Promoting/Maintaining Resident Dignity dated October 2022 revealed 9. Groom and dress residents according to resident preference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .<BR/>Based on observation, interview, and record review the facility failed to establish and maintain <BR/>an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility, reviewed for infection control in that:<BR/>1.The DON exited a designated droplet transmission-based precautions room after doffing her N95 mask in the room. <BR/>2.The facility failed to ensure CNA F utilized appropriate infection control practices when entering a designated droplet transmission-based precautions room. <BR/>3.MA E did not sanitize bp cuff between residents. <BR/>4. CMA L did not have eye protection when entered a COVID positive room. <BR/>This deficient practice could affect all residents, staff and visitors at risk for infection.<BR/>Findings include:<BR/>1. In an observation and interview on 6/20/2023 at 5:45 PM, the DON was observed exiting room [ROOM NUMBER], a room designated droplet transmission-based precautions, without an N95 mask in place. The DON stated she doffed all her Personal Protective Equipment (PPE) in the room just prior to exiting the room. The DON stated the trash receptacle is just inside and behind the door. The DON stated staff are expected to doff their PPE in the room designated droplet transmission-based precautions perform hand hygiene, exit the room and immediately obtain a new mask from the isolation supply cart placed just outside of the room if they will be continuing with care in either warm zone or hot zone rooms. The DON stated she would review the policy and make any necessary changes to procedures. <BR/>Further observations between 6/21/2023 8:00 AM and 6/23/2023 8:00 PM revealed a roll of small clear trash bags on top of each isolation cart outside a designated droplet transmission-based precaution room. Staff were observed to exit the room with only their N95 mask in place, upon exiting the room, the staff members opened a trash bag, doffed their N95 masks directly into the trash bag, and tied it securely closed. The staff members performed hand hygiene and discarded the sealed trash bag with the used N95 mask(s) in an appropriate receptacle. <BR/>2.In an observation and interview on 6/20/2023 at 5:20 PM, CNA F entered room [ROOM NUMBER], designated droplet, transmission-based precautions without wearing an appropriate N95 mask. CNA F donned PPE gown, gloves and face shield appropriately. CNA F exited the room at 5:37 PM, with only a face shield in place. CNA F stated she had worn an N95 mask to enter the room but doffed all other PPE prior to exiting. CNA F stated the face shield could be sanitized between uses. CNA F took the face shield off, set it on the isolation cart outside of the room, and used disinfecting wipes to clean the mask. <BR/>3.In an observation, and interview on 6/23/2023 between 9:00 AM and 9:36 AM, MA E did not sanitize the blood pressure cuff between residents during observation of medication administration. MA E stated she forgot to sanitize the blood pressure cuff between each use due to being observed. MA E stated that she understood infection control principles, and that the blood pressure cuff should be sanitize between each resident to prevent possible cross-contamination. MA E stated residents on isolation precautions have dedicated equipment for their use. MA E stated none of the residents she had used the blood pressure cuff on were on transmission-based precautions at this time. MA E stated in the worse possible scenario would be if the first resident had an undisclosed infectious condition, it would be possible the next residents that used the dirty blood pressure cuff could get it through cross contamination. <BR/>4.Observation on 6/2023 at 11:58 PM revealed CNA L entered a COVID positive room with no eye protection.<BR/>Observation on 6/2023 at 11:59 PM in the front of the COVID positive room was a PPE cart with gloves, N95 mask, gowns and eye protections. Observation in front of all COVID rooms where posted PPE droplet precautions and what to wear in a resident COVID positive room, included eye protection. Observation of another posting in front of all COVID positive room Hot Zone room must have appropriate PPE.<BR/>During an interview on 6/20/2023 at 12 PM with LVN M confirmed CNA L entered resident room with no eye protection and handed her eye protections from outside the door. LVN M provided CNA L with eye protection from the PPE drawer in front of the COVID room. <BR/>During an interview on 6/20/2023 at 2:02 PM with CNA L confirmed she was not wearing eye protection in positive COVID room because she could not find in the PPE cart. <BR/>During an interview on 6/21/2023 at 6 PM with the Administrator discussed concerns and she only listened and did no reply further. <BR/>Review of undated Transmission-Based (Isolation) Precautions policy revealed, under the heading Policy Explanation and Compliance Guidelines: 7. f. The facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions. g. If sharing noncritical equipment between residents, the equipment will be cleaned and disinfected following manufacturer's instructions with an EPA-registered disinfectant after use. 9. Droplet Precautions- Healthcare personnel will wear a facemask for close contact with an infectious resident.<BR/>Review of undated infographic entitled Doffing (taking off the gear) placed on the door of each room designated droplet transmission-based precautions revealed the following order for removing PPE: 1. Remove gloves. 2. Remove gown. 3. Health Care Personnel may now exit patient room. 4. Perform hand hygiene. 5. Remove face shield or googles. 6. Remove and discard respirator [N95 mask]. 7. Perform hand hygiene after removing respirator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .<BR/>Based on observations, interviews and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public when water temperatures were below 100 degrees Fahrenheit or above 110 degrees Fahrenheit at hand sinks, shower stalls, communal shower room and public restrooms reviewed for environment: in that:<BR/>1. Water temperatures at hand sinks, shower stalls, communal shower room, and public restrooms were outside safe parameters between 100 to 110 degrees Fahrenheit. <BR/>2. A brown cardboard could be observed secured with screws into the air conditioning vent in the ceiling over Resident #42's recliner.<BR/>3. Resident #6s shower water was cold. <BR/>This deficient practice could place the residents living in, staff working in, and visitors experiencing an environment that is unsafe, nonfunctional, unsanitary or uncomfortable and could impact the residents' ability to achieve or maintain their highest practicable physical, mental, and psychosocial well-being resulting in a diminished quality of life. <BR/>The findings were:<BR/>1.Record review of the quarterly MDS assessment, dated 4/05/2023, reveal Resident #28 was a [AGE] year-old male admitted [DATE]. Primary medical condition for admission was medically complex conditions related to schizophrenia. Other active diagnoses included cerebrovascular accident, transient ischemic attack, or stroke. Functional status coded as total dependence for set up only. Formal, clinical skin assessment revealed Resident #28 was not at risk for developing pressure ulcers. <BR/>Record review of the admission record revealed Resident #42 was a [AGE] year-old female admitted on [DATE]. <BR/>Record review of the quarterly MDS assessment dated [DATE], revealed Resident #42's primary medical condition category for admission was medically complex conditions related to COVID-19. Resident #42 had a summary BIMS score of 13, indicative of intact cognition. Resident #42 required physical help limited to transfer only by one staff member for bathing. Resident #42 had a formal, clinical assessment that indicated she was at risk of developing pressure injuries. <BR/>In an interview on 6/20/2023 at 12:31 PM, Resident #28 stated the water gets too hot in the [communal] shower room. Resident #28 stated, It's surprising no one has gotten hurt, it's so hot! Resident #28 stated there were frequently times when there was no hot water at all. Resident # 28 stated, he had skipped showers because there was no hot water available before he wanted to go to bed. <BR/>In an interview on 6/21/2023 at 2:16 PM Resident #42 stated she usually get showers on the evening shift [2p-10p] on Tuesdays/Thursdays/Saturdays. Resident #42 stated she did receive a shower on Monday [6/19/2022] just prior to her therapy session. Resident #42 stated halfway through the shower, they ran out of hot water. Resident #42 could not recall the name of the female aide assisting her. Resident #42 stated the aid had to get a basin of warm water to rinse all the soap off her. Resident #42 stated that today she felt itchy but was not sure if it was because of the shower she received on Monday or she might be sensitive to the material [wool blend] her sweater was made of. <BR/>In an observation on 6/21/2023 at 6:16 PM, the hand sink water temperature was 138 degrees Fahrenheit, and the shower stall water temperature was 156 degrees Fahrenheit in room [ROOM NUMBER]. <BR/>In an observation and interview on 6/21/2023 at 6:30 PM, with ADON present, the hand sink water temperature was 136 degrees Fahrenheit, and the shower stall water temperature was 154 degrees Fahrenheit in the communal shower room. The ADON stated no residents or staff have voiced any concerns; and there were no reports of scalding of any resident, staff or visitor. In room [ROOM NUMBER], the hand sink water temperature was 132 degrees Fahrenheit, and the shower temperature was 154 degrees Fahrenheit. <BR/>In an interview on 6/21/2023 at 6:45 PM, with Resident #68 stated the water temperatures have been fine. Resident #68 did not think there had been any problems with the water temperature or pressure. Resident #68 stated sometimes the facility runs out of hot water. Resident #68 stated he had never gotten halfway through a shower and then had no hot water. Resident #68 stated, it's an all or nothing situation, you can tell immediately if there is no hot water. Resident #68 stated he like to take extra hot showers. Resident #68 stated he was independent with showering, as long as staff brought him the necessary supplies. Resident #68 stated he had to wait an hour or two only once or twice to take a shower due to lack of hot water. <BR/>In an interview on 6/21/2023 at 7:05 PM with the ADON present, the MTN stated three days prior the maintenance assistant had been sent unsupervised to adjust the boiler thermostat higher in response to resident complaints that the water temperatures at the furthest point from the boiler were too cool. The MNT stated the maintenance assistant was not available for interview [hospitalized , not expected to return to employment at the facility]. The MNT stated he checked the water temperatures twice weekly and none of the temperatures had been above 120 degrees Fahrenheit. The MNT stated he did not realize the boiler thermostat had been set to 145 to 150 degrees Fahrenheit. The MNT stated the water temperatures closer to the boiler would be higher than the water temperatures at the furthest point in the building. The MNT stated the communal shower is the furthest point from the boiler. The MNT stated the 300 hall rooms would be the closest to the boiler. The MNT stated he checked the water temperatures at multiple locations daily since the assistant had adjusted the boiler thermostat, and those temperatures ranged between 114 to 120 degrees Fahrenheit at the furthest point from the boiler. The MNT stated he would turn the thermostat down, but it would probably take all night for a noticeable temperature decrease.<BR/>In an interview on 6/22/2023 at 7:39 AM, the MNT stated he was able to get the water temperatures down significantly. The MNT stated the showers were now temping at 111 degrees Fahrenheit and the hand sinks were temping at 108 degrees Fahrenheit. <BR/>In an observation on 6/22/2023 at 12:26 PM the communal shower room water temperature in the shower stall was 125 degrees Fahrenheit. <BR/>In an observation on 6/22/2023 at 12:31 PM, in room [ROOM NUMBER], the hand sink and shower stall water temperatures did not rise above 75 degrees Fahrenheit after 5 minutes of running hot water simultaneously at the hand sink and the shower stall.<BR/>In an observation and interview on 6/22/2023 at 4:50 PM, with MNT present, the communal shower room hand sink water temperature was 76.5 degrees Fahrenheit, and the shower stall water temperature was 78.5 degrees Fahrenheit. The MNT stated it would probably be an hour to an hour and half before there is hot water again. The MNT did not have an explanation as to why the water temperature was 125 degrees Fahrenheit at the communal shower room which was the farthest point from the boiler but in room [ROOM NUMBER], which was closer to the boiler, there was no hot water just after lunch. <BR/>In an interview on 6/22/2023 at 5:02 PM, CNA D stated that she provided a shower to Resident #42 on Monday [6/19/2023] but did not recall running out of hot water before completing the shower for Resident #42. CNA D stated that if the hot water stopped prior to completing the shower for any resident, she would obtain a basin of warm water to finish the task. CNA D stated she could not recall that happening recently. <BR/>In an interview on 6/22/2023 at 5:20 PM, RA C stated on there are approximately 2 to 4 showers scheduled on the Monday/Wednesday/Friday 2p-10p shift per aide, with 8 to 10 showers scheduled on the Tuesday/Thursday/Saturday 2p-10p shift per aide. RA C stated frequently there is not enough hot water to complete all the scheduled showers in one block of time on the 2p-10p shift. RA C stated when this happens, residents are advised to wait approximately one hour for the hot water to be adequate for the rest of the showers. RA C stated that right as of this moment, 10 of the scheduled 19 showers for this shift (2p-10p) were completed, with 9 showers still to be provided. RA C stated, if we wait until after dinner, or in about an hour, there should be enough hot water to complete the rest of the residents' showers for the day. RA C stated no resident had missed getting a shower because of a lack of hot water, although they may have had to wait for the hot water [tank] to fill back up.<BR/>In an observation on 6/22/2023 at 5:24 PM the shower stall water temperature was 126.4 degrees Fahrenheit in room [ROOM NUMBER]. <BR/>In an observation on 6/23/2023 at 8:34 AM, the water temperature in the communal shower room shower stall read 78 degrees Fahrenheit. <BR/>In an observation on 6/23/2023 between 4:36 PM and 5:22 PM, The MNT obtained water temperatures at the hand sink and shower stall at 13 different locations (communal shower room, rooms 209, 208, 304, 305, 308, 309, 313, 315, 503, 515, 409, and 417) with temperatures ranging from 76.8 to 127 degrees Fahrenheit. <BR/>Record review of the Grievance Form dated 2/13/2023, revealed the following statement, Maintenance is working to rectify all water issues and a plumbing company has been hired to handle any repairs. Resident (unnamed) has been offered alternate shower options while awaiting repairs. Grievance Form dated 3/29/2023 revealed under explanation of concern: Complaint of no hot water . Handwritten on the back of this form, House Keeping and maintenance were notified and are rectifying the issues of concern with a date of 3/29/2023; Further, with a date of 4/18/2023, Maintenance has been diligently attempting to correct all plumbing issues. Repairs are being made daily. Resident (unnamed) was offered another room without issues and declined to accept. Offer extended on several occasions. <BR/>Review of Maintenance Water Temperatures logbook revealed no readings out of the safe parameters of 100-110 degrees Fahrenheit on any of the entries. There were omitted or missed entries. The log was up to current date (6/22/2023) and contained 5 or more years of data. <BR/>Review of undated Safe and Homelike Environment policy revealed statement, . facility will provide a safe, clean, comfortable and homelike environment, . and does not pose a safety risk. Under the heading Policy Explanation and Compliance Guidelines: 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. <BR/>Review of undated Safe Water Temperatures policy revealed statement, .facility to maintain appropriate water temperatures in resident care areas. Under the heading Policy Explanation and Compliance Guidelines: 5. Water temperatures will be set to a temperature of no more than 110 degrees Fahrenheit. 6. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. <BR/>2.In an observation, and interview on 6/20/2023 at 12:46 PM, a section of brown cardboard could be observed secured with screws into the air conditioning vent in the ceiling over Resident #42's recliner. [See P1, photograph.] Resident #42 stated the cardboard had been in place since she moved into the facility. Resident #42 stated the cardboard was the only way the MNT could keep the cold air from blowing so hard on her. Resident #42 stated she is always cold and dressed for warmth every day. Resident #42 was observed to be wearing dress slacks, a long-sleeved blouse and a long sleeved, thick sweater. Resident #42 stated she thought the cardboard was ugly but stated she would rather live with ugly than be miserably cold all the time. Observations of ambient room temperatures throughout the facility between 6/19/2023 and 6/23/2023 revealed temperatures between 71-81 degrees Fahrenheit. Local area under heat advisory during this time frame, with environmental temperature highs above 100 degrees Fahrenheit, with heat index over 110 degrees Fahrenheit. [Accessed 6/22/2023 via https://forecast.weather.gov/]<BR/>In an interview on 6/21/2023 at 2:02 PM, MNT stated that one thermostat controlled a block of 3 rooms. MNT stated Resident #42 is cold natured, but residents in the other rooms on her thermostat were not. MNT stated Resident #42 complained about being able to feel and hear the air conditioning blowing on her harder with the just the vent set in the closed position. MNT stated the vent was in the closed or off position. MNT stated he screwed a section of brown cardboard into the vent to appease Resident #42. MNT stated he had only recently screwed the cardboard into the air conditioning vent but could not recall exactly when that was done. MNT stated he would move the brown cardboard section to the inside of the air conditioning vent, so it would not be visible. <BR/>3.Record review of Resident #6's admission Record dated 6/23/2023 revealed she was admitted on [DATE] with diagnoses of diabetes II, heart failure, muscle weakness and age-related decline. <BR/>Record review of Resident #6's Quarterly MDS dated [DATE] was documented in Section C Cognition Pattern, BIMs was 14/15 (cognitively intact), Section G Functional Status, personal hygiene she required supervision with one person assistance, and Bathing she required physical help in part of bathing activity with one person assistance. <BR/>Record review of Resident #6's Care Plan dated 2/6/2023 revealed ADL, bathing she required stand by assist of one staff with showers three times a week, as necessary.<BR/>In interview on 6/20/2023 at 4 PM with Resident #6 stated her shower room water was always cold in the morning and had been this week. <BR/>Observation on 6/21/2023 at 3:18 PM in Resident #6's room revealed the shower room was 85.5 Degrees Fahrenheit. <BR/>Observation on 6/22/2023 at 4:51 PM with the Maintenance Supervisor took the water temperature with his thermometer, Resident #6's shower water was 76.2 Degrees Fahrenheit. <BR/>In interview on 6/22/2023 at 4:51 PM with Resident #6 stated her shower room water was always cold in the morning and had been this week. Resident #6 stated she had reported this concerns to the Maintenance Supervisor. (was not sure when).<BR/>In interview on 6/22/2023 at 4:52 PM with the Maintenance Supervisor confirmed with his thermometer, Resident #6's shower water was 76.2 Degrees Fahrenheit. The Maintenance Supervisor stated the facility water was cold in morning when he stated his shift, he stated he came in the morning before resident shower to adjust water heaters, then adjust resident shower waters. The Maintenance Supervisor stated when he adjusts all the resident waters, he had a valve in the shower that the staff/residents have been educated on using when taking residents showers. <BR/>Review of undated Safe and Homelike Environment policy revealed statement, . facility will provide a safe, clean, comfortable and homelike environment . Under definitions, homelike environment should include the residents' opinion of the living environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 4 Residents (Resident #22) whose MDS records were reviewed for accuracy, in that: <BR/>Resident #22's Quarterly MDS assessment, dated 1/10/2024, was incorrectly coded that the resident did not have a fall since admission/entry or reentry or the prior assessment, whichever was more recent. <BR/>This failure could place residents at risk for inadequate care due to inaccurate assessments.<BR/>The findings included: <BR/>Record review of Resident #22's face sheet, dated 2/15/2024, revealed the resident #22 was admitted to the facility 12/19/2023 with diagnoses that included: acute kidney failure, unspecified convulsions, aphasia, type 2 diabetes mellitus.<BR/>Record review of Resident #22's Quarterly MDS, dated [DATE], revealed the resident did not have any falls since readmission to the facility on [DATE].<BR/>Record review of Resident #22's nursing notes, dated 12/29/2023 at 7:15 PM by LVN B, revealed in part, the resident fell from his wheelchair and was observed laying on the floor on his left side.<BR/>During an interview with MDS Coordinator A on 2/15/2024 at 3:52 PM) code for Resident #22's re-admission on [DATE], MDS Coordinator A confirmed she missed the coding for Resident #22's fall on 12/29/2023 on the MDS and did not know why she missed it. She stated the, MDS has the purpose for billing and for Care Plans, to make sure they get the services they need and assessing properly to make sure they take the measures they need in order to give the correct services to the residents.<BR/>Record review of the CMS MDS 3.0 Manual, dated October 2023, revealed, The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both to conduct initial and periodic assessments for all their residents. The RAI (Resident Assessment Instrument) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part to that assessment process and is required by CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 4 Residents (Resident #22) whose MDS records were reviewed for accuracy, in that: <BR/>Resident #22's Quarterly MDS assessment, dated 1/10/2024, was incorrectly coded that the resident did not have a fall since admission/entry or reentry or the prior assessment, whichever was more recent. <BR/>This failure could place residents at risk for inadequate care due to inaccurate assessments.<BR/>The findings included: <BR/>Record review of Resident #22's face sheet, dated 2/15/2024, revealed the resident #22 was admitted to the facility 12/19/2023 with diagnoses that included: acute kidney failure, unspecified convulsions, aphasia, type 2 diabetes mellitus.<BR/>Record review of Resident #22's Quarterly MDS, dated [DATE], revealed the resident did not have any falls since readmission to the facility on [DATE].<BR/>Record review of Resident #22's nursing notes, dated 12/29/2023 at 7:15 PM by LVN B, revealed in part, the resident fell from his wheelchair and was observed laying on the floor on his left side.<BR/>During an interview with MDS Coordinator A on 2/15/2024 at 3:52 PM) code for Resident #22's re-admission on [DATE], MDS Coordinator A confirmed she missed the coding for Resident #22's fall on 12/29/2023 on the MDS and did not know why she missed it. She stated the, MDS has the purpose for billing and for Care Plans, to make sure they get the services they need and assessing properly to make sure they take the measures they need in order to give the correct services to the residents.<BR/>Record review of the CMS MDS 3.0 Manual, dated October 2023, revealed, The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both to conduct initial and periodic assessments for all their residents. The RAI (Resident Assessment Instrument) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part to that assessment process and is required by CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide, for a resident who is incontinent of bladder, appropriate treatment, and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents, (Resident #4), reviewed for catheter care.<BR/>The facility failed to ensure Resident #4's urinary catheter was anchored to the leg. <BR/>This deficiency could place residents with catheters at risk of a blockage in urine flow, infection, and injury. <BR/>The findings were:<BR/>Record review of Resident #4's face sheet, dated 05/03/23, and EMR (electronic medical record) revealed, the resident was re-admitted on [DATE] with diagnoses that included: acute respiratory failure, pulmonary edema (fluid in the lungs), and obstructive and reflex uropathy (blockage in the urinary tract). Resident was a female; age [AGE]. RP (responsible party) was listed as: the resident. <BR/>Record review of Resident #4's quarterly MDS assessment, dated 01/20/23, revealed: <BR/>o <BR/>BIMS (brief interview of mental status) Score was 12 (moderate impairment). <BR/>o <BR/>ADLs (activities of daily living): B/B (bowel and bladder) listed bowel was incontinent. Bladder was indwelling catheter. Transfer was extensive one person Bed Mobility extensive two persons assistance. ROM (range of motion): resident had no impairment<BR/>Record review of Resident #4's CP, dated 03/14/23, on the goal/ intervention of indwelling catheter read: Ensure catheter strap is in place each shift.<BR/>Record review of Resident#4's Physician's Orders, dated 03/14/23 read: Ensure catheter strap in place and holding<BR/>Record review of Resident # 4's TAR (treatment administration record), dated May 2023, revealed the resident received treatment for indwelling catheter which included: monitor for infection, ensure catheter strap in place, and ensure privacy bag was present. Nursing staff initialed that the catheter was anchored on 05/02/23 and 05/03/23. <BR/>Observation and interview on 05/03/23 at 11:30 AM, Resident #4 was lying in bed, there were no skin tears, bruising or wounds; observed. Supra pubic catheter site care at 11:38 AM by LVN A. Catheter was not anchored to the leg. <BR/>During an interview on 05/03/23 at 1:36 PM, LVN A (charge nurse ) stated: she provided catheter care to Resident #4 on 05/03/23 in the morning and did not notice that the catheter was not properly anchored to the resident's leg. LVN A stated that there was an order to check on the proper placement of the catheter. <BR/>During a telephone interview on 05/03/23 at 3:10 PM, LVN D stated: Resident (#4) had the habit of loosening the adhesive tape anchoring the catheter. LVN D did document on the TAR on 05/02/23 (night shift (10 PM-6 AM) that the catheter strap [was] in place and holding . <BR/>During an interview on 05/03/23 at 1:40 PM, The DON stated there was an order to anchor the catheter and the policy was to anchor the catheter correctly. The DON stated, Resident #4's may need a stronger adhesive and we will look into it (adhesive) .also Resident (#4) had the habit of loosening the indwelling catheter [since re-admission]. <BR/>Record review of facility's Catheter Care policy dated 2021 read: .6. Leg bags will be attached to the resident's thigh or calf making sure to have slack on the tubing to minimize pressure and tension. Ensure straps are snug but not tight .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 4 Residents (Resident #22) whose MDS records were reviewed for accuracy, in that: <BR/>Resident #22's Quarterly MDS assessment, dated 1/10/2024, was incorrectly coded that the resident did not have a fall since admission/entry or reentry or the prior assessment, whichever was more recent. <BR/>This failure could place residents at risk for inadequate care due to inaccurate assessments.<BR/>The findings included: <BR/>Record review of Resident #22's face sheet, dated 2/15/2024, revealed the resident #22 was admitted to the facility 12/19/2023 with diagnoses that included: acute kidney failure, unspecified convulsions, aphasia, type 2 diabetes mellitus.<BR/>Record review of Resident #22's Quarterly MDS, dated [DATE], revealed the resident did not have any falls since readmission to the facility on [DATE].<BR/>Record review of Resident #22's nursing notes, dated 12/29/2023 at 7:15 PM by LVN B, revealed in part, the resident fell from his wheelchair and was observed laying on the floor on his left side.<BR/>During an interview with MDS Coordinator A on 2/15/2024 at 3:52 PM) code for Resident #22's re-admission on [DATE], MDS Coordinator A confirmed she missed the coding for Resident #22's fall on 12/29/2023 on the MDS and did not know why she missed it. She stated the, MDS has the purpose for billing and for Care Plans, to make sure they get the services they need and assessing properly to make sure they take the measures they need in order to give the correct services to the residents.<BR/>Record review of the CMS MDS 3.0 Manual, dated October 2023, revealed, The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both to conduct initial and periodic assessments for all their residents. The RAI (Resident Assessment Instrument) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part to that assessment process and is required by CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document a resident's discharge to ensure that appropriate information is communicated to the receiving health care provider for 1 or 6 residents (resident #1) reviewed for transfer or discharge. <BR/>The facility failed to ensure that:<BR/>1.Resident #1 did have a documented discharge order written by the resident's physician for the resident's discharge from the facility.<BR/>2. Resident #1 did have a documented discharge summary written by the resident's physician or nurse for the resident's discharge from the facility.<BR/>This deficient practice could affect resident's planned discharge destination by contributing to a discharge from the facility that was not properly documented. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet, dated 04/01/25, revealed a [AGE] year-old resident initially admitted on [DATE] with diagnoses including autistic disorder (a neuro-developmental disorder of repetitive patterns of behavior), trisomy 21-mosaicism (a genetic condition in which there is a mixture of two types of cells-Down's syndrome), and type 2 diabetes with hyperglycemia (a condition in which the body does not produce enough insulin).<BR/>Record review of Resident #1's re-admission MDS assessment dated [DATE] reflected that Resident #1 had a BIMS of 14, indicating intact cognition.<BR/>Record review of Resident #1's initial care-plan dated 9/30/24 revealed Resident #1 was dependent on staff for meeting her emotional, intellectual, physical, and social needs.<BR/>Record review of Resident's #1's progress notes dated 4/1/25 revealed Resident #1 was discharged on 12/6/24 with the following notation: Resident left in good spirits via gurney with EMT, all belongings were taken with resident.<BR/>Record review of Resident #1's electronic medical record on 4/1/25 revealed that there was not a physician order for the discharge on [DATE] or a completed discharge summary pertaining to the discharge.<BR/>During an interview with the Assistant Director of Nurses (ADON) on 4/1/25 at 12:25 p.m., she stated that Resident #1 did not have a physician's order for discharge on [DATE]. The ADON stated that a discharge summary pertaining to Resident #1's discharge had not been completed by Resident #1's physician or by the nursing staff. The ADON stated she was aware of the documentation requirements for a physician order for discharge and for the completion of a discharge summary.<BR/>During an interview with the MDS Nurse on 4/1/25 at 1:00p.m., she stated that a physician's order for discharge for Resident #1 on 12/6/24 was not completed. The MDS Nurse stated that she was not aware of a discharge summary completed by the resident's physician or nurse for Resident #1's discharge on [DATE].<BR/>During an interview with the Administrator on 4/2/25 at 2:50pm stated the facility would be completing in-service for nursing staff on obtaining physician orders for discharge and for the completion of the discharge summaries.<BR/>Record review of the facility policy and procedure titled Discharge Summary and Plan of Care dated 2021 reflected Upon discharge of a resident a discharge summary will be provided to the receiving care provider. The Discharge Summary should include; an overview of the resident's stay, and a final summary of the resident's status at the time of discharge.

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, for 1 of 1 medication room refrigerator and freezer, reviewed for security and medication storage and labeling, in that:<BR/>Medication room refrigerator and freezer did not have up to date temperature logs. <BR/>This deficient practice could place residents at risk of adverse effects and ineffective therapeutic effects of their medications that require refrigeration.<BR/>The findings included:<BR/>In an observation , interview and record review, on 6/23/2023 at 6:45 PM, MA A unlocked and escorted this surveyor into the Medication Room for inspection. The Refrigeration Temperature Log, dated June 2023, which also included freezer temperatures, was missing entries for 6/22/2023 and 6/23/2023. CMA A stated staff on the overnight shift is responsible for checking the refrigerator and freezer temperatures and completing the log and should have had an entry for 6/23/2023 as they usually do it sometime after midnight and before the end of their shift. This refrigerator contained prescription medications; the freezer was empty. The displayed refrigerator and freezer temperatures were within acceptable parameters <BR/>In an interview on 6/23/2023 at 7:00 PM, the DON stated she believed that the maintenance supervisor (MNT) had record of accurate temperature readings for the medication room refrigerator and freezer. The DON stated as part of his [MNT] daily morning rounds nursing staff unlock and escort him into the medication room to check on the refrigerator and freezer.<BR/>In an record review, observation, and interview on 6/23/2023 at 7:15 PM, the DON stated she had checked the refrigerator and freezer temperature in the medication room and completed the log for the days' entry, but inaccurately documented the time as 9:00 AM; The DON then corrected the entry to read 7:00 PM while in this surveyors' presence. The DON stated she had spoken with LVN B, who had checked the refrigerator and freezer temperature in the medication room yesterday morning (6/22/2023) around 9:00 AM. The DON completed that days' entry (6/22/2023) with her [the DON] signature, based off the verbal report she had from LVN B. The form indicated temperatures within parameters , but did not indicate late entry, or verbal report from LVN B. This surveyor requested to speak with both the MNT and LVN B, but neither presented themselves for interview prior to exit. <BR/>Review of undated Medication Storage policy, revealed statement, all medications .stored .to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. Under the heading of Explanation and Compliance guidelines 1. a.) .stored in locked compartments under proper temperature controls. Further, 6. Refrigerated Products: b.) Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 6 residents (Resident #25) reviewed for care plan revisions. The facility failed to ensure Resident #25's care plan was comprehensive and reflected uncontrollable nausea and vomiting during the resident's menstrual cycles. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included:Record review of Resident #25's face sheet, dated 09/11/2025, reflected that Resident #25 was a [AGE] year-old female resident with an initial admission of 10/08/2021 with diagnoses of hypoglycemia (condition in which the body's blood sugar level goes below the standard range), bipolar disorder, and type 2 diabetes mellitus. Record review of Resident #25's Quarterly MDS Assessment, dated 06/09/2025, reflected that Resident #25 had a BIMS score of 11, indicating moderate cognitive impairment. Record review of Resident #25's Comprehensive Person-Centered Care Plan, dated 09/08/2025, did not reflect any information related to Resident #25's menstrual cycle. Interview on 09/08/2025 at 2:05 PM, LVN B stated that Resident #25 has uncontrollable nausea and vomiting while she was on her menstrual cycle most months. Interview on 09/09/2025 at 9:37 AM, NP C stated that Resident #25 had frequent uncontrollable nausea and vomiting while she was on her menstrual cycle most months, and that there is a standing order for Zofran because of it. Interview on 09/11/2025 at 4:37 PM, the DON stated that Resident #25's uncontrollable nausea and vomiting during her menstrual cycle should be on a care plan. The DON stated that if it is not in the care plan the resident has the risk of other staff not being aware of that symptom and could lead to misdiagnosis. A policy on updating care plans was requested on 09/11/2025 at 4:45 PM and was not provided to the survey team prior to exit.

Based on observations, interviews and record review the facility failed to ensure Food safety requirements. The facility must distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that:<BR/>Administrative Assistance walked into and out of kitchen without a hairnet and delivered 2 ice bags to the freezer approximately 5 feet from the back door. <BR/>This could place residents at risk for food contamination.<BR/>The Findings were:<BR/>Observation on 6/22/2023 at 2:19 PM with in the kitchen revealed dietary aid K opened the back door for Administrative Assistant she came into the kitchen with 2 ice bags in each hand and was not wearing a hairnet. Observation of Administrative Assistant had long loosened hair that was not contained. Observation of Administrative Assistant walked past the dietary manager's office and placed ice bags in freezer that was more than 5 feet from the back door. <BR/>During an interview on 6/22/2023 at 2:21 PM with dietary aide K stated she did not notice Administrative Assistant was not wearing a hairnet. Dietary aide K stated the Administrative Assistant came in really fast and was not expecting her to come into kitchen. <BR/>During an interview on 6/22/2023 at 2:22 PM with the Dietary Manager (DM) stated she did not see the Administrative Assistant walked by her office with no hairnet. The DM stated all staff and visitors were supposed to wear a hairnet while in the kitchen. <BR/>During an interview on 6/22/23 02:22 PM with Administrative Assistant revealed she was not wearing a hairnet when she entered the kitchen and delivered several ice bags to the freezer. The Administrative Assistant stated she was aware that she had to wear a hairnet in kitchen, but just went in really fast to drop of ice bags. <BR/>During an interview on 6/22/2023 at 3 PM with Administrator discussed that Administrative Assistant came into the kitchen with no hairnet. The Administrator stated Administrative Assistant did let her know and was going to in-service her on wearing hairnets in the kitchen. <BR/>Record review of policy (no date) Dietary Employee Personal Hygiene Policy: It is the policy of this facility to utilize the following as guidelines for employee personal hygiene to prevent contamination of food and food service employees. Policy Explanation and Compliance Guidelines: 4. a. All dietary staff must wear hair restraints to prevent hair form contacting food. References, U.S. Public Health Service, U.S. FDA, 2017 Food Code.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 8 (Resident #21) residents reviewed in that:<BR/>Resident #21's diagnosis of Generalized Anxiety Disorder was not listed on her face sheet. <BR/>This failure could result in inadequate care due to incomplete and inaccurate medical records. <BR/>The findings included: <BR/>Record review of Resident #21's face sheet, dated 6/23/2023, revealed the resident was admitted on [DATE] with diagnosis including Type 2 Diabetes Mellitus, Heart Failure, and Recurrent Depressive Disorders. <BR/>Record review of Resident #21's Quarterly MDS assessment, dated 4/19/2023, revealed a BIMS Score of 12, indicating moderate cognitive impairment. <BR/>Record review of Resident #21's Physician Orders, dated 6/23/2023, revealed an order beginning on 3/24/2023 for Buspirone HCl Oral Tablet 15 MG, three times daily, for Anxiety. <BR/>Record review of Resident #21's psychological services progress note, dated 3/04/2023, revealed diagnosis of Major Depressive Disorder, Recurrent, Severe, and Generalized Anxiety Disorder (GAD). <BR/>Record review of Resident #21's psychological services progress note, dated 6/09/2023, revealed diagnosis of Major Depressive Disorder, Recurrent, Severe, and Generalized Anxiety Disorder (GAD). <BR/>Further review of Resident #21's face sheet revealed her diagnoses of Generalized Anxiety Disorder was not listed.<BR/>During an interview with the MDS Coordinator on 6/23/2023 at 3:00 PM, the MDS Coordinator verbally confirmed that Resident #21 had been diagnosed with Generalized Anxiety Disorder by the resident's psychological services provider. The MDS Coordinator verbally confirmed that this diagnosis was not listed as a diagnosis in Resident #21's face sheet or electronic health record. The MDS Coordinator stated the resident has been diagnosed with Generalized Anxiety Disorder since at least March of 2023. The MDS Coordinator verbally confirmed that there is a risk to residents if care providers are not aware of resident's psychological diagnosis. <BR/>Record review of facility policy on Maintenance of Electronic Clinical Records, undated, revealed A complete and accurate electronic clinical record will be maintained on each resident and systematically organized for appropriate personnel to deliver the appropriate level of care for each resident while maintaining the confidentiality of the residents' information.

Based on observations, interviews, and record reviews the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility for 1 of 3 years of recertification surveys (2024) for survey results reviewed. The facility posted the results for annual recertification survey for 2023 and omitted the most recent survey results from 2024. This failure could deny residents, Resident representatives, and the public from examining the most recent survey results. The findings included:The findings included: During an observation and record review on 9/7/2025 at 3:50 PM revealed the facility's survey results binder by the receptionist desk in the facility's public common area. the survey results binder was kept in a wall mounted binder holder. The binder contained results from previous surveys with the latest date of 2/16/2024. A record review of the Texas Unified Licensure Information Portal (TULIP) website accessed 9/7/2025 revealed the last recertification survey for the facility was 8/30/2024. During an interview on 9/11/2025 at 5:00 PM the Administrator stated it was their policy to ensure the most recent survey results were kept in the binder and made public. The Administrator stated the binder with the most recent survey results was kept in a binder on the wall by the receptionist desk in the facility's public lobby. The Administrator stated it was her responsibility to ensure the results of the most recent survey were kept in the binder and stated the most recent survey results were from August 2024. The Administrator stated she was unaware the results were not in the binder. The administrator stated the potential negative outcome could be that Residents, Resident representatives, and the public would be denied examining the most recent survey results. A policy was requested, and the Administrator stated the facility followed HHSC guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Bbased on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices forresident for 1 of 4 (#123) residents on dDialysis in that:<BR/>Resident #123 did not have an order for Ddialysis services.<BR/>This could place residents at risk for not receiving appropriate care and treatment. <BR/>The Findings were: <BR/>Record Review of Resident #123's admission Record dated [DATE] revealed she was admitted to facility on [DATE] with diagnoses of end stage renal disease, dependence on renal dialysis and acute respiratory failure with hypoxia (deficiency of oxygen reaching the tissues). Record of Resident #123's admission Record was documented for Advanced Directive section-Resident is a full code perform CPR. <BR/>Record Review of Resident #123's admission MDS dated [DATE] revealed Section C -Cognitive Patterns, BIMS score was 13/15 (cognitively intact), and Section O Special Treatments, Procedures and programs, under other was J. Dialysis services was marked. <BR/>Record Review of Resident #123's Care plan dated [DATE] revealed Resident #123 did not have a care plan for Dialysis services with interventions. <BR/>Record Review of Resident #123's consolidated physician orders for [DATE] revealed no Dialysis Services and Treatment was ordered. <BR/>During an interview on [DATE] at 4:26 PM with MDS coordinator after reviewing the orders , MDS and Care plan for Resident #123, verbally stated she did not have a Dialysis service and treatment order. Interview with the MDS nurse stated she had recently started taking over resident MDS assessments and was not sure why Resident #123 did not have an order for Ddialysis, so there was no care plan. <BR/>During an interview on [DATE] at 5 PM with the Administrator discussed concerns and she only listened and did no reply further. <BR/>Record review of Verbal Orders policy dated [DATE] was documented Policy: Physician orders may be received by telephone, by a licensed nurse or other licensed or registered health care specialist who are legally authorized to do so. Definition-verbal order are those given to the nurse by the physician in person or by telephone, however, are not written by the physician in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 8 (Resident #21) residents reviewed in that:<BR/>Resident #21's diagnosis of Generalized Anxiety Disorder was not listed on her face sheet. <BR/>This failure could result in inadequate care due to incomplete and inaccurate medical records. <BR/>The findings included: <BR/>Record review of Resident #21's face sheet, dated 6/23/2023, revealed the resident was admitted on [DATE] with diagnosis including Type 2 Diabetes Mellitus, Heart Failure, and Recurrent Depressive Disorders. <BR/>Record review of Resident #21's Quarterly MDS assessment, dated 4/19/2023, revealed a BIMS Score of 12, indicating moderate cognitive impairment. <BR/>Record review of Resident #21's Physician Orders, dated 6/23/2023, revealed an order beginning on 3/24/2023 for Buspirone HCl Oral Tablet 15 MG, three times daily, for Anxiety. <BR/>Record review of Resident #21's psychological services progress note, dated 3/04/2023, revealed diagnosis of Major Depressive Disorder, Recurrent, Severe, and Generalized Anxiety Disorder (GAD). <BR/>Record review of Resident #21's psychological services progress note, dated 6/09/2023, revealed diagnosis of Major Depressive Disorder, Recurrent, Severe, and Generalized Anxiety Disorder (GAD). <BR/>Further review of Resident #21's face sheet revealed her diagnoses of Generalized Anxiety Disorder was not listed.<BR/>During an interview with the MDS Coordinator on 6/23/2023 at 3:00 PM, the MDS Coordinator verbally confirmed that Resident #21 had been diagnosed with Generalized Anxiety Disorder by the resident's psychological services provider. The MDS Coordinator verbally confirmed that this diagnosis was not listed as a diagnosis in Resident #21's face sheet or electronic health record. The MDS Coordinator stated the resident has been diagnosed with Generalized Anxiety Disorder since at least March of 2023. The MDS Coordinator verbally confirmed that there is a risk to residents if care providers are not aware of resident's psychological diagnosis. <BR/>Record review of facility policy on Maintenance of Electronic Clinical Records, undated, revealed A complete and accurate electronic clinical record will be maintained on each resident and systematically organized for appropriate personnel to deliver the appropriate level of care for each resident while maintaining the confidentiality of the residents' information.

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, for 1 of 1 medication room refrigerator and freezer, reviewed for security and medication storage and labeling, in that:<BR/>Medication room refrigerator and freezer did not have up to date temperature logs. <BR/>This deficient practice could place residents at risk of adverse effects and ineffective therapeutic effects of their medications that require refrigeration.<BR/>The findings included:<BR/>In an observation , interview and record review, on 6/23/2023 at 6:45 PM, MA A unlocked and escorted this surveyor into the Medication Room for inspection. The Refrigeration Temperature Log, dated June 2023, which also included freezer temperatures, was missing entries for 6/22/2023 and 6/23/2023. CMA A stated staff on the overnight shift is responsible for checking the refrigerator and freezer temperatures and completing the log and should have had an entry for 6/23/2023 as they usually do it sometime after midnight and before the end of their shift. This refrigerator contained prescription medications; the freezer was empty. The displayed refrigerator and freezer temperatures were within acceptable parameters <BR/>In an interview on 6/23/2023 at 7:00 PM, the DON stated she believed that the maintenance supervisor (MNT) had record of accurate temperature readings for the medication room refrigerator and freezer. The DON stated as part of his [MNT] daily morning rounds nursing staff unlock and escort him into the medication room to check on the refrigerator and freezer.<BR/>In an record review, observation, and interview on 6/23/2023 at 7:15 PM, the DON stated she had checked the refrigerator and freezer temperature in the medication room and completed the log for the days' entry, but inaccurately documented the time as 9:00 AM; The DON then corrected the entry to read 7:00 PM while in this surveyors' presence. The DON stated she had spoken with LVN B, who had checked the refrigerator and freezer temperature in the medication room yesterday morning (6/22/2023) around 9:00 AM. The DON completed that days' entry (6/22/2023) with her [the DON] signature, based off the verbal report she had from LVN B. The form indicated temperatures within parameters , but did not indicate late entry, or verbal report from LVN B. This surveyor requested to speak with both the MNT and LVN B, but neither presented themselves for interview prior to exit. <BR/>Review of undated Medication Storage policy, revealed statement, all medications .stored .to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. Under the heading of Explanation and Compliance guidelines 1. a.) .stored in locked compartments under proper temperature controls. Further, 6. Refrigerated Products: b.) Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide notification of a resident's discharge to ensure that appropriate information is communicated to the Office of the State Long-Term Care Ombudsman for 1 or 6 residents (Resident #1) reviewed for transfer or discharge. <BR/>The facility failed to ensure that:<BR/>1. Resident #1's discharge notification was sent to the Office of the State Long-Term Care Ombudsman.<BR/>This deficient practice could affect resident's safe discharge planning by missed notification to the proper authorities.<BR/>The findings included: <BR/>Record review of Resident #1's face sheet, dated 04/01/25, revealed a [AGE] year-old resident initially admitted on [DATE] with diagnoses including autistic disorder (a neuro-developmental disorder of repetitive patterns of behavior), trisomy 21-mosaicism (a genetic condition in which there is a mixture of two types of cells-Down's syndrome), and type 2 diabetes with hyperglycemia (a condition in which the body does not produce enough insulin).<BR/>Record review of Resident #1's re-admission MDS assessment dated [DATE] reflected that Resident #1 had a BIMS of 14, indicating intact cognition.<BR/>Record review of Resident #1's initial care-plan dated 9/30/24 revealed Resident #1 was dependent on staff for meeting her emotional, intellectual, physical, and social needs.<BR/>Record review of Resident's #1's social worker progress notes dated 4/1/25 revealed that Resident #1 had requested alternate nursing facility placement during the month of 10/24 and was agreeable with the social worker's search for alternate nursing facility placement.<BR/>During an interview with the facility's Ombudsman on 4/1/25 at 1:45pm she stated that she had not received written notification of Resident #1's discharge to another nursing facility on 12/6/24.<BR/>During an interview with the facility's admission Director on 4/3/25 at 9:05 a.m , she stated that Resident #1 was her own responsible party (RP) and had signed her own admission documents to the facility.<BR/>During an interview with the facility's Social Worker on 4/3/25 at 9:15am she stated that she was responsible for sending the Ombudsman's office the discharge notification information and that Resident #1 had been discharged to another nursing facility on 12/6/24. The Social Worker stated that at the time of the resident's discharge she was unaware of the notification requirement.<BR/>During an interview with the Administrator on 4/3/25 at 10:15am she stated that the local Ombudsman had not been notified of Resident #1's discharge on [DATE]. The Administrator stated that the notification was important to meet the proper resident discharge requirement.<BR/>Record review of the facility policy and procedure titled Discharge Summary and Plan of Care dated 2021 reflected, The Discharge Summary should include: A final summary of the resident's status at the time of discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.

Based on observations, interviews and record review the facility failed to ensure Food safety requirements. The facility must distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that:<BR/>Administrative Assistance walked into and out of kitchen without a hairnet and delivered 2 ice bags to the freezer approximately 5 feet from the back door. <BR/>This could place residents at risk for food contamination.<BR/>The Findings were:<BR/>Observation on 6/22/2023 at 2:19 PM with in the kitchen revealed dietary aid K opened the back door for Administrative Assistant she came into the kitchen with 2 ice bags in each hand and was not wearing a hairnet. Observation of Administrative Assistant had long loosened hair that was not contained. Observation of Administrative Assistant walked past the dietary manager's office and placed ice bags in freezer that was more than 5 feet from the back door. <BR/>During an interview on 6/22/2023 at 2:21 PM with dietary aide K stated she did not notice Administrative Assistant was not wearing a hairnet. Dietary aide K stated the Administrative Assistant came in really fast and was not expecting her to come into kitchen. <BR/>During an interview on 6/22/2023 at 2:22 PM with the Dietary Manager (DM) stated she did not see the Administrative Assistant walked by her office with no hairnet. The DM stated all staff and visitors were supposed to wear a hairnet while in the kitchen. <BR/>During an interview on 6/22/23 02:22 PM with Administrative Assistant revealed she was not wearing a hairnet when she entered the kitchen and delivered several ice bags to the freezer. The Administrative Assistant stated she was aware that she had to wear a hairnet in kitchen, but just went in really fast to drop of ice bags. <BR/>During an interview on 6/22/2023 at 3 PM with Administrator discussed that Administrative Assistant came into the kitchen with no hairnet. The Administrator stated Administrative Assistant did let her know and was going to in-service her on wearing hairnets in the kitchen. <BR/>Record review of policy (no date) Dietary Employee Personal Hygiene Policy: It is the policy of this facility to utilize the following as guidelines for employee personal hygiene to prevent contamination of food and food service employees. Policy Explanation and Compliance Guidelines: 4. a. All dietary staff must wear hair restraints to prevent hair form contacting food. References, U.S. Public Health Service, U.S. FDA, 2017 Food Code.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Bbased on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices forresident for 1 of 4 (#123) residents on dDialysis in that:<BR/>Resident #123 did not have an order for Ddialysis services.<BR/>This could place residents at risk for not receiving appropriate care and treatment. <BR/>The Findings were: <BR/>Record Review of Resident #123's admission Record dated [DATE] revealed she was admitted to facility on [DATE] with diagnoses of end stage renal disease, dependence on renal dialysis and acute respiratory failure with hypoxia (deficiency of oxygen reaching the tissues). Record of Resident #123's admission Record was documented for Advanced Directive section-Resident is a full code perform CPR. <BR/>Record Review of Resident #123's admission MDS dated [DATE] revealed Section C -Cognitive Patterns, BIMS score was 13/15 (cognitively intact), and Section O Special Treatments, Procedures and programs, under other was J. Dialysis services was marked. <BR/>Record Review of Resident #123's Care plan dated [DATE] revealed Resident #123 did not have a care plan for Dialysis services with interventions. <BR/>Record Review of Resident #123's consolidated physician orders for [DATE] revealed no Dialysis Services and Treatment was ordered. <BR/>During an interview on [DATE] at 4:26 PM with MDS coordinator after reviewing the orders , MDS and Care plan for Resident #123, verbally stated she did not have a Dialysis service and treatment order. Interview with the MDS nurse stated she had recently started taking over resident MDS assessments and was not sure why Resident #123 did not have an order for Ddialysis, so there was no care plan. <BR/>During an interview on [DATE] at 5 PM with the Administrator discussed concerns and she only listened and did no reply further. <BR/>Record review of Verbal Orders policy dated [DATE] was documented Policy: Physician orders may be received by telephone, by a licensed nurse or other licensed or registered health care specialist who are legally authorized to do so. Definition-verbal order are those given to the nurse by the physician in person or by telephone, however, are not written by the physician in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Bbased on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices forresident for 1 of 4 (#123) residents on dDialysis in that:<BR/>Resident #123 did not have an order for Ddialysis services.<BR/>This could place residents at risk for not receiving appropriate care and treatment. <BR/>The Findings were: <BR/>Record Review of Resident #123's admission Record dated [DATE] revealed she was admitted to facility on [DATE] with diagnoses of end stage renal disease, dependence on renal dialysis and acute respiratory failure with hypoxia (deficiency of oxygen reaching the tissues). Record of Resident #123's admission Record was documented for Advanced Directive section-Resident is a full code perform CPR. <BR/>Record Review of Resident #123's admission MDS dated [DATE] revealed Section C -Cognitive Patterns, BIMS score was 13/15 (cognitively intact), and Section O Special Treatments, Procedures and programs, under other was J. Dialysis services was marked. <BR/>Record Review of Resident #123's Care plan dated [DATE] revealed Resident #123 did not have a care plan for Dialysis services with interventions. <BR/>Record Review of Resident #123's consolidated physician orders for [DATE] revealed no Dialysis Services and Treatment was ordered. <BR/>During an interview on [DATE] at 4:26 PM with MDS coordinator after reviewing the orders , MDS and Care plan for Resident #123, verbally stated she did not have a Dialysis service and treatment order. Interview with the MDS nurse stated she had recently started taking over resident MDS assessments and was not sure why Resident #123 did not have an order for Ddialysis, so there was no care plan. <BR/>During an interview on [DATE] at 5 PM with the Administrator discussed concerns and she only listened and did no reply further. <BR/>Record review of Verbal Orders policy dated [DATE] was documented Policy: Physician orders may be received by telephone, by a licensed nurse or other licensed or registered health care specialist who are legally authorized to do so. Definition-verbal order are those given to the nurse by the physician in person or by telephone, however, are not written by the physician in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 8 (Resident #21) residents reviewed in that:<BR/>Resident #21's diagnosis of Generalized Anxiety Disorder was not listed on her face sheet. <BR/>This failure could result in inadequate care due to incomplete and inaccurate medical records. <BR/>The findings included: <BR/>Record review of Resident #21's face sheet, dated 6/23/2023, revealed the resident was admitted on [DATE] with diagnosis including Type 2 Diabetes Mellitus, Heart Failure, and Recurrent Depressive Disorders. <BR/>Record review of Resident #21's Quarterly MDS assessment, dated 4/19/2023, revealed a BIMS Score of 12, indicating moderate cognitive impairment. <BR/>Record review of Resident #21's Physician Orders, dated 6/23/2023, revealed an order beginning on 3/24/2023 for Buspirone HCl Oral Tablet 15 MG, three times daily, for Anxiety. <BR/>Record review of Resident #21's psychological services progress note, dated 3/04/2023, revealed diagnosis of Major Depressive Disorder, Recurrent, Severe, and Generalized Anxiety Disorder (GAD). <BR/>Record review of Resident #21's psychological services progress note, dated 6/09/2023, revealed diagnosis of Major Depressive Disorder, Recurrent, Severe, and Generalized Anxiety Disorder (GAD). <BR/>Further review of Resident #21's face sheet revealed her diagnoses of Generalized Anxiety Disorder was not listed.<BR/>During an interview with the MDS Coordinator on 6/23/2023 at 3:00 PM, the MDS Coordinator verbally confirmed that Resident #21 had been diagnosed with Generalized Anxiety Disorder by the resident's psychological services provider. The MDS Coordinator verbally confirmed that this diagnosis was not listed as a diagnosis in Resident #21's face sheet or electronic health record. The MDS Coordinator stated the resident has been diagnosed with Generalized Anxiety Disorder since at least March of 2023. The MDS Coordinator verbally confirmed that there is a risk to residents if care providers are not aware of resident's psychological diagnosis. <BR/>Record review of facility policy on Maintenance of Electronic Clinical Records, undated, revealed A complete and accurate electronic clinical record will be maintained on each resident and systematically organized for appropriate personnel to deliver the appropriate level of care for each resident while maintaining the confidentiality of the residents' information.

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, for 1 of 1 medication room refrigerator and freezer, reviewed for security and medication storage and labeling, in that:<BR/>Medication room refrigerator and freezer did not have up to date temperature logs. <BR/>This deficient practice could place residents at risk of adverse effects and ineffective therapeutic effects of their medications that require refrigeration.<BR/>The findings included:<BR/>In an observation , interview and record review, on 6/23/2023 at 6:45 PM, MA A unlocked and escorted this surveyor into the Medication Room for inspection. The Refrigeration Temperature Log, dated June 2023, which also included freezer temperatures, was missing entries for 6/22/2023 and 6/23/2023. CMA A stated staff on the overnight shift is responsible for checking the refrigerator and freezer temperatures and completing the log and should have had an entry for 6/23/2023 as they usually do it sometime after midnight and before the end of their shift. This refrigerator contained prescription medications; the freezer was empty. The displayed refrigerator and freezer temperatures were within acceptable parameters <BR/>In an interview on 6/23/2023 at 7:00 PM, the DON stated she believed that the maintenance supervisor (MNT) had record of accurate temperature readings for the medication room refrigerator and freezer. The DON stated as part of his [MNT] daily morning rounds nursing staff unlock and escort him into the medication room to check on the refrigerator and freezer.<BR/>In an record review, observation, and interview on 6/23/2023 at 7:15 PM, the DON stated she had checked the refrigerator and freezer temperature in the medication room and completed the log for the days' entry, but inaccurately documented the time as 9:00 AM; The DON then corrected the entry to read 7:00 PM while in this surveyors' presence. The DON stated she had spoken with LVN B, who had checked the refrigerator and freezer temperature in the medication room yesterday morning (6/22/2023) around 9:00 AM. The DON completed that days' entry (6/22/2023) with her [the DON] signature, based off the verbal report she had from LVN B. The form indicated temperatures within parameters , but did not indicate late entry, or verbal report from LVN B. This surveyor requested to speak with both the MNT and LVN B, but neither presented themselves for interview prior to exit. <BR/>Review of undated Medication Storage policy, revealed statement, all medications .stored .to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. Under the heading of Explanation and Compliance guidelines 1. a.) .stored in locked compartments under proper temperature controls. Further, 6. Refrigerated Products: b.) Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee.

Based on observations, interviews and record review the facility failed to ensure Food safety requirements. The facility must distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that:<BR/>Administrative Assistance walked into and out of kitchen without a hairnet and delivered 2 ice bags to the freezer approximately 5 feet from the back door. <BR/>This could place residents at risk for food contamination.<BR/>The Findings were:<BR/>Observation on 6/22/2023 at 2:19 PM with in the kitchen revealed dietary aid K opened the back door for Administrative Assistant she came into the kitchen with 2 ice bags in each hand and was not wearing a hairnet. Observation of Administrative Assistant had long loosened hair that was not contained. Observation of Administrative Assistant walked past the dietary manager's office and placed ice bags in freezer that was more than 5 feet from the back door. <BR/>During an interview on 6/22/2023 at 2:21 PM with dietary aide K stated she did not notice Administrative Assistant was not wearing a hairnet. Dietary aide K stated the Administrative Assistant came in really fast and was not expecting her to come into kitchen. <BR/>During an interview on 6/22/2023 at 2:22 PM with the Dietary Manager (DM) stated she did not see the Administrative Assistant walked by her office with no hairnet. The DM stated all staff and visitors were supposed to wear a hairnet while in the kitchen. <BR/>During an interview on 6/22/23 02:22 PM with Administrative Assistant revealed she was not wearing a hairnet when she entered the kitchen and delivered several ice bags to the freezer. The Administrative Assistant stated she was aware that she had to wear a hairnet in kitchen, but just went in really fast to drop of ice bags. <BR/>During an interview on 6/22/2023 at 3 PM with Administrator discussed that Administrative Assistant came into the kitchen with no hairnet. The Administrator stated Administrative Assistant did let her know and was going to in-service her on wearing hairnets in the kitchen. <BR/>Record review of policy (no date) Dietary Employee Personal Hygiene Policy: It is the policy of this facility to utilize the following as guidelines for employee personal hygiene to prevent contamination of food and food service employees. Policy Explanation and Compliance Guidelines: 4. a. All dietary staff must wear hair restraints to prevent hair form contacting food. References, U.S. Public Health Service, U.S. FDA, 2017 Food Code.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program for residents with newly evident or possible serious mental disorder for 1 of 8 Residents (Resident #6) whose records were reviewed related to PASARR screenings. The facility failed to refer Resident #6 for Level I screening after being diagnosed with a mental disorder. This failure could place residents with new mental diagnoses at risk for not receiving services as identified by PASARR. The findings included:Record review of Resident #6's admission Record, dated 09/11/2025, reflected that Resident #6 was initially admitted on [DATE] with diagnoses of Bipolar II Disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), end stage renal disease (condition in which the kidneys lose the ability to remove waste and balance fluids), and type 2 diabetes mellitus. Record review of Resident #6's Diagnosis Report, dated 09/11/2025, reflected that Resident #6 was diagnosed with Bipolar II Disorder on 04/10/2025. Record review of Resident #6's Quarterly MDS Assessment, dated 06/11/2025, reflected that Resident #6 had a BIMS score of 9, indicating moderate cognitive impairment. Further review reflected Resident #6 had a diagnosis of bipolar disorder. Record review of Resident #6's Comprehensive Person-Centered Care Plan, dated 09/10/2025, reflected, [Resident #6] has a mood problem r/t Bipolar disorder initiated on 04/23/2025. Record review of Resident #6's Electronic Health Record reflected that Resident #6 had not had a PASARR since his admission PASARR. PASARR dated 3/31/2025did not reflect resident had a diagnosis of bipolar disorder and depression. Interview on 09/10/2025 at 10:04 AM, the Social Worker stated that she had recently become the person who oversaw PASARR at the facility. The Social Worker stated she was uncertain if a new PASARR should be done if a new diagnosis is added if they have already had a PASARR assessment that has resulted in a negative initial PASARR screening. Interview on 09/11/2025 at 4:37 PM, the DON stated her expectation was for PASARR screenings to be completed if they receive a new diagnosis. The DON stated that all notes from behavioral health are reviewed by MDS for new diagnoses and staff would be informed by MDS about these new diagnoses. The DON stated that there is the risk for residents to not receive appropriate benefits if they do not get a new PASARR screening after receiving a new diagnosis. Record review of facility policy titled, Resident Assessment - Coordination with PASARR Program, undated, reflected, Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.