WATERSIDE NURSING & REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure for accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 residents (Resident #14) reviewed for medications and pharmacy services. The facility failed to ensure Resident #14 morning meds were disposed of appropriately when the resident refused the medications on 9/06/2025 by MA P. The facility failed to ensure Resident #1's hydrocodone was appropriately wasted and documented when it was removed from original container on 8/29/2025 by LVN A. These deficient practices could put residents at risk for medication errors. The findings included: Record review of Resident #14's face sheet, dated 9/06/2025 revealed an [AGE] year-old male admitted on [DATE] with diagnoses which included severe dementia, anxiety disorder, restlessness and agitation. Record review of Resident #14's modified quarterly MDS dated [DATE] revealed a BIMs score of 4 which indicated a severe cognitive impairment with no behavior symptoms. His ADL function was listed as set up assistance. Record review of Resident #14's care plan revealed was on hospice care with interventions which included administer medications and treatments as ordered. A plan of care for behavior problems with intervention which included administer medications as ordered and behavior monitoring. A plan of care for resistance to care such as care refusals related to dementia with interventions which included: if resident resists with ADL's, reassure resident, leave and return 5-10 minutes later and try again. Record review of Resident #14's September MAR revealed the following medications were marked as refused by MA P: Fluoxetine 20 mg-give 2 capsules by mouth one time a day for depressionLisinopril 2.5 mg-give one tablet by mouth in the morning for hypertension.Provera 2.5 mg-give one tablet by mouth one time a day for lower testosterone levels related to dementia. Depakote Sprinkles delayed release 125 mg-give 3 capsules by mouth two times a day related to dementiaLorazepam 0.5 mg-give one tablet by mouth three times a day for anxiety and agitations related to anxiety disorder. During an observation on 9/06/2025 at 4:05 pm of the medication cart on 100 hallway assigned to MA P revealed a medication cup with pudding and crushed meds mixed with the pudding in the second drawer of the medication cart. The medication cup had the Resident #14's first name handwritten on the cup. During an interview on 9/06/2025 at 4:11 p.m., MA P stated the medication in the pudding belonged to Resident #14 and it was his morning medications. She stated Resident #14 had allowed her to take his vital signs this morning but when she went to administer the medication he refused, pushed it away and tried to hit her. She stated she put it in the medication cart to give it later. MA P stated the medication included Depakote, fluoxetine, lisinopril, Provera and lorazepam 0.5mg (controlled substance). She stated she had signed the medication off in the medical record. MA P stated she had received the in-service training on medication administration. She stated she thought as long as the name was on the cup it was okay to keep it. MA P stated she told LVN C what she was doing and the LVN said it was fine. MA P stated she learned in training as long as the resident name was on the cup that it was fine to keep and hold on to. During an interview on 9/06/2025 at 4:22 p.m., LVN C stated MA P had informed her Resident #14 had refused medication. She stated she did not know MA P held the meds mixed in pudding in the cart. She stated she should have had MA P and herself wasted (disposed) the medications together because of the risk for medication error with pre-dispensed medications. 2. Record review of Resident #1's face sheet dated 9/03/2025 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: epilepsy, hypotension (low blood pressure), cardiomyopathy (disease of the heart muscle) and schizophrenia (serious mental health condition that affects how people think feel and behave). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicated a severe cognitive impairment with behaviors that included rejection of care less than daily. Resident #1's functional status was listed partial assistance showering/bathing and supervision for oral care and eating. Record review of Resident #1's care plan dated 7/15/2025 revealed she was on hospice care with interventions to observe for pain and administer pain medications as ordered by a physician. Record review of Resident #1's BIMS evaluation dated 9/02/2025 revealed a score of 15 which indicated the resident was cognitively intact. Record review of Resident #1's physician order summary for August 2025 revealed the following medication order: Hydrocodone-acetaminophen oral tablet 10/325 mg, give 0.5 tablet by mouth every 8 hours as needed for pain with a start date 8/29/2025. Record review of Resident #1's Narcotic Administration Record for hydrocodone-acetaminophen 10/325 mg revealed LVN A signed out one dosage (0.5 mg) of the narcotic on 8/29/2025 at 8 p.m. Record review of Resident #1's August 2025 MAR revealed hydrocodone-acetaminophen 10/325 mg tablet, give 0.5 tablet every 8 hours as needed was not documented as administered. Record review of Resident #1's hospital records dated 8/31/2025 revealed the resident was admitted to the hospital due to inadvertent administration of another patient's medication while at her nursing facility. The hospital MD called the nursing facility and confirmed medications which included eight medications and a question mark for hydrocodone. Nursing facility staff stated this (hydrocodone) may not have been administered as it was a later dose for this patient. Urine drug screen noted positive for opioids, TCA's (tricyclic antidepressants) and benzos (benzodiazepines). During an interview on 9/03/2025 at 1:45 p.m., Resident #1 stated on Friday 8/29/2025 she was approached by an unknown staff member and given medications two times in a short period of time. She stated she was not sure what she was given as she trusted the staff and just took the medications. During an interview on 9/04/2025 at 1:30 p.m., LVN A stated she signed Resident #1's hydrocodone out on the narcotic record. She stated she does not believe she administered the hydrocodone to the resident. She stated pulled the hydrocodone and intended to give it when she made a medication error with Resident #1. She stated she was more worried about caring for Resident #1 than she was about documentation or the disposal of medication. She stated she threw the hydrocodone in the sharps container but did not have another staff member witness the wasting of the medication as required for a narcotic or correct any documentation. She stated she was trained to have another nurse witness the waste (disposal) with her and then document the medication waste with double signatures. During an interview on 9/04/2025 at 1:39 p.m. the DON stated she had reviewed the narcotic record for Resident #1's hydrocodone which indicated the medication was documented as removed at 8:00 pm on 8/29/2025. The DON stated she does not believe the hydrocodone was given to Resident #1 and the time did not match when it was actually pulled. She stated LVN A documented on the narcotic record when the time it was supposed to be given rather than the time it was given. The DON stated she had reviewed with LVN A. The DON stated LVN A should document the medication at the actual time the medication was given. During an interview on 9/07/2025 at 3:01 p.m., the DON stated medications should be wasted and discarded if not administered to avoid confusion. Record review of a facility policy, titled Medication Administration last revised 5/07/2025 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.3. Identify resident 10. Ensure that the six rights of medication administration are followed. a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation. 11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form dose, route and time. 14. Remove medication from source.15. Administer medication as ordered in accordance with manufacturer specifications 19. Observe resident consumption of medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents are free of any significant medication errors and that accepted professional standards and principles which apply to administration were followed for 2 (Resident #288 and Resident # 4) of 15 Residents observed and reviewed for medication administration in that:<BR/>1. <BR/>Resident # 288's medications were in a medicine cup in the top drawer of the medication cart.<BR/>2. <BR/>Resident #4's medications were in the medicine cup in the top drawer of the medication cart. <BR/>This deficient practice could affect residents who receive medications, resulting in needed medications not being taken and documented as taken. <BR/>The findings were:<BR/>1.Review of Resident # 288's electronic face sheet dated 4/23/23 revealed he was admitted on [DATE] with a diagnosis of [Acute Respiratory Distress] when fluid builds up in the tiny, elastic air sacs in the lungs. [Muscle Weakness] Lack of muscle strength. [ Essential Hypertension] abnormally high blood pressure that's not the result of a medical condition. <BR/>Review of Resident 288's electronic medication administration record dated 4/23/23 revealed that resident # 288 had seven medications scheduled for 0:800 a.m. Amlodipine 10 mg, one tablet by mouth daily for hypertension, B-12 Complex, for vitamin supplementation; Divalproex 250 mg, one capsule by mouth daily for dementia; Omeprazole 40 mg, one capsule by mouth daily, for reflux, Potassium Chloride 10 MEQ, one tablet daily for hypertension, Pyridostigmine bromide60 mg, one tablet by mouth daily for myasthenia gravis, Seroquel 25 mg, one tablet by mouth daily for dementia. <BR/>Review of Resident 288's admission MDS dated [DATE], revealed BIMS left blank, indicating resident # 288 could not complete the interview and suggesting severe impairment. <BR/>Review of Resident #288's comprehensive plan of care dated 4/17/23 revealed intervention administer medications and treatments as ordered.<BR/>Observation on 4/23/23 at 10:15 am revealed Resident # 288's morning medication of seven pills was in a medication cup on the top drawer of the medication cart. <BR/>Interview on 4/23/23 at 10:45 a.m., LVN A stated, I attempted to give him his medication earlier, but he refused and was going to try again later; I signed the electronic administration record as administered since medications had been pulled. LVN A stated, She knows that storing medications in cups in a medication drawer is not the best practice, as they should be disposed of if a resident refuses. LVN A stated resident risked the possibility of a medication error.<BR/>2.Review of Resident # 4's electronic face sheet dated 4/23/23 revealed resident was admitted on [DATE] with a diagnosis of [schizophrenia], a serious mental disorder in which people interpret reality abnormally. [Dementia] condition characterized by progressive or persistent loss of intellectual functioning. Cognitive Communication Deficit] difficulty with thinking and how someone uses language. <BR/>Review of resident # 4's electronic medication administration record dated 4/23/23 revealed that resident # 4 had four medications scheduled for 0:800. Lexapro 10 mg, one tablet daily by mouth for schizophrenia, Lipitor 20 mg, one tablet daily by mouth for hyperlipidemia, Metformin 1000 mg take one tablet daily by mouth for diabetes mellitus, Risperdal 2mg one tablet daily by mouth for schizophrenia. <BR/>Review of Resident # 4 Quarterly MDS dated [DATE] revealed a BIMS of 8, suggesting moderate impairment. <BR/>Review of Resident #4's comprehensive plan of care dated 7/18/22 revealed intervention administer medications and treatments as ordered.<BR/>Observation on 4/23/23 at 10:20 a.m. revealed Resident # 4's morning medication of four pills in a medicine cup on the top drawer of the medication cart. <BR/>Interview on 4/23/2023 at 10:55 a.m. with CMA B stated she had to pull medications early as she was tending to patient care and passing out medications. Therefore, she had pre-pulled her medications. She had signed the medication administration record as administered as she had pulled the medicine for resident # 4. She confirmed that she should not have pre-pulled medications as she risked a possible medication error by not following the medication rights. <BR/>Interview on 4/23/23 at 11:50 a.m. with the clinical nurse consultant revealed that LVN A should have stayed with Resident #288 until he swallowed all his medications. If Resident # 288 refused medications, LVN A should have marked medications on the electronic medical record as refused, not as administered. The clinical nurse consultant revealed that CMA B should not have pre-poured her morning medications for Resident # 4 and should not have marked medications on electronic medical record as administered; if she had not given them, she stated that both practices were not safe, and she would be in-servicing nursing staff, as this practice could lead to possible medication errors. <BR/>Review of the facility policy and procedure titled Administering medications dated 2001, revised December 2012, revealed, Medications shall be administered safely, timely, and as prescribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents had suitable, nourishing meals and snacks outside of scheduled meal service times for 3 of 4 residents (Resident #1, Resident #3, and Resident #5) reviewed for snacks.<BR/>The facility failed to ensure Resident #1, Resident #3, and Resident #5 were offered snacks at bedtime as prescribed by the physician.<BR/>This failure could affect residents who received meals/snacks served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and inadequate nutrition status.<BR/>The findings included:<BR/>1. Record review of Resident #1's face sheet dated 6/11/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (loss of muscle mass), diabetes with ketoacidosis (condition characterized by high blood glucose levels and elevated levels of ketones in the blood or urine), adult failure to thrive, and limitation of activities due to disability.<BR/>Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills, received a therapeutic diet, and received dialysis treatments (a medical treatment that performs the essential functions of the kidneys when they are no longer able to work effectively).<BR/>Record review of Resident #1's Order Summary Report dated 6/11/25 revealed the following:<BR/>- Renal (Dialysis) diet Regular texture, Regular/Thin consistency, Dairy Free, Large Protein Portions, no milk or anything made with milk, no cheese, no ice cream, no fortified pudding, no Yogurt, no health shakes, no cream causes, no butter, no dressing on salads with order date 10/1/24 and no end date<BR/>- One High Protein Snack at HS in the evening for One High Protein Snack at HS with order date 11/24/24 and no end date<BR/>Record review of Resident #1's MAR/TAR Schedule for June 2025 revealed the residents order to receive one high protein snack at HS was not included on the schedule therefore there was no documentation the resident was receiving the high protein snack.<BR/>Record review of Resident #1's Dietary Profile dated 12/20/24 revealed the resident received a liberal renal diet with large protein portions, regular texture and 1 high protein snack daily.<BR/>Record review of Resident #1's comprehensive care plan with revision date 1/22/25 revealed the resident was lactose intolerant, had a behavior problem related to obsessive/compulsive tendency about diet/foods, and had a nutritional problem related to dietary restrictions and preferences, with interventions that included to provide and serve diet as ordered.<BR/>2. Record review of Resident #3's face sheet dated 6/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included protein-calorie malnutrition, muscle weakness, feeding difficulties, muscle wasting and atrophy, Vitamin D deficiency, fatigue, and irritable bowel syndrome.<BR/>Record review of Resident #3's most recent MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and required supervision with eating.<BR/>Record review of Resident #3's Order Summary Report dated 6/11/25 revealed the following:<BR/>- Chopped Meats texture, Regular/Thin consistency, Health shakes HS, Sandwiches TID for snack with order date 10/22/24 and no end date.<BR/>- Med pass 60 cc PO due to weight loss three times a day for weight loss with order date 3/27/25 and no end date.<BR/>Record review of Resident #3's MAR/TAR Schedule for June 2025 revealed the residents order to receive health shakes at bedtime was not included on the schedule therefore there was no documentation the resident was receiving the health shakes.<BR/>Record review of Resident #3's Dietary Profile dated 11/12/24 revealed the resident received a regular diet, regular texture with cut up meats, and the resident's intake had decreased due to cognitive decline.<BR/>Record review of Resident #3's comprehensive care plan with revision date 2/21/25 revealed the resident received a regular diet, regular texture with cut up meats and regular/thin liquids, and had a potential nutritional problem related to poor eating habits and had unplanned/unexpected weight loss with interventions that included to administer medications as ordered, and to give the resident supplements as ordered.<BR/>3. Record review of Resident #5's face sheet dated 6/11/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dysphagia-oropharyngeal phase (problems with chewing or tongue control and delayed swallow reflex), muscle weakness, iron deficiency anemia, Vitamin D deficiency, symptoms and signs concerning food and fluid intake, muscle wasting and atrophy (muscle tissue deterioration caused by inactivity), deficiency of other vitamins, weakness, and fatigue.<BR/>Record review of Resident #5's most recent quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills, required partial/moderate assistance with eating, and required a mechanically altered diet.<BR/>Record review of Resident #5's Order Summary Report dated 6/11/25 revealed the following:<BR/>- Regular diet Mechanical Soft texture, Regular/Thin consistency, Request 1 sandwich with meal at lunch and supper. Prefers food in bowls and metal spoon. Health Shake with snacks TID with order date 10/2/24 and no end date.<BR/>- ENCOURAGE PO FLUIDS EACH SHIFT every day and night shift with order date 10/2/24 and no end date. <BR/>- Offer snack every night A = Accepted, R = Refused every night shift with order date 3/28/25 and no end date.<BR/>Record review of Resident #5's MAR/TAR Schedule for June 2025 revealed the residents order to offer a snack every night and to mark A for accepted or R for refused was documented with a check mark.<BR/>Record review of Resident #5's comprehensive care plan with revision date 3/20/25 revealed the resident had an ADL self-care performance deficit related to fatigue, limited mobility, limited range of motion, musculoskeletal impairment and pain with interventions that included, when eating, the resident was to be provided with finger goods when the resident had difficulty using utensils. Resident #5's comprehensive care plan revealed the resident had a swallowing disorder and interventions included to follow diet as prescribed. <BR/>Record review of Resident #5's Dietary Profile dated 3/6/25 revealed the resident received a regular diet, cut up meats, House Shakes TID, House Snack TID, and required partial assistance with eating. <BR/>During an interview on 6/11/25 at 10:13 a.m., CNA H stated snacks were provided by the kitchen and would often leave bags of food like sandwiches, cookies and other snacks. CNA H stated whatever the residents didn't eat was offered at night. CNA H stated sometimes some snacks came with names on them and others did not. CNA H stated when the snacks were delivered from the kitchen, she walked around the unit and offered the snacks to the residents. <BR/>During an interview on 6/11/25 at 10:52 a.m., CNA F stated there was not a problem with the kitchen staff providing snacks, but the problem was the kitchen staff delivering the snacks to the units dropped them off at the nurse's station counter and would leave. CNA F stated it was a problem because residents from different units would go to the nurse's station counter and take the snacks. CNA F stated there were times snacks were labeled with a resident's name but not all the time. CNA F stated she believed the CNA staff were responsible for distributing the snacks.<BR/>During an interview on 6/11/25 at 11:48 a.m., CNA I stated snacks were offered three times per day and the kitchen staff dropped off the snacks at the nurse's station counter. CNA I stated when residents requested a particular food item she would fill out a menu request and hand it over to the kitchen staff. CNA I stated, sometimes they (the kitchen staff) followed through but some kitchen staff questioned the request and won't follow through. CNA I stated the DM and the [NAME] have told her, we can't give them (the residents) what they want, this is not a hotel. CNA I stated if there were left over snacks, residents could help themselves to them, they just don't have the kind of food they want.<BR/>During an interview on 6/11/25 at 1:14 p.m., the Administrator stated it was assumed the DM did not have the credentials she was supposed to have to be the DM. The Administrator stated he had heard of staff getting upset about residents and special meal requests. The Administrator stated there needed to be systemic changes about the process and understanding of snacks and meal tickets.<BR/>During an interview on 6/11/25 at 2:09 p.m., CNA G stated the kitchen staff provided snacks three times per day but when the snacks were brought out into the units, they placed the snacks on top of the nurse's station counter and leave and half the time other residents from the other units see it and they grab them (the snacks). CNA G stated the CNA staff were responsible for distributing the snacks and stated, the nurses have nothing to do with the snacks, they don't help. CNA G stated sometimes the snacks had names on them and sometimes they didn't. CNA G stated Resident #3 did not get a health shake and usually received an oatmeal cake with a cream filling and the item sometimes had Resident #3's name on it and sometimes it did not. CNA G stated Resident #5 received a snack with her name on it and if it's a sandwich, she refuses. We tell the nurse; Resident #5 doesn't eat sandwiches.<BR/>During an observation and interview on 6/11/25 at 3:20 p.m., Resident #5 stated she received snacks, and was given a milkshake about a week ago, but I won't take it because I don't want to gain weight. Resident #5 was observed sitting up in the dining room with two cups of water, one cup with a soft drink, one pack of crackers and one wrapped cream filled cake with the resident's name and House Snack, Morning Snack on the label. Resident #5 stated when there were agency staff working, they did not know where to find her and did not get a snack at all.<BR/>Observation on 6/11/25 at 3:30 p.m. revealed a large metal bin on the nurse's station counter between the 300 and 400 halls. The counter was waist high, and the metal bin contained a package of peanut butter cookies, two half sandwiches and an open container of cookies to the right of the metal container. The food items did not have any labels with names on them. <BR/>During an interview on 6/11/25 at 3:32 p.m., LVN J stated she was charged with the 300 hall and one resident on the 400 hall and she distributed some of the snacks. LVN J stated a resident who was unable to get out of bed without assistance was offered a snack. LVN J stated, typically the snacks just get dropped off at the nurse's station because most of the residents can get up and get their own. They can come get whatever they want. LVN J stated she only knew of one resident on the unit who she would try to make sure got a snack because this resident did not eat a whole lot.<BR/>During an interview on 6/11/25 at 3:49 p.m., RN K stated she worked at the facility through an agency and stated the kitchen staff would bring out a metal bin with assorted snacks and dropped them off on the nurse's station counter. RN K stated she delivered the snacks and the CNAs helped. RN K stated she was unsure if any of the snacks came with a label with the resident's name on it, I don't think they were. RN K stated she was handed a house shake to give to Resident #3 by the night shift nurse at shift change. RN K stated, it says on the MAR if Resident #3's appetite was low, to offer the house shake to her. RN K stated she did not recall if Resident #5 had an order for a house shake on the MAR.<BR/>During an interview on 6/11/25 at 4:06 p.m., Resident #1 stated he had not been getting snacks and stated it had been a long time since he had been offered a snack. Resident #1 stated he was not offered a high protein snack at night. <BR/>During an interview on 6/11/25 at 4:26 p.m., the DM stated the residents were given snacks three times per day but had been an issue since she was employed by the facility 2 &frac12; weeks ago. The DM stated she was told by the kitchen staff we do maybe 5 sandwiches. The DM stated where she worked previously, she was trained to have a set menu for snacks to determine how many snacks to make and prepare. The DM stated snacks with labels were for residents who had specific physician orders for a specific snack which were supplements or sometimes a sandwich. The DM stated The Dietician came last week and talks to some residents and then leaves. I've asked him about solutions to the snack problem and asked about a snack menu and he just sent me a list of what to use for puree. I didn't fix it because I am not a dietician. We're trying to get a new meal system in place to alleviate the guess work. The DM stated, the facility was well-stocked and house shakes were available but had noticed at least 6 of them (house shakes) were coming back, unopened. The DM stated she had not been told about residents not receiving snacks and did not have control of what went on after the snacks left the kitchen. The DM stated the kitchen staff dropped off the snacks at the nurse's station and the nurses delivered the snacks to the residents. <BR/>During an interview on 6/11/25 at 5:48 p.m., Medication Aide A stated snacks were offered at least 3 times per day and some of the snacks were delivered with labels with the resident's name on them. Medication Aide A stated the snacks used to have all the resident's names on them but not anymore. Medication Aide A stated the labels with the resident names stopped about 9 or 10 months ago. Medication Aide A stated snacks labeled with a resident's name were for those residents who had a specific order for a specific snack or supplement. Medication Aide stated the CNA staff were responsible for delivering snacks, but she helped when the CNA staff were busy. Medication Aide A stated she did not document on the MAR/TAR for a snack given per physician orders, maybe the nurse, I really don't know. <BR/>During an interview on 6/11/25 at 6:08 p.m., the Interim DON stated the residents received snacks three times a day and were delivered by the kitchen staff to the nurse's station. The Interim DON stated the problem was that there were some residents who will walk to the snacks and help themselves and have walked to other nurse's stations and help themselves. The Interim DON stated, of the three units, the snacks for the memory care unit were kept locked behind the nurse's station. The Interim DON stated the labeled snacks with resident names were for those residents with specific physician's orders. The Interim DON stated the CNA staff were responsible for distributing the snacks, but the nurses helped when CNA staff were busy. The Interim DON stated we have to document on the TAR the order like bedtime snack or health shake or offer nutrition for those snacks that have a doctor's order and was not aware there were not enough snacks. <BR/>During an interview on 6/11/25 at 6:33 p.m., the [NAME] stated snacks were delivered to the nurse's station three times per day. The [NAME] stated the Dietary Aide assembled the snacks, and the DM printed out the labels for those residents who had to have a certain snack. The [NAME] stated he did not know the reason why only certain residents had their names on a snack. <BR/>During an interview on 6/12/25 at 8:58 a.m., Dietary Aide L stated, kitchen staff were instructed by the DM not to give out snacks unless the resident had an order for it, and the other residents were not supposed to get snacks. Dietary Aide L stated the DM had observed the snacks being assembled and was told they were getting too much. Dietary Aide L stated the facility had an abundance of snacks, so it was not for a lack of supplies. Dietary Aide L stated there was no set menu for snacks, except for the snacks that were labeled for those residents with a specific order.<BR/>During a telephone interview on 6/12/25 at 10:07 a.m., the Registered Dietician stated he visited the facility twice a month and performed nutritional assessments, reviewed weight discrepancies and reviewed dietary assessments for new admissions. The Registered Dietician stated in his experience, obviously if there are orders for snacks, those have to be given, but I feel like all of the residents should be offered a snack at some point of the day. The Registered Dietician stated he did not provide the facility with a snack menu, and it was up to the DM to offer snack options and to curate a snack preference list. The Registered Dietician stated he was not aware of snacks not being offered at the facility. <BR/>During a follow-up interview on 6/12/25 at 10:22 a.m., the DM stated, snacks were delivered to the nurse's station and the nurses should be giving the snacks to the residents. The DM stated, nursing should be keeping track of where and how the snacks were being distributed. The DM stated, we just set the tray out for snacks this morning and they are still sitting at the nurse's station. They get snacks three times a day here, but the other places I have worked at only offered snacks twice a day. They (the residents) eat a lot. <BR/>A snack policy was requested on 6/12/25 at 10:22 a.m. from the DM, but was not provided at the time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide comfortable and safe temperature levels maintained within a range of 71 to 81 degrees Fahrenheit for 7 of 7 residents (Resident #s 1, 2, 3, 5 on Hall 100 Male Secured Unit) and (Resident #s 4, 6, 7 - Hall 200) reviewed for environment. <BR/>The facility presented with 2 non-functioning Heating Ventilation and Air Conditioning [HVAC] systems, which resulted in cold resident room interior temperatures (low 50s - 60s Fahrenheit) for residents living in 100 Hall (Male Secured Unit) and 200 Hall. Facility leadership was aware the HVAC systems were not adequately functioning since October 2023. <BR/>An Immediate Jeopardy (IJ) situation was identified on 01/17/24. While the IJ was removed on 01/22/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure placed residents at risk for harm by a diminished quality of life, specifically, sleep deprivation and cold-related injuries (hypothermia).<BR/>The findings were:<BR/>Observation on 01/17/24 at 2:15 PM, when entering the facility, revealed it was noticeably cold and residents/staff were still wearing winter clothing (jackets/gloves/scarfs/ski caps) while in the building. <BR/>Record review of website: Past Weather in [city] Texas, USA - Yesterday or Further Back (timeanddate.com) of the air temperatures for [city], Texas revealed the following air temperatures and corresponding dates for the city this facility was located:<BR/>Date: Low High<BR/>1/12/2024 29 F 59 F<BR/>1/13/2024 24 F 61 F<BR/>1/14/2024 16 F 28 F<BR/>1/15/2024 14 F 30 F <BR/>1/16/2024 15 F 34 F<BR/>1/17/2024 13 F 52 F<BR/>Interview on 01/16/2024 at 2:34 PM, the administrator stated the facility's heating units for 100 Hall (Male Secured Unit) and 200 Hall were not functioning and pending replacement. The administrator stated 2 portable heating units had been placed at both ends of the 100 Hall (Male Secured Unit) and one large space heater was placed at the end of 200 Hall until the facility's permanent heating units could be replaced. The administrator also said portable heaters were purchased and offered to residents who wanted one in their room in response to staff and residents complaining of cold temperatures within the building on the night of 1/13/2024.<BR/>Observation on 01/16/2024 at 3:06 PM of 100 Hall (Secured Men's) revealed 2 temporary heating units (THU) located at both ends of the hall. Further observation revealed the THU at the beginning of 100 Hall was running at a setting of 80 F and indicated room temperature (Hallway) of 69 F. Observation of the THU at the end of 100 Hall revealed the THU was not running. <BR/>Observation and interview on 01/16/2024 at 3:09 PM, Resident #1 was observed walking 100 Hall (Male Secured Unit) and lead this investigator his room. Resident #1 indicated his room was cold and would get colder at night. Resident #1 proceeded to show this investigator 4 blankets on his bed he was utilizing in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. <BR/>Observation and interview on 01/16/2024 at 3:14 PM, Resident #2 (100 Hall - Male Secured Unit) was observed lying in his bed. Resident #2 was observed wearing gloves and when asked why, Resident #2 responded, because I like them! When asked if the resident was cold at night, he responded, Yes! When asked how the resident was doing in an attempt to stay warm, he responded, The blankets. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation and interview on 01/16/2024 at 3:16 PM, Resident #3 (100 Hall - Male Secured Unit) was observed sitting in the secured dining area in his wheelchair. During the interview, Resident #3 said that this week had been, really cold. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation on 01/16/2024 at 3:38 PM revealed a space heater at the end of Hall 200.The space heater was on and glowing. The room temperature in this hall felt uncomfortably cold while wearing a jacket. <BR/>Observation and interview on 01/16/2024 at 3:40 PM, Resident #4 (200 Hall) was asked about the temperature of her room and indicated she had been, Very cold, and said she had been using multiple blankets in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation and interview on 01/17/2024 at 7:38 AM, facility staff were observed wearing winter-clothing in the building which consisted of extra layers and ski hats. At this time, an unknown staff shouted, It's cold in there, 50 degrees.<BR/>Observation and interview on 01/17/2024 at 7:44 AM, Resident #1 was observed lying in his bed with a blanket over his head. A reading of the room's temperature revealed a temperature of 56 F. During an interview at this time, Resident #1 was asked if he was cold and responded, Yes The resident stated he did not sleep well because his room was cold. <BR/>Observation and interview on 01/17/2024 at 7:57 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #1's bed which revealed a temperature reading of 56 F. LVN B confirmed the temperature in Resident #1's room was 56 F and responded, Oh wow, that's cold.<BR/>Observation and interview on 01/17/2024 at 7:44 AM, Resident #5 was observed lying in bed with a navy blue blanket over his head (photo taken). A reading of the room's temperature revealed a temperature of 51 F. During an interview at this time, Resident #5 was asked how he was doing and responded, Cold. When asked if the Resident #5 felt tired, he responded, Yeah, I can't sleep. <BR/>Observation and interview on 01/17/2024 at 7:58 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #5's bed which revealed a temperature reading of 51 F. During an interview at this time, LVN B was asked what the temperature should be to be considered comfortable to which she responded, Around 70 F.<BR/>Observation and interview on 01/17/2024 at 8:07 AM with Staff C, this investigator pointed a thermal thermometer laser at the wall closest to Resident #4's bed which revealed a temperature reading of 51 F. Staff C confirmed the temperature for Resident #4's room was 51 F. During an interview at this time, Staff C said Resident #4 had requested to be moved to a new location due to feeling cold in her room. Staff C mentioned another resident, Resident #7 - Hall 200, had also requested to be moved because she was cold in her room. <BR/>Interview and observation on 01/17/2024 at 9:50 PM, the Maintenance Supervisor and this investigator compared thermal temperature guns and confirmed their readings matched within +/-.3 degrees F. The Maintenance Supervisor's thermal temperature gun was orange and black (IR1 Infrared Thermometer), The Maintenance Director was asked what the room temperatures should be and responded, Around 75 F in the winter and around 70 F in the summer.<BR/>Interview and observation on 01/17/2024 at 10:00 AM, the Maintenance Supervisor measured Resident #1's room (100 Hall - Male Secured Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 61 F. During an interview at this time, the Maintenance Supervisor said, It feels chili in here, I would need more blankets and double socks.<BR/>Interview and observation on 01/17/2024 at 10:04 AM, the Maintenance Supervisor measured Resident #5's room (100 Hall - Male Secured Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #5's which revealed a temperature of 61 F. Resident #5 was observed still lying in bed with blankets over his head. A space heater was observed in this resident's room and was emitting heat but the room still felt cold. During an interview at this time, Resident #5 was asked if he was still cold to which he responded, Ya. At this time, the Maintenance Director said, Even with a space heater the room still feels cold. I don't see why the main heating unit (for 100 Hall) wasn't fixed before the cold weather.<BR/>Interview on 01/17/2024 at 10:15 AM, the administrator stated she had moved all but 1 resident on 200 Hall from the second half of 200 Hall to other locations including the first half of 200 Hall. The Administrator also stated she had closed the smoke barrier doors located in the middle of 200 Hall in an effort to prevent cold air coming down the first half of the 200 hall. Additionally, the Administrator said all residents on the 100 Hall (Male Secured Unit) were moved to the 100 Hall (Female Secured Unit) and indicated that section of 100 Hall had a HVAC. <BR/>Interview and observation on 01/17/2024 at 10:29 AM, the Maintenance Supervisor measured Resident #7's room (200 Hall) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 57.7 F. Resident #6 was observed lying in her bed under layers of blankets. During an interview at this time, Resident #6 was asked how she was doing to which she responded, I'm cold. The Maintenance Director then said, Ya, it's cold, I wouldn't want to be in there. The Maintenance Director then confirmed Resident #7's room was on the first half of 200 Hall that was supposed to be the side residents were moved to because it was warmer than the second half of 200 Hall. The Maintenance Supervisor agreed it felt much colder in the resident's room than in the hall. <BR/>Interview on 01/17/2024 at 4:45 pm with the Chief Operations Officer (COO) and the administrator revealed the facility discovered in October 2023 the HVAC for 100 Hall Male Secured Unit and 200 Hall were not adequately functioning. The administrator indicated the facility had been in the process of replacing the units since then but there had been delays. The administrator further stated she anticipated the heating units for 200 Hall and 100 Hall (Male Secured Unit) would be replaced by 01/19/2024.<BR/>Record review of facility policy, Quality of Life - Homelike Environment, (Revised May 2017), stated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . 2. The facility and staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .h. Comfortable and safe temperatures (71 F - 81 F) .<BR/>Record review of website, https://www.nia.nih.gov/health/safety/cold-weather-safety-older-adults , dated, 01/03/2024 , stated: Older adults have a higher chance of being affected by cold weather. Changes that come with aging can make it harder for older adults to be aware of their body becoming too cold, which can turn into a dangerous health issue quickly. Hazards of cold weather include falls on wintry surfaces; injury caused by freezing (frostbite); and hypothermia, a medical emergency that occurs when your body temperature gets too low. Being informed and taking certain actions can help lessen risks during the colder months . Staying warm indoors. About 20% of injuries related to exposure to cold occur in the home. Here are some tips to help keep warm: Even mildly cool homes with temperatures from 60 to 65&deg;F can lead to hypothermia in older adults.<BR/>This was determined to be an Immediate Jeopardy on 01/17/24 at 5:50 PM. The administrator and COO were notified. The administrator was provided the Immediate Jeopardy template on 01/17/24 at 6:00 PM .<BR/>The following Plan of Removal submitted by the facility was accepted on 01/19/24 at 2:00 PM:<BR/>Plan for REMOVAL<BR/>The facility failed to provide a safe, clean, comfortable, and homelike environment, to<BR/>include maintenance services necessary to maintain comfortable and safe temperature<BR/>levels, for 1 of 1 facility reviewed for a safe, clean, comfortable, and homelike<BR/>environment.<BR/>F584<BR/>1- On 1/17/2024 Residents on 100 unit (men's secure unit) were moved to warm secure<BR/>unit. Residents on 200 hallway cold areas were moved to warm side of the unit by IDT.<BR/>Units that are not holding temperature of 71 degrees Fahrenheit were temporarily closed by Maintenance Director. <BR/>2- On 1/17/2024 Maintenance Director ordered and paid for heating units repairs which are scheduled for 1/22/204 to be installed due to a delay<BR/>in the crane delivery. Per the contractor all work on the HVAC units will be repaired on<BR/>the same day as arrival.<BR/>3- On 1/17/2024 Social Worker/Designee notified RPs of the room changes.<BR/>4- On 1/17/2024 Director of Nursing/Designee assessed residents for s/s of hypothermia or sleep deprivation due to feeling cold - no negative findings noted. The Medical Director updated on findings by Administrator on 1/17/2024.<BR/>5- On 1/17/2024 COO (Chief Operating Officer) completed 1:1 in-service with<BR/>Administrator and Maintenance Director on emergency readiness, inclement weather<BR/>preparedness, and s/s of hypothermia.<BR/>6- On 1/17/2024 Director of Nursing/Designee initiated in-services with staff of identifying s/s of hypothermia, timely notification of Administrator/Supervisor when noting patients room/residents' areas feel cold or residents/staff/visitors complaints of feeling cold, residents' sleep deprivation, and cold-related injuries (hypothermia) due to cold temperatures in the facility. Staff will not be allowed to work until they receive training, including agency staff and PRN. Anyone who is not able to receive training will not be allowed to work until the in servicing is completed.<BR/>7- Ad-Hoc QAPI meeting was held on 1/17/2024, with the Medical Director, NHA (Nursing Home Administrator), DON, and Maintenance Director to review the alleged<BR/>deficiencies, policy and procedure, and the plan for removal of immediacy.<BR/>The policies pertaining to Emergency readiness were reviewed on 1/17/2024 by the<BR/>NHA (Nursing Home Administrator), DON, and Medical Director.<BR/>8- Starting on 1/17/2024, IDT (Interdisciplinary team), including Administrator, Activity<BR/>Director, DON, Social Worker, admission manager, MDS, and Maintenance Director will<BR/>meet with residents daily to identify if any residents have sleep deprivation and s/s of<BR/>hypothermia due to cold temperatures Monday through Friday, and Manager on Duty<BR/>on Saturday, Sunday, until heating units are repaired. Any issues or concerns will be<BR/>brought up to the Administrator immediately and IDT team members for any follow-up<BR/>needed. Residents' room temps will be taken daily to ensure compliance by<BR/>Maintenance Director or designee until HVAC units are installed. If any room<BR/>temperatures are below 71 degrees; the Administrator will be contacted and the<BR/>resident will be offered another room that is above 71 degrees. Temperatures of the<BR/>rooms will be taken 2xs a day and temps recorded in the temperature spreadsheet in<BR/>maintenance book until HVAC units are installed. Residents' temperature will be taken<BR/>daily to ensure no signs or symptoms of hypothermia.<BR/>9-The Administrator/designee will monitor compliance by completing an audit of five (5)<BR/>residents per week for four (4) weeks until heating units are repaired. This was initiated<BR/>on 1/17/2024. Any identified concern will be addressed immediately and if trends and<BR/>patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if<BR/>additional interventions are needed to ensure compliance.<BR/>10- The COO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed.[sic]<BR/>The facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by:<BR/>-Observations on 01/19/2024 of 200 Hall, between 3:15 PM and 3:17 PM revealed room temperatures between 71.4 F to 74.4 F. Further observation reviewed smoke barrier doors were closed in the middle of 200 Hall to prevent the escape of warm air. <BR/>Observations on 01/19/2024 of 100 Hall, between 3:18 PM and 3:19 PM revealed room temperatures between 71.4 F to 74.4 F. <BR/>Observations on 01/19/2024 at 3:20 PM revealed 100 Hall (Male Secured Unit) had been completely vacated by all residents.<BR/>Interview on 01/19/2024 at 4:08 PM, the Maintenance Director stated 3 HVAC three units had been ordered and paid for and had heard they would be installed on Monday 01/22/2024. Record review at this time supported the information provided specific to this interview.<BR/>Observation on 01/22/2024 at 2:00 PM, HVAC staff were observed over 200 Hall working on the HVAC Unit on the roof. <BR/>Interview on 01/22/2024 at 2:05 PM, the administrator stated the new HVAC unit was being in-stalled over 200 Hall and said HVAC installers were in the process of custom fitting the plenum and anticipated both units would be completely installed by cob. <BR/>Record review of the facility's Electronic Resident Database under section, Progress Notes. Revealed documentation inputted by the facility's social worker indicating RP and/or attempted RP notifications for residents that had been moved to a different room. <BR/>Interview and record review on 01/19/2024 at 3:42 PM, the DON stated she assessed all residents impacted by the cold weather to ensure they did not have s/s of hypothermia. Record review of facility documentation supported this statement. <BR/>Interview on 01/19/2024 at 3:53 PM, the administrator stated the emergency preparedness in-service covered inclement weather and other items specific to disasters. This included checking the generator, making sure an evacuation plan was in place, extra blankets were available, and a phone roster for staff in-case of an emergency. Regarding hypothermia, the administrator said this can be determined by body temperature, vital signs, and alert/oriented status. <BR/>Interview on 01/19/2024 at 4:00 PM, the Maintenance Director stated he would look for drowsiness, confusion, shivering, memory loss et specific to hypothermia. Regarding emergency preparedness, the Maintenance Director said he was instructed to make sure there were adequate blankets, an addendum to have heaters, check room temps periodically throughout the day. He said he was also in-serviced regarding inclement weather, specifically ensuring thermostats were set properly, windows were to be shut, the generator was adequately working, et. He further stated the generator was tested on [DATE] and added a solution to prevent gelling of the gasoline.<BR/>Interview with the administrator on 01/22/2024 at 5:44 PM, the administrator said that if conditions were extreme, heaters would be used as needed. The Administrator stated they would be placed in the hallways within the line of sight of nurses/aides). The administrator said this was indicated in her emergency preparedness manual. <BR/>Record review of sign in sheets on 01/22/2024 provided by the administrator revealed information that supported this interview. <BR/>Interview on 01/19/2024, the Corporate Nurse stated staff that have been in-serviced by person or via telephone were documented on a list and said that staff who have not yet received the in servicing will not be able to work. <BR/>Record review of a 3 page document titled, Employee Roster, generated on 01/17/2024, revealed a list of all facility staff. Further review of this document revealed signatures next to staff who had completed the trainings. This list also showed attempts to contact 6 staff but had been unsuccessful. <BR/>Observations and interviews on 01/18/2024 thru 01/22/2024 of resident rooms where residents were temporarily transferred 100 Hall (Women's Secured Unit) and the first half of 200 Hall (before smoke barrier doors) measured above 71 degrees F and it was noticeably a comfortable temperature in those resident rooms. <BR/>Interviews with a sample of staff (CNAs, LVNs, RNs, DON - from all 3 facility shifts), the Maintenance Director, and administrative staff 01/19/2024 thru 01/22/2024 revealed staff had been in-serviced specific to the Plan of Removal and knew to immediately notify the administrator if they noticed an unusual occurrence, which included if the heat went out in the building. Staff were also able to explain their familiarity with signs and symptoms of hypothermia and indicated they would provide blankets, warm liquids, and ensure all doors and windows were closed to keep the heat inside. <BR/>Record review of sign in sheets on 01/22/2024 provided by the administrator revealed information that supported this interview. <BR/>Interview on 01/19/2024 at 4:06 PM, the Maintenance Director stated he had been checking room temps 4 times daily to ensure compliance and said the nurses were also checking room temps in the evening utilizing his thermal temperature gun (the same thermal temperature gun utilized during previous temperature observations with this investigator). <BR/>Record review facility documentation revealed monitoring was occurring in accordance to this plan. <BR/>Interview on 01/18/2024 at 4:42 PM, the administrator said she would be monitoring 5 residents a week for 4 weeks and would be monitoring residents daily to ensure there were not signs or symptoms of hypothermia or other potential adverse reactions related to cold weather or new interventions. She said they would be utilizing a resident roster daily to document this information. <BR/>Record review of documentation on 01/22/2024 provided by the administrator revealed information that supported this interview. <BR/>Interview on 01/18/2024 at 4:29 PM, the COO stated she would be frequenting the facility once per month to provide oversite to the Administrator to ensure items on the plan of removal are reviewed and completed. <BR/>The administrator was informed the Immediate Jeopardy was removed on 01/22/2024. The facility remained out of compliance at a severity of potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all residents were free from abuse for 2 of 6 residents (Residents #1 and #5) reviewed for abuse in that:<BR/>The facility staff failed to implement adequate interventions to ensure Resident #1 did not enter other resident rooms, which caused him to be abused by Resident #2 and Resident #3. Eventually, Resident #1 was pushed by Resident #3 and Resident #1 broke his right hip and his left index finger. Resident #1 was no longer independent after breaking his hip.<BR/>The facility failed to implement adequate interventions to ensure Resident #5 felt safe at the facility after he was pushed by resident #3.<BR/>This failure resulted in identification of an Immediate Jeopardy (IJ) on 3/17/23. While the IJ was removed on 3/19/23, the facility remained out of compliance level of actual harm with a scope identified as isolated until interventions were put in place to ensure residents were free from abuse. <BR/>This failure could place residents at risk for abuse from other residents.<BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated 3/15/23, revealed Resident #1 was originally admitted to the facility on [DATE] with diagnoses of unspecified dementia [a general term for impaired ability to remember, think, or make decisions], unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, pain, unspecified, and hypocalcemia (History of) [low levels of calcium in the blood.]<BR/>Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 did not have a BIMS score because Resident #1 was rarely/never understood. <BR/>Record review of Resident #1's care plan, obtained 3/15/23, revealed the following:<BR/>- Problem last updated 11/2/22: Behavior problem related to: Dementia AEB [As Evidenced By:] Roams into others rooms. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review date. One of the interventions was last updated on 11/2/22 read: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. <BR/>- Problem last updated 1/18/23: Resident resides in secure unit and is at risk for injury from wandering in an unsafe environment R/T [related to] impaired safety awareness. Resident is at risk for injury from others while residing in secure unit D/T [due to] altered cognition. This problem area had the following goal: Dignity will be maintained and resident will wander about unit without occurrence of any injury over the next quarter. One of the interventions last updated on 1/18/23 was: Keep environment free from possible hazards. This problem area also had the following goal dated 1/18/23: Activities director to monitor/discuss activity preference. This problem area also had the following goal dated 1/18/23: Allow resident to choose activities inside and outside that don't pose a safety risk. <BR/>Record review of activities documentation from 2/1/23 to 3/14/23 revealed Resident #1 had outside activity, which was outside (walk), as early as 2/2/23. Other activities that took place outside of the locked unit, like bingo were seen documented as early as 2/6/23 and a coffee social on 2/15/23.<BR/>Record review of Resident #2's face sheet, dated 3/15/23, revealed Resident #2 was originally admitted to the facility on [DATE] with diagnosis of dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, depression, unspecified, Type 2 diabetes mellitus without complications, and unspecified dementia with behavioral disturbance. Further record review of this document revealed Resident #2 was discharged on 3/10/23.<BR/>Record review of Resident #2's Discharge MDS, dated [DATE], revealed Resident #2 had a BIMS score of 3, signifying severe cognitive impairment.<BR/>Record review of Resident #2's care plan, obtained 3/15/23, revealed the following: <BR/>- Problem last updated 11/17/22: [Resident #2] is territorial of room/personal belongings r/t: Dementia with Behaviors. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review date. This problem area had the following intervention dated 11/3/22: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. <BR/>- Problem area last updated 1/4/23: Behavior problem related to: Dementia with behaviors AEB: Physical and Verbal aggression towards others. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review date. This problem area had the following interventions dated 1/4/23: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed.<BR/>Record review Resident #3's face sheet, dated 3/15/23, revealed Resident #3 was admitted to the facility on [DATE] with diagnosis of other lack of coordination, unspecified dementia, unspecified severity, with other behavioral disturbance, anxiety disorder, unspecified, unspecified psychosis not due to a substance of known physiological condition, and persistent mood [affective] disorder [a persistent and usually fluctuating disorders of mood which can last for many years that involve considerable distress and disability], unspecified.<BR/>Record review of Resident #3's 5-day MDS, dated [DATE], revealed Resident #3 had a BIMS score of 9, signifying moderate cognitive impairment.<BR/>Record review of Resident #3's care plan, obtained 3/15/23, revealed the following:<BR/>- Problem dated 3/10/23: Behavior problem related to: Dementia AEB: Physical Aggression/Verbal aggression. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily through next review date. This problem area had the following interventions dated 3/10/23: intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed.<BR/>Record review of Resident #5's face sheet, dated 3/15/23, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease [a progressive disease that affects memory and other important mental functions], unspecified, other abnormalities of gait and mobility, other lack of coordination, weakness, other malaise, and muscle wasting and atrophy not elsewhere classified, unspecified site. <BR/>Record review of Resident #1's incident report, dated 2/15/23 and written by LVN E, revealed the following: Brief Description of Incident: hit by another resident [Resident #2] in the head Description of injury: laceration [cut] over left eye . At 2:25 pm this nurse heard loud voices coming from . another resident's room, this resident [Resident #1] came out of the room, this nurse asked the other resident [Resident #2] what was the problem, the other resident [Resident #2] stated that he [Resident #2] hit this [sic] because he repeatedly told him [Resident #1] to get out of his [Resident #2's] room but he [Resident #1] refused. [sic]<BR/>Record review of Resident #2's nursing progress note, dated 2/15/23 and written by LVN E, revealed the following: this nurse heard loud voices coming from this resident's [Resident #2's] room, another resident [Resident #1] . came out of the room, this nurse asked the resident [Resident #2] what was the problem, resident [Resident #2] stated he hit the other [Resident #1] because he [Resident #2] repeatedly told him [Resident #1] to get out of his [Resident #2's] room but he refused.<BR/>Record review of Resident #1's incident report, dated 3/9/23 and written by LVN F, revealed the following: Patient went into another patient room when the Aggressor Punched other patient in the nose . Nurse was notified by CNA Patient was seen walking up and down hall with Excessive bleeding coming down from nose and another patient verbalized to her he came into his room and 'he got what he deserved.'<BR/>Record review of Resident #2's nursing progress note, dated 3/9/23 and written by LVN F, revealed the following: Nurse was notified by CNA Patient admitted to hitting another patient in the nose verbalized He got what he deserved because he walked into his room. <BR/>Record review of Resident #2's electronic health record revealed no 30-day discharge notice dated prior to his discharge on [DATE]. <BR/>Record review of Resident #5's nursing progress note, dated 3/11/23 at 10:31 a.m. and written by LVN F, revealed the following: Patient requested to [NAME] [sic] to nurse out in 'secret' He feels unsafe around another resident and would like for him to leave him alone. Nurse spoken [sic] to other resident and separated the two nurse will continue to monitor patients.<BR/>Record review of Resident #5's nursing progress note, dated 3/11/23 and written at 10:31 a.m. by LVN F, revealed Rm changed to 116B. <BR/>Record review of Resident #3's nursing progress note, dated 3/11/23 at 10:42 a.m. and written by LVN F, revealed the following: Patient seen trying to shove roommate into his room. When asked patient to please leave other patient alone he does not want to be in the room he shouted, 'I didn't touch him, I don't have blood on my hands.' Nurse talked to patient about keeping his hands to himself and patient understood.<BR/>Record review of Resident #3's nursing progress note, dated 3/11/23 at 4:06 p.m. and written by LVN F, revealed the following: Patient arguing and yelling at other patients in the hall, Nurse instructed patient to sit at nurse station for 1:1 Observation. For behavior problems. <BR/>Record review of Resident #1's incident report, dated 3/12/23 and written by LVN C, revealed the following: Brief description of incident: wandered to another resident room, pushed to the floor by another resident [Resident #3] . 3/12/23 at 9:29 a.m This hour resident [Resident #1] sent out to ER to evaluate/tx [treat.] Pushed to floor by another resident [Resident #3.] <BR/>Record review of Resident #3's nursing progress note, dated 3/12/23 and written by LVN C, revealed the following: This am [a.m., meaning morning,] Resident voiced 'I didn't do it. I have no blood on my hands' A commotion could be heard during resident smoke hour. This resident shouted, 'get outta my room'! Then a slapping noise. This writer check the hall another resident [Resident #1] on the floor. That resident [Resident #1] is unable to communicate the incident related to DX.<BR/>Record review of Resident #1's hospital physician progress note, dated 3/13/23, revealed the following: Presents after was wondering about other patients room, was pushed, fall, subsequent inability to stand up, brought to the ED [Emergency Department] which showed nondisplaced fracture of right femoral neck [right broken hip] as well as fracture of [left] proximal second digit [broken index finger.] He is scheduled to have surgical correction his afternoon.<BR/>Record review of Resident #1's hospital X-ray results, dated 3/13/23, revealed total right hip arthroplasty [hip replacement] without hardware complication.<BR/>Record review of Resident #1's Physical Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following short-term goals:<BR/>-Patient able to perform sit &lt;&gt;[to] stand 3x [3 times] mod A [Moderate Assistance] to improve safety with transfers . PLOF [Prior Level of Function] (prior to onset) Independent. Baseline (3/15/23) dependent.<BR/>-Patient able to stand with BUE [Bilateral Upper Extremities, meaning both arms] 1 minute min A [minimal assistance] to improve safety with transfers . PLOF (prior to onset) independent for most of the day. Baseline (3/15/23) unable limited by pain.<BR/>Further record review of this same Physical Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following long-term goals: <BR/>-Patient able to perform supine [lying on bed face-up] &lt;&gt; [to] sit supervision to decrease caregiver assistance . PLOF (prior to onset) independent. Baseline (3/15/23) dependent.<BR/>-Patient able to transfer bed &lt;&gt; [to] W/C [wheelchair] supervision to decrease caregiver assistance and risk for falls . PLOF (prior to onset) independent. Baseline (3/15/23) unable. Admit on stretcher to facility. Limited by pain.<BR/>-Patient able to ambulate [walk] with FWW [four wheel walker] 150' [150 feet] with supervision to decrease risk for falls . PLOF (prior to onset) independent no device. Baseline (3/15/23) unable.<BR/>Record review of Resident #1's Occupational Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following short-term goals:<BR/>-Patient will increase activity tolerance for functional activities of choice to 20 min in order to w/o [without] signs/symptoms of physical exertion increased participation with ADL tasks . PLOF Prior to onset) 20 min. Baseline (3/15/23) 30-60 seconds.<BR/>-Patient will safely perform self feeding tasks with Set-up (A) with use of for initiation/termination of tasks in order to facilitate self esteem through increased independence with tasks . PLOF (prior to onset) S/U [set up.] Baseline (3/15/23) Min (A) [Minimal Assistance]<BR/>-Patient will complete toilet/commode transfers with Modified Independence for clothing management with recognition of safety hazards . PLOF (prior to onset) MI [Modified Independence.] Baseline: Max (A) [Max Assistance].<BR/>Further record review of this same Occupational Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following long-term goals:<BR/>-Patient will complete hygiene and grooming tasks while standing at sink with Modified Independence for initiate/termination of tasks with recognition of safety hazards in order to facilitate ability to live in environment with least amount of supervision and assistance . PLOF (prior to onset) Modified Independence. Baseline (3/15/23) Max (A).<BR/>-Patient will safely perform toileting tasks using grab bars with Modified Independence for clothing management with recognition of safety hazards . PLOF (prior to onset) MI. Baseline (3/15/23) Max (A).<BR/>-Patient will safely and efficiently perform LB [Lower Body] Dressing with Modified Independence with use of for initiation/termination of tasks in order to be able to return to prior level of living . PLOF (prior to onset) MI. Baseline (3/15/23) Max (A)<BR/>Record review of Daily Schedule, dated 3/12/23, revealed the facility had 1 LVN, 1 CMA, and 1 CNA on 3/12/23. A second CNA was seen noted for the locked unit, but the second CNA's name scratched out and moved to another unit.<BR/>Record review of the facility's current staff roster, provided on 3/15/23, revealed the facility had 17 CNAs, 11 Nurse Aides, 4 CMAs, 9 LVNs, and 1 RN. Including the non-clinical staff, the facility had 65 total employees.<BR/>Record review of the facility's uploaded files from TULIP for Intake #411419 (which was the incident involving Resident #1 and Resident #2 on 3/9/23), revealed the following in-services conducted on the following dates:<BR/>-On 3/9/23, the facility educated 14 staff members on Falls and Unmanageable Residents. <BR/>-On 3/9/23, the facility also educated 22 staff members on Prevention of Abuse and Neglect. However, of the 22 staff members, 2 staff members signed their names twice for a total of 20 staff members. Of these now 20 staff members, 14 were the same staff members educated on Falls and Unmanageable residents. Only 6 new staff members received this education. <BR/>-On 3/13/23, the facility also educated 13 staff members on Abuse Reporting. <BR/>-On 3/13/23, the facility also educated 13 staff members on Managing Fall Risk. The 13 staff members on this in-service were the same 13 staff members who were educated on Abuse Reporting.<BR/>During an observation and interview on 3/15/23 at 1:11 p.m., Resident #1 was seen in bed, awake, alert, and fully-dressed. CO H was at Resident #1's bedside and CO H stated Resident #1 may not be able to answer questions due to his diagnosis of dementia. An interview was attempted with Resident #1. When asked if he had any issues with other residents, Resident #1 answered, yes, but he did not elaborate on his answer when this surveyor prompted Resident #1 to elaborate. CO H stated Resident #1 was attacked 3 times last week and stated Resident #1's last attack was on Sunday, 3/12/23. CO H stated she received a call from CO J and they both went to a local emergency department. CO H stated, the story they told [CO J] is that the nurse was out on the patio and she heard someone yell 'get out of here.' She [the nurse] went to investigate and [Resident #1] was on the floor. And that's when the hip was broken . They [the facility] promised me they were going to keep [Resident #1 and Resident #2] separate and keep [Resident #1] safe.<BR/>During an interview on 3/15/23 at 3:11 p.m., NA G stated if [Resident #3] sees anyone walking by, he'll try to pick a fight. Usually Resident #5 is afraid of Resident #3.<BR/>In a follow-up interview on 3/15/23 at 3:20 p.m., NA G stated she had heard [Resident #2] had struck [Resident #1.] NA G stated Resident #2 was no longer in the facility. <BR/>During an interview on 3/17/23 at 9:21 a.m., Resident #5 stated he did not feel safe in the facility. Resident #5 stated the other residents make him feel unsafe and have hurt him before. Resident #5 did not provide the names of the other residents who had hurt him. <BR/>During an interview on 3/17/23 at 9:22 a.m., LVN C stated she ensured the safety of residents in the facility's locked unit by frequently monitoring the residents. LVN C stated she currently had 2 CNAs, but she was supposed to have a 3rd CNA that was supposed to come in later. When asked how they ensured Resident #1's safety, LVN C stated frequent re-direction all the time . to the best of our ability educate the residents that it's not intentional on his part to invade their space. LVN C stated [Resident #2] could go for a good amount of time [without being aggressive] and then slowly start to show the signs and then explode. When asked how they managed Resident #2's aggressive behavior, LVN C stated they spoke with [Resident #2] firmly. LVN C stated after Resident #2 struck Resident #1 they had temporarily moved Resident #1 to the women's side until lunch the next day, 3/10/23, after Resident #2 was discharged . LVN C stated only new interventions she was aware of for [Resident #1] was to consider alternative placement but it was difficult to find alternative placement for Resident #1 due to his wandering. <BR/>Continuing the interview on 3/17/23 at 9:22 a.m., LVN C stated Resident #3's aggressive behavior was new for Resident #3. LVN C stated she believed Resident #3 may be mimicking Resident #2's aggressive behavior. LVN C stated, [Resident #3] somehow got attached to him and he was always calling out for [Resident #2.] And I found that extremely odd because [Resident #3] was becoming dependent on [Resident #2.] [Resident #3] felt safe around him. LVN C stated prior to 3/12/23, Resident #3 was approaching other residents with the intent to push them over, but when [Resident #3] was aware he was being watched by the facility staff, he would leave the other residents alone. LVN C confirmed she was working on 3/12/23, the day Resident #3 pushed Resident #1. LVN C stated, We were short [a staff member] that day. I remember because I had to take them out to smoke because usually a CNA would do it. So to keep the [other residents] calm I went and initiated the smoke [smoke break.] So I let them [the residents] out and then it happened. LVN C stated after Resident #3 pushed over Resident #1 and caused Resident #1 to break his hip they made sure [Resident #3] stayed away from the others.<BR/>During an interview on 3/17/23 at 10:48 a.m., LVN I stated he was currently the primary nurse for Resident #1. LVN I stated Resident #1 was currently on physical therapy and occupational therapy, which was new for Resident #1. LVN I stated Resident #1 could previously walk independently and currently cannot bear weight on his broken hip.<BR/>During an interview on 3/17/23 at 12:28 p.m., the DOR stated Resident #1 was currently on physical therapy and occupational therapy for his broken right hip. The DOR stated Resident #1 never required therapy before because he was ambulatory [able to walk] without any device and was independent with ADLs prior to his broken hip. The DOR stated Resident #1 was currently bed-bound at this point. He was independent, but now he's dependent. <BR/>During an interview on 3/17/23 at 1:34 p.m., the Director of Marketing LVN stated his current role at the facility was a Nurse Manager due to the fact the facility did not have a DON and ADON. The Director of Marketing LVN stated the facility ensured the safety of residents in the locked unit by frequent monitoring. The Director of Marketing LVN stated if 2 residents had a physical altercation the staff would ensure the altercation doesn't happen again by monitoring continuously. When asked about the incident involving Resident #1 and Resident #2 on 2/15/23, the Director of Marketing stated he could not recall much about the incident as that was around the time he began to become more involved in nurse management. The Director of Marketing LVN stated after the incident we did our frequent monitoring and then our redirection and then provided activities on the unit. <BR/>Continuing the interview on 3/17/23 at 1:34 p.m., the Director of Marketing LVN stated a resident was considered unmanageable when medication management failed to manage a resident's behavior and once that was identified the facility would find alternative placement. The Director of Marketing LVN stated Resident #2 was very nice . but he would have his spurts where if an individual invaded his space too closely, he might get a little aggressive . He was more of a verbal yelling and screaming. Just whenever his personal space was invaded. The Director of Marketing LVN stated to manage Resident #2's aggression they provided activities for him. We have an activity assistant back there [in the unit] to encourage to do activities throughout the day. The Director of Marketing LVN stated the facility had attempted to discharge Resident #2 to other nursing homes but was denied. The Director of Marketing LVN stated he was unsure if the facility ever issued a 30 day discharge notice to Resident #2. When asked about what happened between Resident #1 and Resident #2 on 3/9/23, the Director of Marketing LVN stated the facility sent out Resident #2 to the hospital for medical clearance but Resident #2 was sent back. The facility then scheduled Resident #2 to be sent out to another local hospital and when transportation arrived Resident #2 became combative, law enforcement was involved, Resident #2 was arrested and was currently not in the facility. The Director of Marketing LVN stated afterwards the facility initiated in-services on abuse, neglect, and resident-to-resident altercation. The Director of Marketing LVN stated the facility continued their current interventions from 2/15/23 for Resident #1 which included redirection, music therapy, providing more staff in the locked unit, and posting an identification marker on his Resident #1's room to help Resident #1 find where his room is.<BR/>Continuing the interview on 3/17/23 at 1:34 p.m., the Director of Marketing LVN stated Resident #3 had a diagnosis of dementia, anxiety, unspecified psychosis, and persistent mood disorder. The Director of Marketing LVN stated from admission until these recent events he's been very pleasant and after Resident #3 pushed Resident #1 the facility provided redirection, a calming environment, and scheduled a psychiatric evaluation for Resident #3 after he returned to the facility on 3/12/23. The Director of Marketing LVN stated the ideal staffing in the locked unit was 1 nurse and 2 CNAs, but on 3/12/23, the locked unit was short 1 CNA. The Director of Marketing LVN stated he did not feel the short-staffing contributed to Resident #1's incident on 3/12/23. When asked about the incident on 3/12/23, the Director of Marketing LVN stated the initial report was not made to him but to the facility's former MDS Nurse who was no longer employed at the facility. The Director of Marketing LVN stated, the only thing I remember is that the resident stated he didn't do it. I know [the former MDS Nurse] set up for [Resident #3] to be sent to [a local hospital] to be evaluated for psychiatric treatment and he came back. When asked if the facility implemented new interventions for Resident #3, the Director of Marketing LVN stated, just our general intervention. Just to provide a calm environment, redirection, and continuous monitoring. When asked if they implemented anything new for the staff, the Director of Marketing LVN stated, I know they did some in-services on abuse and neglect. The Director of Marketing LVN stated Resident #1 was independent before his incident on 3/12/23. When asked if they implemented anything new for Resident #1, the Director of Marketing LVN stated, we did incorporate a lot of activities that were off the unit to change his environment for him. The Director of Marketing LVN stated, I think they did everything they could have done to ensure the safety of all residents in this facility. They followed the procedures meant to be implemented in these situations.<BR/>During an interview on 3/17/23 at 3:05 p.m., the Administrator stated he had been the Administrator at the facility since early February 2023 and was currently the abuse coordinator. The Administrator stated they ensured the safety of residents in their locked unit by supervision and increased activities. The Administrator stated he did not recall if the facility had implemented any interventions for the locked unit after the incident involving Resident #1 and Resident #2 on 2/15/23. The Administrator stated he was not too familiar with Resident #2 beyond the incident between Resident #1 and Resident #2 on 3/9/23. The Administrator stated he was not aware of any new interventions for Resident #2 prior to 3/9/23. The Administrator stated he was aware the facility had attempted to discharge Resident #2 before 3/9/23 but with no success. The Administrator stated aside from in-servicing, the facility did not make any major changes after the incident between Resident #1 and Resident #2 on 3/9/23. <BR/>Continuing the interview on 3/17/23 at 3:05 p.m., the Administrator stated he heard Resident #3 became aggressive towards Resident #5 prior to Resident #3 pushing over Resident #1 on 3/12/23. The Administrator stated on 3/12/23 he was notified of the incident between Resident #3 and Resident #1 and he came on-site the same day to conduct safe surveys with other residents. When asked if there were any interventions in place to ensure Resident #1's safety, the Administrator stated, just the 15-minute check thing that we've done. I'll tell you what the problem is, it's the size of the hall . Most everyone has dementia and some of those guys get into people's personal space and some people don't like it. And [Resident #1] does that. He'll enter people's personal space and these guys-they have dementia too and I assume they don't like it. The Administrator stated he was unsure if there were any considerations to place Resident #1 in another facility. When asked if he felt the facility had done everything they could to ensure Resident #1's safety, the Administrator stated, I don't think I could have done anything to make that not happen. An updated education for the facility's incident report on 3/12/23 was requested at this time. <BR/>In a follow-up interview on 3/17/23 at 5:47 p.m., the Marketing Director LVN stated the facility's education on 3/9/23 carried over to the incident on 3/12/23. <BR/>During an interview on 3/18/23 at 10:45 a.m. with the Administrator, this surveyor requested for a copy of a 30-day discharge for Resident #2, if one was available.<BR/>In a follow-up interview on 3/18/23 at 11:03 a.m., LVN C stated she was aware Resident #3 attempted to push Resident #5 before and heard Resident #3 raised a fist at Resident #5. LVN C stated Resident #5 felt unsafe around Resident #3 and wanted to change rooms.<BR/>In a follow-up interview on 3/18/23 at 11:15 a.m. with CO H, CO H stated, [Resident #1] walks and always has. That honestly is my biggest concern . He used to sit up by himself and stand and now he can't do that . Something that he's never done before that's really concerned me is that I went to move his hair out of his eyes and he flinched. And that broke my heart. He knows I'd never lay a hand on him . He sleeps a lot more. He never used to sleep during the day. He was always up and walking.<BR/>During an interview on 3/18/23 at 11:59 a.m., the Assistant Activities Director stated she conducted activities for the locked unit. The Assistant Activities Director stated she was told to do more activities with the men's locked unit, but added, I'm still making it work because she was trying to balance doing activities for the men and women's locked unit. When asked about any new changes to their activities schedule, the Assistant Activities Director stated the facility started having weekly outings on Thursdays since 3/2/23. The Assistant Activities Director stated off-unit activities had been implemented since October 2022. The Assistant Activities Director state the facility's off-unit activities included coffee socials on Tuesday, and bingo on Tuesdays and Thursdays. When asked about Resident #1, the Assistant Activities Director stated the resident liked to go for walks and she would take him to walk through the dining hall and outside at least 2 or 3 times per week for 30 minutes. <BR/>During an interview and record review on 3/18/23 at 12:28 p.m., the Assistant Activities Director stated she was asked to pass to this surveyor a print-out of Resident #2'nursing and physician progress notes with highlighted portions indicating the facility's unsuccessful attempts to discharge Resident #2. No 30-day discharge notice was provided with this print-out and there was no documentation in the progress notes that indicated a 30-day discharge notice was provided.<BR/>Record review of a facility policy titled, Preventing Resident Abuse, dated February 2014, revealed the following, Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse . The facility's goal is to achieve and maintain an abuse-free environment. <BR/>Record review of Resident #1's signed admission agreement, dated 10/19/23, revealed the following: Each Resident has the right to be free from verbal, sexual, mental and physical abuse, corporal punishment, and involuntary seclusion.<BR/>The Administrator was notified of an IJ on 3/17/23 at 5:48 p.m. and was given a copy of the IJ Tem[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that: S483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 5 of 16 residents (Residents #5, #19, #23, #44, and #65) reviewed for abuse and neglect. 1.The facility did not make a report to local law enforcement or State Survey Agency (HHS) of an allegation on [DATE] when Resident #65 suffered a scalp laceration requiring 12 staples from a resident-to-resident altercation with Resident #19 on [DATE].2. The facility failed to report an unwitnessed fall resulting in a femur fracture for Resident #5 on [DATE].3. The facility failed to report an incident of witnessed abuse from Resident #23 on [DATE].4. The facility failed to report an incident in which Resident #44 sustained an injury of unknown source on [DATE]. These failures could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: 1. Record review of R#19's face sheet, dated [DATE], reflected resident was a male age [AGE] admitted on [DATE] with diagnoses that included: dementia, HTN (hypertension), anxiety and DM (diabetes). The RP was listed as: family member. Record review of Resident #19's Quarterly MDS, dated [DATE] reflected: the resident's BIMS score was 3, indicative of severe impairment in cognition. The resident was ambulatory and had no range of motion impairment. Record review of Resident #19's Care Plan, undated, reflected, the goals and interventions included the following:Goal: behavior management. Interventions included: monitoring for safety of resident and others, medication review, monitoring behaviors, and for staff to report any change in behaviors. Record review of Resident #19's Physician' Orders, dated [DATE] reflected the following psychotropics: hydroxyzine (for anxiety and agitation), 50 mg tab, given twice per day. Depakote (for mood) 125 mg, 3 tablets daily. And, Zoloft (for anxiety), 25 mg, 1 tablet once per day. Record review of Resident #19's MAR, dated [DATE], reflected, the psychotropic medications were given as ordered. Record review of Resident #19's incident report dated [DATE] at 9:36 PM authored by LVN A reflected: resident was involved in an altercation with R#65 in R#19's room in the secured unit. During the altercation both residents were on the ground involved in a struggle. LVN A assessed and examined R#19 and no injuries were noted to R#19. LVN A observed that the window in R#19's room was broken. Record review of Resident #19's risk management note dated [DATE] authored by LVN A reflected vitals were normal (BP was 121/66 (normal), pulse was 89 (normal), respiration was 19 (normal), temp was 98.2 (normal), and O2 was 96% (normal). No first aide was given to R#19. Record review of Resident #65's face sheet, dated [DATE] reflected resident was a male age [AGE] admitted on [DATE] and discharged (aggression with another resident-sent to Psychiatric Hospital Unit) [DATE] and re-admitted on [DATE] with diagnoses that included: Alzheimer's ( a progressive neurological disease that primarily affects memory, thinking , and behavior) , dementia, (loss of cognitive functioning-thinking, remembering and reasoning) HTN (hypertension), and pseudobulbar affect (changes in mood). The RP (responsible party) was listed as: family member. Record review of Resident #65's Quarterly MDS, dated [DATE] reflected the resident's BIMS score was 3, indicative of severe impairment in cognition. The resident was ambulatory with no range of motion impairment. Record review of Resident #65's Care Plan, undated, revealed, the goals and interventions included:Goal: behavior management: interventions-minimize triggers, anticipate needs, de-escalate, and medication management. Also, seek alternate placement ([DATE]). As needed [[DATE]], 1:1 monitoring during episodes of increased behaviors and aggression. Record review Resident #65's Care Plan prior to incident on [DATE] reflected the following interventions for aggressive behaviors: monitor, re-direct, and provide visual reminders of the resident's room. Record review of Resident #65's Physician' Orders, dated [DATE], reflected the only psychotropic was risperidone, 1.5 mg, at morning and bedtime to control behaviors. Also, the physician's order on behaviors reflected the interventions of monitoring for restless, hitting, kicking, biting, elopement seeking, delusions, hallucinations, and psychosis. [Note: no order for close monitoring or 1:1 supervision until the incident on [DATE]] Record review of Resident #65's MAR, dated [DATE] reflected, psychotropic given medications given as ordered. Record review of Resident #65's Nurse Note dated [DATE] at 3:32 AM, authored by LVN J read, Resident entered other resident ['] s room [R#19] when we [LVN J and CNA K] heard noise of a loud bang. Upon entering he [R#65] was still holding on to other residents' shirt [R#19] and they went to the ground landing on [there] bottom. I told them to stop and let go. They did and got up without incident. [R#65] noted to have open laceration] . to top of head. We walked him into his room. I cleaned and dressed it. Decision was made to send him to local E.D. He came back with 12 staples which will need to be removed in 5 to 7 days. Report given to me was his CT scan of head was negative. Record review of Resident #65's risk management reported dated [DATE] at 10:36 PM authored by LVN J reflected: vitals were normal: BP was 134/59, pulse was 90, respiration was 22, temperature was 98, and O2 was 97 %. LVN J provided first aide to Resident #65. LVN J assessed for injury; cleaned and dressed the wound. Record review of Resident #65's elopement evaluation dated [DATE] reflected: resident had wandering behaviors that were likely to affect the safety or well-being of self/others. Record review of Resident #65's Care Plan dated [DATE] for the focus of wandering behavior listed the interventions as: monitoring, provide one to one care if the resident was agitated or triggered. Also, other interventions included: redirection, and visual reminders outside the resident's room to assist with correct room location. Record review of Resident#65's ER record, dated [DATE] at 11:14 PM reflected: R#65 presented at ER with laceration to the left frontal scalp from an altercation with another resident (R#19). CT scan performed was negative. Treatment given to R#2 was 12 staples to the head laceration and discharged back to the facility. Discharge diagnosis was Laceration of scalp. Record review of R#19's and R#65's law enforcement report dated [DATE] reflected: Given both residents had dementia, law enforcement made no arrests or charged a resident with a crime. Criminal investigation reflected R#2 fell and hit his head on the window resulting in a scalp laceration. Law Enforcement Officer stated in the report, . [had] concerns regarding .[facility] Waiting over nine hours before reporting a violent altercation at their facility to law enforcement . Based on interview on [DATE] at 2:30 PM with the ADON Q and record review of facility's incident report dated [DATE], there was the following timeline authored by LVN J (charge nurse): [DATE] at 9:36 PM was the date and time of the incident. CNA K while monitoring another resident in the common area in the secured unit heard a noise coming from room [room number]. [4 staff were on the night shift in the secured unit for a census of 23;1 LVN, 2 CNAs on men's section and 2 CNAs at women's section], When the LVN J and CNA K entered R#19's room R#19 and R#65 were holding each other's shirt while standing. LVN J completed assessments on both residents with R#65 being sent to ER for evaluation for head laceration. LVN J provided first aide to R#65 and stopped the bleeding to the scalp. LVN J discovered that R#19's room had a broken window. Interview of R#19 by LVN reflected that R#19 alleged that R#65 came into the room and He threw a cup and started beating me up. [DATE] between 9:36 PM and 10:00 PM, LVN J notified family, and left a message at the physician call center. [DATE] at 10:01 PM-facility [ADON Q] became aware of the incident from phone call from LVN J and had advised her to send the resident to ER immediately. LVN J was unsuccessful in a getting physician's orders from 9:36 PM to 10:01 PM. [DATE] between 9:36 PM and 10:00 PM, LVN J notified family, physician call center and message left. [DATE] around 10:30 PM-10:45 PM EMS arrived to take R#65 to the ER. [DATE] around 1:45 AM, R#65 returned from ER with 12 staples on scalp and placed on 1:1 monitoring. [DATE]: starting around 8:00 AM in-service training on ANE, de-escalation and calming techniques for residents with dementia. [total number of staff based on staff list dated [DATE] reflected 103 employees] [DATE] around 8:30 AM, law enforcement was notified of the incident. [LVN J stated she did not call law enforcement] [DATE] around 9:30 AM: self-report to HHS. Record review of R#65's 30-day notice dated [DATE] reflected an involuntary discharge for the reason listed as safety of other residents. Notice was issued to the RP. Observation and interview on [DATE] at 11:17 AM, R#65 was ambulatory and walking in the secure unit halls; there were 12 staples present on left side of scalp; with old blood present, dark red to black in color. R#65 was alert and oriented to self. The Resident stated, I hit my head .someone push me or hit my head .someone pushed me down .do not remember when it happened .I feel safe here Yes, they watch me . The resident stated that he had pain to is head. [The resident could not describe the level of the head pain.] The resident stated he had no complaints about the secure unit or his safety. Observation revealed 1:1 monitoring by CNA AR. Observation and interview on [DATE] at 11:30, R#19 was in his room, lying in bed, alert and oriented person and place. The resident had no injuries, skin tears or bruises present. Call light was in reach; room was cleaned; there were no fall hazards; and the room was homelike. Observation further revealed the window blind was not present; and there was a new top portion of windowpane. The Resident stated, he felt safe. The resident stated that staff checked on him to keep him safe. At first, the resident denied that he had an altercation with another resident and could not explain why law enforcement made a visit to him yesterday ([DATE]). The resident recalled that he and another resident named [R#65] had an argument and struggled on the floor; and resident [R#65] fell on the window and hit his scalp; blood was present. The resident stated he could not remember the actions taken by the staff. The resident stated the window broke and was replaced. The resident stated that the resident [R#65] just walked into my room and started fighting with me .I tried to grab him .no time to ask for help .during the fight . he hit the window. The resident stated that it was the first time he had an altercation with R#65. R#19 denied he had any past altercations with Resident #65. The resident repeated that he felt safe and denied any ANE. During interview on [DATE] at 11:39 AM, the Maintenance Supervisor stated, the window in room R#19's was shattered and an indention in the bottom of the window was present; and the window blind was broken. The Maintenance Director stated he replaced the window yesterday ([DATE]) and would replace the blind today ([DATE]). The Maintenance Director stated he needed to replace the window blind in R#1's s room because there was an altercation between two residents. During interview on [DATE] at 11:57 AM, CNA AR stated R#2 was placed on 1:1 when he returned from the hospital on [DATE] in the morning. CNA AR stated the residents were kept safe by checking every hour. CNA AR stated the resident was on 1:1 for safety for his safety and the safety of other residents [1:1 was in place prior to the surveyor's arrival of [DATE]]. CNA AR stated that he attended ANE, and highlight was to report immediately to the abuse coordinator any abuse. During interview on [DATE] at 12:12 PM, LVN A stated she was not a witness to the incident on [DATE]. LVN A stated R#65 liked to pace the hallways in the secure unit; and it was the first time an altercation occurred in the past month (she had been on duty only one month). LVN A stated that residents were kept safe by monitoring and routine checks. LVN A stated she attended the ANE training in the past and the message was to report immediately. LVN A stated once the situation was safe, the facility needed to call the MD and the RP. During interview on [DATE] at 12:24 PM, CNA U stated residents were kept safe by having call lights in reach, meet the resident's needs, and observe residents walking the hallways. CNA U stated that if a resident was injured in an altercation resulting in a head or scalp injury with blood, the facility needed to call 911 immediately because a head injury could be serious and result in trauma. During an interview on [DATE] at 3:10 PM, the ADON Q stated the resident-to-resident altercation resulting in R#65 sustaining a scalp laceration requiring 12 staples should have been reported to law enforcement as soon as possible. ADON Q stated that law enforcement was called the next morning, and she could not explain the delay call to law enforcement. Further, the ADON stated when there was an injury in an alleged abuse case HHS should have been notified within 2 hours. ADON Q could not give an explanation why HHS was not notified within 2 hours of the incident. During an interview on [DATE] at 3:22 PM, the DON stated that law enforcement should be called within a timely manner. The DON stated the facility wanted to wait on the results of the ER visit before notifying law enforcement. The DON stated she was not fully aware of the 2-hour HHS regulation for reporting abuse when a resident suffered an injury during a resident-to-resident altercation. The DON stated there was an injury but it was not an emergency because the resident did not lose a lot of blood [R#65] and was conscious .vital signs were stable .and CT scan was negative . During telephone interview on [DATE] at 4:05 PM, LVN J stated the timeline was correct. LVN J stated that she was making assessments of both residents and providing first aide to R#65 and vitals were stable for both residents. LVN J stated that it did not come to my head to call the police. Attempted call to CNA K on [DATE] at 4:25 PM, message left. Call not retuned by time of exit on [DATE] at 5:30 PM. During an interview on [DATE] at 4:35 PM, the Administrator stated reports to HHS were based on PL 2019-17. The administrator stated he would report a serious injury or immediate abuse to law enforcement and HHS. The Administrator stated there was no serious injury or immediate abuse that had to be reported to law enforcement at the time of the incident or immediately to HHS [2-hour time limit]. The Administrator stated that given the information he had he waited 9 hours before notifying law enforcement. The Administrator stated R#65 was at the hospital during the 9-hour delay before notifying law enforcement. During interview on [DATE] at 9:15 AM, Law Enforcement Officer stated law enforcement needed to be contacted immediately when there was an altercation between two residents in a nursing home resulting in an injury to one resident. The Officer stated law enforcement's immediate involvement in the incident involving R#19 and R#65 on [DATE] would have allowed law enforcement to investigate and determine whether an assault occurred that constituted a crime. The Law Enforcement Officer stated that notification to law enforcement after nine hours after the incident on [DATE] could result in evidence disappearing in a commission of a crime. The Law Enforcement Officer repeated that law enforcements required an immediate report when an assault or altercation occurred between residents resulting in an injury to one resident. During an interview on [DATE] at 10:24 AM, the DON stated that staffing on the night shift (6P-6A) on [DATE] was more than adequate and the staff quickly responded when the incident occurred at 9:36 PM. During an interview on [DATE] at 3:24 PM, the DON stated R#65 was given a 30-day notice via the RP for a different placement because the facility could not control the resident's behaviors and to ensure the safety of other residents. The DON stated it was not an appropriate setting for the resident and the resident was on 1:1 monitoring pending a placement. During telephone interview on [DATE] at 4:45 PM, Psychiatric NP stated medication adjustments had been attempted various times to control R#65's behavior with mixed results. The NP stated that the resident's aggression was likely due to impulsivity which medications could not control. The NP stated the resident likely required a smaller secured unit with little stimulation or a group home with few residents. The NP stated the resident was not neglected and interventions were in place to attempt to control the resident's behaviors. Record review of R#65's incident reports since admissions ([DATE]) to the present ([DATE]) reflected there was only one resident-to-resident altercation which occurred on [DATE]. Record review of facility's PPD staffing for the date of [DATE] of the secure unit was 3.2 [normal/average staffing based on a rating of 1 through 5 with 1 being poor and 5 excellent staffing.] 2. Record review of Resident #5's face sheet, dated [DATE], reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included unspecified dementia (a progressive disorder that impairs thought processes, including memory and reasoning), other lack of coordination, and anxiety. Record review of Resident #5's admission MDS, submitted [DATE], reflected a BIMS score of 03, indicating severely impaired cognition. Record review of Resident #5's completed assessments revealed the earlier documented fall risk evaluation was completed on [DATE], with a score of 15 and the category of at risk. Record review of Resident #5's progress notes revealed the following documentation dated [DATE] at 5:26 AM:Resident was found on floor at 2:45. Checked vitals wnl noted to have a small cut on left palm. He denied pain and no abrasions or redness noted anywhere else. At about 3:45 resident noted to be restless and sitting complaining of a [NAME] horse to left leg. Upon further assessment left upper thigh noted to be deformity to contour. He was notably tender to touch. I called family member and made aware of this. [Provider] notified and adon also. [sic] Record review of Resident #5's scanned documents revealed discharge documentation from a hospital visit dated [DATE]. The hospital discharge documentation included notation of a surgical repair of a femur fracture to Resident #5's left leg on [DATE]. Due to cognitive decline, Resident #5 was not able to participate in an attempted interview on [DATE] at 7:45 PM. In an interview with the DON on [DATE] at 3:54 PM, she stated she was made aware of the incident by nursing staff around the time the incident occurred on [DATE]. She stated the incident was investigated by the facility, and no deficiencies in care were found. She stated Resident #5 had poor safety-awareness due to the progression of dementia. She stated falls with injury are self-reported by the facility if the fall is unwitnessed and results in a serious injury. The DON stated this incident was not reported to the SSA because the facility determined during their investigation this incident did not meet the criteria for self-reporting as the resident had a prior, similar injury before admission. In an interview with the Admin on [DATE] at 11:27 AM, he stated that investigations of falls were investigated by the DON, and he was only made aware of incidents that involve abuse/neglect. The Admin also stated that the facility does not have a policy directly related to self-reporting incidents/accidents, and that their policy is to adhere to the provider letter and guidelines set forth by the SSA. 3. Record review of Resident #23's face sheet, dated [DATE], reflected a [AGE] year-old female initially admitted to the facility on [DATE]. Relevant diagnoses included disruptive mood dysregulation disorder (chronic irritability and frequent temper outbursts), bipolar disorder (mood instability), and unspecified dementia. Record review of Resident #23's quarterly MDS, submitted [DATE], reflected a BIMS score of 14, indicating intact cognition. Record review of Resident #23's progress notes revealed the following documentation entered on [DATE] at 3:58 PM by LVN W:Pt was in dining room and another resident was sitting at the table where pt normally sits. Pt went up to other resident and told her to get out from her table and go back to hers and called her a Bitch. She followed other pt and continued to call her names. Pt was redirected out of the dining room. [sic] Record review of the facility incident reports from [DATE] to [DATE] did not reveal a report related to the incident. Record review of the self-reported incidents from the facility to the State Survey Agency also did not reveal a report related to the incident. Resident #23 declined to participate in an attempted interview on [DATE] at 1:00 PM. In an interview on [DATE] at 2:35 PM, LVN W recalled the event she narrated in the progress note. LVN W stated Resident #23 became agitated when she discovered a resident sitting in the seat Resident #23 typically uses during dining. LVN W stated Resident #23 told the other resident to get out of her seat and began cursing and following the other resident around the dining room. Resident #23 was directed out of the dining room by LVN W due to the behavior. LVN W could not recall the identity of the other resident. She also could not recall the response from the other resident to the incident. LVN W was unsure if she reported the incident to her supervisors or the abuse coordinator. In an interview with ADON Q on [DATE] at 4:48 PM, she stated she was unsure if she was told about the incident. After reading the progress note, she stated she felt like this incident qualified as abuse by Resident #23 of another resident. In an interview with the DON on [DATE] at 6:05 PM, she stated she was unaware of the incident. She was unsure if the incident qualified as abuse but felt it should have investigated by the facility. In an interview with the Admin on [DATE] at 7:45 PM, he stated he did not feel this incident qualified as abuse as the Resident #23 had known behaviors and was not aware of her actions. He stated that SSA was not helping residents by classifying the behavior enacted by Resident #23 as abuse and leaving the facility no choice but to discharge a resident who displayed similar behavior. 4. Record review of Resident #44's admission Record, dated [DATE], reflected the resident was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included unspecified dementia (a general term for impaired ability to remember, think, or make decisions), depression, and history of falling. Record review of Resident #44's Comprehensive Person-Centered Care Plan, undated, reflected, Resident has experienced a fall R/T weakness, Impaired mobility, cognitive impairment and is at risk for further falls., and Resident is at risk of alter psychosocial well-being related to altercation with another resident. Record review of Resident #44's Significant Change MDS, dated [DATE], reflected the resident had a BIMS score of 0, indicating severe cognitive impairment. Further review reflected the resident had a fall in the last month, but did not reflect that the resident had a major injury such as a bone fracture. Record review of Resident #44's incident report, dated [DATE], reflected, Resident had an un-witnessed fall in peer's room. Nursing staff observed resident in the seated position on the floor with his legs out in front of him. An interview was attempted with Resident #44 on [DATE] at 10:30 AM. Resident #44 was not able to answer questions related to his care at the facility due to severe cognitive impairment. Interview on [DATE] at 10:35 AM, LVN A stated Resident #44 had been found on the floor by a CNA in another resident's room. LVN A stated no one saw the resident fall. LVN A stated she assessed Resident #44 on the floor of another resident's room and the resident said his back hurt. LVN A stated she assessed for pain on Resident #44's backs and legs and the resident did not complain about pain during assessment. LVN A stated shortly later, Resident #44 was walking and complained of pain to his leg and was sent to the hospital where they found a fracture on his left hip. LVN A stated she informed her ADON and DON of the incident. Record review of Resident #44's Emergency Department Report, dated [DATE], reflected, in part, There is an acute nondisplaced fracture through the posterior cortex of the left femur on the subtrochanteric region. Record review of Resident #44's Orthopedic Surgeon Visit, dated [DATE], reflected there was a small fracture within the greater trochanter with the assessment/plan stating, He may weight-bear as tolerated with a walker and needs to be supervised as he had a difficult standing with me at bedside today. Interview on [DATE] at 11:27 AM, the Administrator stated that the incident was handled by nursing. The Administrator stated that the resident fell, so it was an explainable injury. The Administrator stated that nursing staff inform him of incidents of abuse and neglect. When asked if the fall had been unwitnessed, the Administrator stated I couldn't tell you, I'm not looking at it. All I know is that it was a fall. We have provided all of that information to you. The Administrator stated that they follow the provider letter [Texas Health and Human Services Provider Letter PL 2024-14] to determine what to report. Record review of Texas Health and Human Services PL 2024-14, date issued [DATE], reflected, an incident that results in serious bodily injury and that involves any of the following:NeglectExploitationMistreatmentInjuries of unknown sourceMisappropriation of resident propertyWhen to Report: Immediately, but not later than two hours after the incident occurs or is suspected.Further review reflected, an injury should be classified as an injury of unknown source when ALL of the following conditions are met:The source of the injury was not observed by any person; andThe source of the injury could not be explained by the resident; andThe injury is suspicious because of:the extent of the injury; orthe location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); orthe number of injuries observed at one point in time; orthe incidence of injuries over time. Record review of facility's Abuse Prevention Program, dated revised [DATE] read: .Investigate and report any allegations within timeframes required by federal requirements .Record review of State regulations (N3568) on reporting ANE read: A local or state law enforcement agency must be notified of reports described in subsection (a) of this section, that allege that: (1) a resident's health or safety is in imminent danger. (2) a resident has recently died because of conduct alleged in the report of abuse or neglect or other complaint. (3) a resident has been hospitalized or treated in an emergency room because of conduct alleged in the report of abuse or neglect or other complaint. (4) a resident has been a victim of any act or attempted act described in the Texas Penal Code, SS21.02,21.11, 22.011, or 22.021; or (5) a resident has suffered bodily injury, as that term is defined in the Texas Penal Code, S1.07, because of conduct alleged in the report of abuse or neglect or other complaint. Record review of website: https://www.dfps.texas.gov/contact_us/report_abuse.asp, mandates in the State of Texas, Resource Code, Chapter 48, reporting of elder abuse. Further, .in Texas, anyone with reasonable cause to believe a child, an adult with a disability, or a person 65 or older is being abused, neglected, or exploited in a nursing home must report it to the Texas Department of Family and Protective Services (DFPS). While the report should be made to DFPS, law enforcement may also be involved depending on the nature of the abuse . Record review of facility policy titled, Abuse, Neglect and Exploitation dated [DATE], reflected, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. And, The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timelines. a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. a. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. b. The facility will designate an abuse prevention coordinator in the facility who is responsible for reporting allegations of suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 7 of 7 residents (Resident #'s 1-7) reviewed for neglect, in that:<BR/>Resident #'s 1-7 were occupying rooms in 100 Hall (Male Secured Unit) and 200 Hall without functioning HVAC/Heating Systems which resulted in these residents being subjected to enduring cold temperatures during cold winter weather. The facility did not report this to the state agency.<BR/>This deficiency placed residents at risk for harm by a diminished quality of life, specifically, sleep deprivation and cold-related injuries (hypothermia) for residents.<BR/>The findings included:<BR/>Observation on 01/17/24 at 2:15 PM, when entering the facility, revealed it was noticeably cold and residents/staff were still wearing winter clothing (jackets/gloves/scarfs/ski caps) while in the building. <BR/>Record review of website: Past Weather in [city] Texas, USA - Yesterday or Further Back (timeanddate.com) of the air temperatures for [city], Texas revealed the following air temperatures and corresponding dates for the city this facility was located:<BR/>Date: Low High<BR/>1/12/2024 29 F 59 F<BR/>1/13/2024 24 F 61 F<BR/>1/14/2024 16 F 28 F<BR/>1/15/2024 14 F 30 F <BR/>1/16/2024 15 F 34 F<BR/>1/17/2024 13 F 52 F<BR/>Interview on 1/16/2024 at 2:34 PM, the administrator stated the facility's heating units for 100 Hall (Male Secured Unit) and 200 Hall were not functioning and pending replacement. The administrator stated 2 portable heating units had been placed at both ends of the 100 Hall (Male Secured Unit) and one large space heater was placed at the end of 200 Hall until the facility's permanent heating units could be replaced. The Administrator also said portable heaters were purchased and offered to residents who wanted one in their room in response to staff and residents complaining of cold temperatures within the building on the night of 1/13/2024.<BR/>Observation on 1/16/2024 at 3:06 PM of 100 Hall (Secured Men's) revealed 2 temporary heating units (THU) located at both ends of the hall. Further observation revealed the THU at the beginning of 100 Hall was running at a setting of 80 F and indicated room temperature (Hallway) of 69 F. Observation of the THU at the end of 100 Hall revealed the THU was not running. <BR/>Observation and interview on 1/16/2024 at 3:09 PM, Resident #1 was observed walking 100 Hall (Secured Men's) and lead this investigator his room. Resident #1 indicated his room was cold and would get colder at night. Resident #1 proceeded to show this investigator 4 blankets on his bed he was utilizing in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. <BR/>Observation and interview on 1/16/2024 at 3:14 PM, Resident #2 (100 Hall Secured Men's) was observed lying in his bed. Resident #2 was observed wearing gloves and when asked why, Resident #2 responded, because I like them! When asked if the resident was cold at night, he responded, Yes! When asked how the resident was doing in an attempt to stay warm, he responded, The blankets. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation and interview on 1/16/2024 at 3:16 PM, Resident #3 (100 Hall Secured Men's) was observed sitting in the secured dining area in his wheelchair. During the interview, Resident #3 said that this week had been, really cold. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation on 1/16/2024 at 3:38 PM revealed a space heater at the end of Hall 200.The space heater was on and glowing. The room temperature in this hall felt uncomfortably cold while wearing a jacket. <BR/>Observation and interview on 1/16/2024 at 3:40 PM, Resident #4 (200 Hall). Resident #4 was asked about the temperature of her room and indicated she had been, Very cold, and said she had been using multiple blankets in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation and interview on 1/17/2024 at 7:38 AM, facility staff were observed wearing winter-clothing in the building which consisted of extra layers and ski hats. At this time, an unknown staff shouted, It's cold in there, 50 degrees.<BR/>Observation and interview on 1/17/2024 at 7:44 AM, Resident, Resident #1 was observed lying in his bed with a blanket over his head. A reading of the room's temperature revealed a temperature of 56 F. During an interview that this time, Resident #1 was asked if he was cold and responded, Yes The resident stated he did not sleep well because his room was cold. <BR/>Observation and interview on 1/17/2024 at 7:57 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #1's bed which revealed a temperature reading of 56 F. LVN B confirmed the temperature in Resident #1's room was 56 F and responded, Oh wow, that's cold.<BR/>Observation and interview on 1/17/2024 at 7:44 AM, Resident #5 was observed lying in bed with a navy blue blanket over his head (photo taken). A reading of the room's temperature revealed a temperature of 51 F. During an interview at this time, Resident #5 was asked how he was doing and responded, Cold. When asked if the Resident #5 felt tired, he responded, Yeah, I can't sleep. <BR/>Observation and interview on 1/17/2024 at 7:58 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #5's bed which revealed a temperature reading of 51 F. During an interview at this time, LVN B was asked what the temperature should be to be considered comfortable to which she responded, Around 70 F.<BR/>Observation and interview on 1/17/2024 at 8:07 AM with Staff C, this investigator pointed a thermal thermometer laser at the wall closest to Resident #4's bed which revealed a temperature reading of 51 F. Staff C confirmed the temperature for Resident #4's room was 51 F. <BR/>During an interview at this time, Staff C said Resident #4 had requested to be moved to a new location due to feeling cold in her room. Staff C mentioned another Resident, Resident #7 (Hall 200) had also requested to be moved because she was cold in her room. <BR/>Interview and observation on 1/17/2024 at 9:50 PM, the Maintenance Supervisor and this investigator compared thermal temperature guns and confirmed their readings matched within +/-.3 degrees F. The Maintenance Supervisor's thermal temperature gun was orange and black ([NAME] Tools IR1 Infrared Thermometer), The Maintenance Director was asked what the room temperatures should be and responded, Around 75 F in the winter and around 70 F in the summer.<BR/>Interview and observation on 1/17/2024 at 10:00 AM, the Maintenance Supervisor measured Resident #1's room (100 Hall - Secured Men's Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 61 F. During an interview at this time, the Maintenance Supervisor said, It feels chili in here, I would need more blankets and double socks.<BR/>Interview and observation on 1/17/2024 at 10:04 AM, the Maintenance Supervisor measured Resident #5's room (100 Hall - Secured Men's Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #5's which revealed a temperature of 61 F. Resident #5 was observed still lying in bed with blankets over his head. A space heater was observed in this resident's room and was emitting heat but the room still felt cold. During an interview at this time, Resident #5 was asked if he was still cold to which he responded, Ya. At this time, the Maintenance Director said, Even with a space heater the room still feels cold. I don't see why the main heating unit (for 100 Hall) wasn't fixed before the cold weather.<BR/>Interview on 1/17/2024 at 10:15 AM, the administrator stated she had moved all but 1 resident on 200 Hall from the second half of 200 Hall to other locations including the first half of 200 Hall. The Administrator also stated she had closed the smoke barrier doors located in the middle of 200 Hall in an effort to prevent cold air coming down the first half of the 200 hall. Additionally, the Administrator said all residents on the 100 Hall (Male Secured unit) were moved to the 100 Hall (Female Secured unit) and indicated that section of 100 Hall had a HVAC. <BR/>Interview and observation on 1/17/2024 at 10:29 AM, the Maintenance Supervisor measured Resident #7's room (200 Hall) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 57.7 F. Resident #6 was observed lying in her bed under layers of blankets. During an interview at this time, Resident #6 was asked how she was doing to which she responded, I'm cold. The Maintenance Director then said, Ya, it's cold, I wouldn't want to be in there. The Maintenance Director then confirmed Resident #7's room was on the first half of 200 Hall that was supposed to be the side residents were moved to because it was warmer than the second half of 200 Hall. The Maintenance Supervisor agreed it felt much colder in the resident's room than in the hall. <BR/>A record review of the facility's Abuse/Neglect - Clinical Protocol revised 12/2016, stated, Assessment and Recognition - 2. Neglect is defined as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional destress . 4. If there is concern related to possible abuse and/or neglect of a resident, a nurse will assess the individual and document findings. Further review stated, The facility management and staff will comply with applicable laws and regulations pertaining to the documentation and management of abuse and neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to, in response to allegations of abuse or neglect, have evidence that all allegations are thoroughly investigated and to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken, for 2 of 5 residents (Residents #23 and #44) investigated for abuse and neglect. The facility failed to investigate an incident of witnessed abuse from Resident #23 on 5/25/25.The facility failed to investigate an incident in which Resident #44 sustained an injury of unknown source on 7/23/25. These failures could lead to abuse and/or neglect of residents and decreased quality of life. The findings included:<BR/>1. Record review of Resident #23's face sheet, dated 7/22/2025, reflected a [AGE] year-old female initially admitted to the facility on [DATE]. Relevant diagnoses included disruptive mood dysregulation disorder (chronic irritability and frequent temper outbursts), bipolar disorder (mood instability), and unspecified dementia (a progress disorder that impairs thought processes, including memory and reasoning). <BR/>Record review of Resident #23's quarterly MDS, submitted 4/29/2025, reflected a BIMS score of 14, indicating intact cognition. <BR/>Record review of Resident #23's progress notes revealed the following documentation entered on 5/25/2025 at 3:58 PM by LVN W:<BR/>Pt was in dining room and another resident was sitting at the table where pt normally sits. Pt went up to other resident and told her to get out from her table and go back to hers and called her a Bitch. She followed other pt and continued to call her names. Pt was redirected out of the dining room. [sic]<BR/>Record review of the facility incident reports from 1/22/2025 to 7/22/2025 did not reveal a report related to the incident. <BR/>Record review of the self-reported incidents from the facility to the State Survey Agency also did not reveal a report related to the incident. <BR/>Resident #23 declined to participate in an attempted interview on 7/22/2025 at 1:00 PM. <BR/>In an interview on 7/25/2025 at 2:35 PM, LVN W recalled the event she narrated in the progress note. LVN W stated Resident #23 became agitated when she discovered a resident sitting in the seat Resident #23 typically uses during dining. LVN W stated Resident #23 told the other resident to get out of her seat and began cursing and following the other resident around the dining room. Resident #23 was directed out of the dining room by LVN W due to the behavior. LVN W could not recall the identity of the other resident. She also could not recall the response from the other resident to the incident. LVN W was unsure if she reported the incident to her supervisors or the abuse coordinator. <BR/>In an interview with ADON Q on 7/25/2025 at 4:48 PM, she stated she was unsure if she was told about the incident. After reading the progress note, she stated she felt like this incident qualified as abuse by Resident #23 of another resident. <BR/>In an interview with the DON on 7/25/2025 at 6:05 PM, she stated she was unaware of the incident. She was unsure if the incident qualified as abuse but felt it should have investigated by the facility. <BR/>2. Record review of Resident #44's admission Record, dated 06/24/2025, reflected the resident was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included unspecified dementia (a general term for impaired ability to remember, think, or make decisions), depression, and history of falling.<BR/>Record review of Resident #44's Comprehensive Person-Centered Care Plan, undated, reflected, Resident has experienced a fall R/T weakness, Impaired mobility, cognitive impairment and is at risk for further falls., and Resident is at risk of alter psychosocial well-being related to altercation with another resident.<BR/>Record review of Resident #44's Significant Change MDS, dated [DATE], reflected the resident had a BIMS score of 0, indicating severe cognitive impairment. Further review reflected the resident had a fall in the last month, but did not reflect that the resident had a major injury such as a bone fracture.<BR/>Record review of Resident #44's incident report, dated 07/23/2025, reflected, Resident had an un-witnessed fall in peer's room. Nursing staff observed resident in the seated position on the floor with his legs out in front of him.<BR/>An interview was attempted with Resident #44 on 07/24/2025 at 10:30 AM. Resident #44 was not able to answer questions related to his care at the facility due to severe cognitive impairment.<BR/>Interview on 07/28/2025 at 10:35 AM, LVN A stated Resident #44 had been found on the floor by a CNA in another resident's room. LVN A stated no one saw the resident fall. LVN A stated she assessed Resident #44 on the floor of another resident's room and the resident said his back hurt. LVN A stated she assessed for pain on Resident #44's backs and legs and the resident did not complain about pain during assessment. LVN A stated shortly later, Resident #44 was walking and complained of pain to his leg and was sent to the hospital where they found a fracture on his left hip. LVN A stated she informed her ADON and DON of the incident.<BR/>Record review of Resident #44's Emergency Department Report, dated 07/24/2025, reflected, in part, There is an acute nondisplaced fracture through the posterior cortex of the left femur on the subtrochanteric region.<BR/>Record review of Resident #44's Orthopedic Surgeon Visit, dated 07/25/2025, reflected there was a small fracture within the greater trochanter with the assessment/plan stating, He may weight-bear as tolerated with a walker and needs to be supervised as he had a difficult standing with me at bedside today.<BR/>Interview on 07/29/2025 at 11:27 AM, the Administrator stated that the incident was handled by nursing. The Administrator stated that the resident fell, so it was an explainable injury. The Administrator stated that nursing staff inform him of incidents of abuse and neglect, because he is the abuse coordinator. When asked if the fall had been unwitnessed, the Administrator stated I couldn't tell you, I'm not looking at it. All I know is that it was a fall. We have provided all of that information to you. The Administrator stated that they follow the provider letter [Texas Health and Human Services Provider Letter PL 2024-14] to determine what to report and investigating. <BR/>Record review of Texas Health and Human Services PL 2024-14, date issued 08/29/2024, reflected, an incident that results in serious bodily injury and that involves any of the following:<BR/>Neglect<BR/>Exploitation<BR/>Mistreatment<BR/>Injuries of unknown source<BR/>Misappropriation of resident property<BR/>When to Report: Immediately, but not later than two hours after the incident occurs or is suspected.<BR/>Further review reflected, an injury should be classified as an injury of unknown source when ALL of the following conditions are met:<BR/>The source of the injury was not observed by any person; and<BR/>The source of the injury could not be explained by the resident; and<BR/>The injury is suspicious because of:<BR/>the extent of the injury; or<BR/>the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or<BR/>the number of injuries observed at one point in time; or<BR/>the incidence of injuries over time.<BR/>Record review of facility policy titled, Abuse, Neglect and Exploitation dated 06/30/2025, reflected, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. And, The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timelines: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. a. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. b. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 38 residents (Residents #8, #57) whose assessments were reviewed, in that:<BR/>1. Resident #8's Annual MDS dated [DATE] incorrectly documented the resident was on an anticoagulant.<BR/>2. Resident #57 Quarterly MDS did not have depression listed under active diagnoses. <BR/>This failure could place residents at-risk for inadequate care due to inaccurate assessments. <BR/>1. Review of Resident #8's face sheet dated 4/24/2023 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included vascular dementia (problems with reasoning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain) with behavioral disturbance, mild protein-calorie malnutrition (inadequate of food as a source of protein, calories, and other essential nutrients occurring in the absence of significant inflammation, injury or another condition), hyperkalemia (high potassium) and chronic pain. <BR/>Review of Resident #8's April 2023 physician orders revealed an order for aspirin (an antiplatelet that prevent blood cells called platelets from clumping together to form a blood clot) tablet, 81 mg, 1 tablet daily at 8:00 a.m. with a start date of 10/13/2022. Further review of the resident's physician orders revealed she was not receiving an anticoagulant.<BR/>Review of Resident #8's care plan with a start date of 3/14/2022 revealed the resident had a Potential for complications, injury related to anticoagulant or antiplatelet medication.<BR/>Review of Resident #8's Annual MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 3, which indicated she had a severely impaired cognition. Further review of Resident #8's Annual revealed, under section N, Medications, option E., Anticoagulant, the resident was receiving an anticoagulant (used to prevent the formation of blood clots that inhibit circulation) 7 days a week. <BR/>Review of the CMS Minimum Data Set (MDS) 3.0 Instructor Guide dated May 2010, N-18 revealed, 2. Do not code antiplatelet medications such as aspirin/extended release, dipyridamole (used to treat the symptoms of prophylaxis against blood clots after heart valve replacement surgery), or clopidogrel (an antiplatelet medication that prevents platelets from sticking together) under option E. Anticoagulant.<BR/>In an interview on 4/25/2023 at 9:12 a.m. with MDS Coordinator and ADON LVN reported aspirin should not be coded as an anti-coagulant n the MDS.<BR/>In an interview on 4/25/2023 at 9:30 a.m. with the MDS Coordinator revealed she had reviewed Resident #8's medical record and could not find that the resident had been prescribed an anticoagulant. The MDS Coordinator reported the former MDS Coordinator coded aspirin as an anticoagulant on the MDS. The MDS Coordinator reported the MDS described the resident and what needs, or services would be required and determined the amount received from Medicaid for a resident's care. The MDS Coordinator revealed if the coding was wrong then the billing would be wrong. <BR/>2. Review of Resident #57's electronic face sheet dated 04/23/2023 revealed the resident was admitted to the facility on [DATE] and again on 04/14/2023 with diagnoses of pneumonia (an infection that inflames the air sacs in one or both lungs), dysphagia (a condition with difficulty in swallowing food or liquid), major depressive disorder (mental health disorder having episodes of psychological depression; symptoms include feelings of sadness, low esteem, hopelessness), anxiety disorder (Feeling nervous, restless or tense; having a sense of impending danger, panic or doom). <BR/>Review of Resident #57's quarterly MDS assessment dated [DATE] revealed the resident did not have depression listed under active diagnoses. Resident #57's BIMS was 10/15, indicating moderate cognitive impairment.<BR/>Review of Resident #57's Active Orders revealed an order for: Buspirone tablet; 10 mg; amt: 2 tablets; oral. Twice a day - 07:00 AM, 04:00 PM for Depression. Start date: 07/15/2022, End date: Open Ended.<BR/>Review of Resident #57's MAR for April 2023 revealed Resident #57 received Buspirone as prescribed.<BR/>Interview on 04/27/23 at 12:27 p.m. with the MDS coordinator revealed the diagnosis of depression was not properly checked off on Resident #57's quarterly MDS dated [DATE]. The MDS coordinator stated she had been in the job for one week at the facility but had been a MDS Coordinator for two years, and it was critical that all a residents' diagnoses be indicated on the MDS because if a diagnosis was not listed in a resident's MDS, it would likely not be noted in the resident's comprehensive care plan and the staff would not know to look for disease symptoms, progression and assist the resident with disease management.<BR/>Review of the facility policy, Resident Assessment Instrument, revised September 2010 revealed, 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity.

**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 2 of 38 Residents (Resident #55 and #57) reviewed for care plans, in that: <BR/>1. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #55 to address hospice information, details of hospice care provided and coordination of services.<BR/>2. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #57 to address the resident's diagnosis of depression and use of psychotropic medications.<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/>1. Review of Resident #55's face sheet dated 4/24/2023 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's disease (a type of dementia that effects memory, thinking and behavior which eventually grows severe enough to interfere with daily tasks), moderate protein-calorie malnutrition (deficiency of energy, protein and nutrients that result in a person's weight to be 70-80% of ideal body weight and/or Body Mass Index is -2 to -2.9 below ideal body weight based on the weight and height of the person), dysphagia (difficulty swallowing food or liquids) and anxiety disorder.<BR/>Review of a physician order for Resident #55, with a start date of 1/25/2023, revealed the resident was on hospice services for her diagnosis of protein-calorie malnutrition.<BR/>Review of Resident #55s Significant Change in Status MDS dated [DATE] revealed the resident was on hospice services.<BR/>Review of Resident #55's care plan, with the last review date of 4/20/23 revealed there was not a care plan for hospice services.<BR/>In an interview on 4/25/2023 at 9:08 a.m. with the MDS Coordinator started that Resident #55 was on hospice services but did not have a hospice care plan in her medical record. The MDS Coordinator reported the care plan described the care the resident was receiving and without the care plan the being provided by hospice may be missed. <BR/>2. Review of Resident 57's face sheet dated 04/23/2023 revealed the resident was admitted to the facility on [DATE] and again on 04/14/2023 with diagnoses of pneumonia (an infection that inflames the air sacs in one or both lungs), dysphagia (a condition with difficulty in swallowing food or liquid), major depressive disorder (mental health disorder having episodes of psychological depression; symptoms include feelings of sadness, low esteem, hopelessness), anxiety disorder (Feeling nervous, restless or tense; having a sense of impending danger, panic or doom). <BR/>Review of Resident #57's quarterly MDS assessment dated [DATE] the resident's BIMS was 10/15, indicating moderate cognitive impairment.<BR/>Review of Resident #57's Active Orders for April 2023 revealed the following orders : Ativan (lorazepam) - Schedule IV tablet; 0.5 mg; amt: 1 tab; oral, three times a day, 07:00 AM, 01:00 PM, 07:00 PM for Anxiety. Start date: 06/07/2022, End date: Open Ended. Buspirone tablet; 10 mg; amt: 2 tablets; oral. Twice a day - 07:00 AM, 04:00 PM for Depression. Start date: 07/15/2022, End date: Open Ended.<BR/>Review of Resident #57's MAR for April 2023 revealed Resident #57 received the medications Ativan and Buspirone as ordered.<BR/>Review of Resident #57's comprehensive care plan, last revised 12/07/2022 and accessed on 04/23/2023 revealed there was no care plan for Resident #57'ss diagnosis of depression or for Resident #57's orders for psychotropic medications.<BR/>Interview on 04/27/23 at 12:27 with the MDS coordinator revealed Resident #57's diagnosis of depression and psychotropic medications were not documented in Resident #57's care plan and should have been. The MDS coordinator stated she had been in the job for one week but had been a MDS Coordinator for two years, and if a diagnosis or use of psychotropic medications were not listed in a resident's care plan, staff would not know to look for disease symptoms and/or progression or side effects of the medication.<BR/>Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed, 8. The comprehensive, person-centered care plan will: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and j. Reflect the resident's expressed wishes regarding care and treatment goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that respiratory care was provided in accordance with professional standards of practice, the comprehensive care plan, or the residents' goals and preferences for one of one resident reviewed (Resident #69) reviewed for respiratory care. RT P failed to listen to all lobes in Resident #69's lungs prior to the administration of a respiratory medication (albuterol inhaler). This failure placed residents at risk of improper assessment, inaccurate identification of concerns with the respiratory system, and hospitalization. Findings included: Record review of Resident #69's admission Record, dated 7/25/25 reflected a [AGE] year-old female with an original admission date of 06/20/2024 and a current admission date of 11/01/2024. Record review of Resident #69's Diagnosis Report, dated 07/25/2025 reflected diagnoses including other specified interstitial pulmonary disease and unspecified systolic (congestive) heart failure. Record review of Resident #69's MDS dated [DATE], reflected a BIMS score of 9 out of 15, which suggested a moderate cognitive impairment (some difficulty making decisions about care and other areas of daily life). Continued review of the same MDS reflected Resident #69 had debility and cardiorespiratory conditions. Record review of Resident #69's Order Summary Report, dated 07/25/2025 reflected an order dated 07/23/2025, for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally four times a day related to other specified interstitial pulmonary diseases. Record review of Resident #69's Respiratory Therapy Administration Record for July 2025, reflected the albuterol inhaler had been signed out as given for the 8:00 a.m. dose. During an observation on 07/25/2025 at 8:49 AM RT P prepared to administer Resident #69's respiratory inhaler, RT P proceeded to assess Resident #69's lungs, but only used the stethoscope over the front top left and right lobes on each side of the chest or on each side of the top of the chest before administration of inhaler. There was no attempt to listen from the back of the resident or the other three lobes from the front of the resident. RT P did not assess Resident #69 for pain at that time. During an interview on 07/25/2025 at 8:55 AM RT P stated he only listened to the top left and right side of Resident #69's chest because she had complained of pain at another unspecified date and time, but was supposed to check the resident lung sounds in the back, and he should listen to four lobes on the left, and five on the right. When asked if he was trained on how to assess resident lung sounds in the facility, RT P stated he was checked off on listening to all lobes and not only the top of the chest. When asked what some of the risks of an incomplete lung assessment were, RT P stated not getting an accurate assessment of lung sounds. During an interview on 07/25/2025 at 9:10 AM with RN M, when asked what the expectation was for how many lobes should be assessed over the lungs before administration of a respiratory medication RN M stated all lobes, three lobes on one side, and two on the other. When asked what some of the risks of an incomplete lung assessment were, RN M stated missed resident breathing concerns and inaccurate assessments. Record review of the facility's policy titled Airway Inhalation Treatment: Metered-Dose Inhaler and dated 11/01/2024, reflected no guidance on respiratory assessment. Record review of the facility provided form titled Clinical Skills Competency Validation Checklist, dated 07/24/2025, showed competencies for respiratory therapy patient assessment included demonstrates auscultation with a stethoscope. performs pre-assessment and post-assessment of patient vital signs, breaths sounds, and respiratory status. Record review of an email sent from the Administrator on 07/25/2025 at 1:54 PM in response to a policy request regarding respiratory assessment, reflected We don't have a policy for that specifically.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure it received registry verification for 3 (CNA AB, NA G, NA AH) of 24 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide in that: The facility failed to ensure CNA AB, NA G, NA AH had a current nurse aide certification while employed at the facility while actively providing care for residents. This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care. The findings included: 1. Record review of Licensure worksheet for survey, completed by HR, reflected CNA AB reflected CNA had a hire date of [DATE] and her nurse aide certification expired on [DATE]. Record Review of Nurse Aide Registry, accessed [DATE] at 09:57 AM, for CNA AB reflected NAR status was expired on [DATE]. Record review of CNA AB's Time Clock History from [DATE] to [DATE] revealed CNA worked [DATE] and [DATE], clock in and clock out times not noted. Interview on [DATE] at 07:03 PM, the ADM revealed HR oversaw making sure licenses were up to date, but he took responsibility of this oversight as he oversaw tasks being done appropriately by his staff. Combined interview on [DATE] at 08:55PM, the DON revealed CNA AB worked [DATE] and [DATE]. The ADM revealed he found out that CNA AB attempted to re-instate the first or the second of July and thought she was re-instated. Unable to leave voicemail for CNA AB on [DATE] at 11:19AM with no answer or call back and sent CNA AB a text message with no response. Interview on [DATE] at 11:05AM, HR revealed she oversaw ensuring CNAs were certified. She revealed she was currently reviewing all CNAs to ensure they were up to date. She revealed CNAs must renew their certification every 2 years. Interview [DATE] at 03:37 PM, CNA AB revealed she was actively working on getting her CNA certification renewed. She revealed she accidentally let it expire and thought she had it renewed in time. 2. Record review of Licensure worksheet for survey, completed by HR, reflected NA G had a hire date of [DATE]. Record review of Certificate of Completion for LTCR-NATCEP reflected NA G completed this program on [DATE]. Interview on [DATE] at 08:40AM, NA G revealed she was doing CNA duties but had to be working while a CNA oversaw her work. She revealed she had been working as a NA for about a year and had not become a CNA yet. Interview on [DATE] at 05:53PM, the DON and ADM revealed NA G had been working on the floor as a nurse aide. The corporate nurse revealed NA G should not be working on the floor as a nurse aide and should be working a hospitality aide until she got certified. 3. Record Review of Nurse Aide Registry, accessed [DATE] at 06:45 PM, for NA AH reflected NAR status was expired on [DATE]. Record review of NA AH's hours worked reflected NA AH was working as a full time CNA. It further reflected she worked 152.5 hours in [DATE] with her last day she clocked in was [DATE]. Interview on [DATE] at 06:10PM, the HR revealed they were looking for another facility for NA AH when the previous administrator hired her to work at this facility. She revealed they never continued NA AH's education or progress towards becoming a CNA. HR revealed she repeatedly told NA AH that she needed to become a CNA or she would not be able to work at the facility as a CNA. HR further revealed NA AH was working full time (40 hours per week) since she was hired on [DATE]. She further revealed NA AH no longer worked at the facility. Interview on [DATE] at 06:16 PM, the DON revealed it was important for nurse aides to get certified to provide resident care. She revealed nurse aides had to become certified 4 months after the LTCR NATCEP was completed. Record review of the Certified Nursing Assistant Job Description, undated, reflected Certificates, Licenses, Registrations. Must be a Certified Nursing Assistant as required by state and federal law. Record review of the facility's policy License Verification, dated [DATE], reflected All personnel that require a license or certification shall be verified through the appropriate issuing agency. 1. The Human Resources Director, or designee, is responsible for maintaining and ensuring the validity and current status of individual certification/licensure. 2. An individual will not be employed and or will be terminated from employment (whichever case may apply) if: a. The individual has lost licensure/certification for any reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents are free of any significant medication errors and that accepted professional standards and principles which apply to administration were followed for 2 (Resident #288 and Resident # 4) of 15 Residents observed and reviewed for medication administration in that:<BR/>1. <BR/>Resident # 288's medications were in a medicine cup in the top drawer of the medication cart.<BR/>2. <BR/>Resident #4's medications were in the medicine cup in the top drawer of the medication cart. <BR/>This deficient practice could affect residents who receive medications, resulting in needed medications not being taken and documented as taken. <BR/>The findings were:<BR/>1.Review of Resident # 288's electronic face sheet dated 4/23/23 revealed he was admitted on [DATE] with a diagnosis of [Acute Respiratory Distress] when fluid builds up in the tiny, elastic air sacs in the lungs. [Muscle Weakness] Lack of muscle strength. [ Essential Hypertension] abnormally high blood pressure that's not the result of a medical condition. <BR/>Review of Resident 288's electronic medication administration record dated 4/23/23 revealed that resident # 288 had seven medications scheduled for 0:800 a.m. Amlodipine 10 mg, one tablet by mouth daily for hypertension, B-12 Complex, for vitamin supplementation; Divalproex 250 mg, one capsule by mouth daily for dementia; Omeprazole 40 mg, one capsule by mouth daily, for reflux, Potassium Chloride 10 MEQ, one tablet daily for hypertension, Pyridostigmine bromide60 mg, one tablet by mouth daily for myasthenia gravis, Seroquel 25 mg, one tablet by mouth daily for dementia. <BR/>Review of Resident 288's admission MDS dated [DATE], revealed BIMS left blank, indicating resident # 288 could not complete the interview and suggesting severe impairment. <BR/>Review of Resident #288's comprehensive plan of care dated 4/17/23 revealed intervention administer medications and treatments as ordered.<BR/>Observation on 4/23/23 at 10:15 am revealed Resident # 288's morning medication of seven pills was in a medication cup on the top drawer of the medication cart. <BR/>Interview on 4/23/23 at 10:45 a.m., LVN A stated, I attempted to give him his medication earlier, but he refused and was going to try again later; I signed the electronic administration record as administered since medications had been pulled. LVN A stated, She knows that storing medications in cups in a medication drawer is not the best practice, as they should be disposed of if a resident refuses. LVN A stated resident risked the possibility of a medication error.<BR/>2.Review of Resident # 4's electronic face sheet dated 4/23/23 revealed resident was admitted on [DATE] with a diagnosis of [schizophrenia], a serious mental disorder in which people interpret reality abnormally. [Dementia] condition characterized by progressive or persistent loss of intellectual functioning. Cognitive Communication Deficit] difficulty with thinking and how someone uses language. <BR/>Review of resident # 4's electronic medication administration record dated 4/23/23 revealed that resident # 4 had four medications scheduled for 0:800. Lexapro 10 mg, one tablet daily by mouth for schizophrenia, Lipitor 20 mg, one tablet daily by mouth for hyperlipidemia, Metformin 1000 mg take one tablet daily by mouth for diabetes mellitus, Risperdal 2mg one tablet daily by mouth for schizophrenia. <BR/>Review of Resident # 4 Quarterly MDS dated [DATE] revealed a BIMS of 8, suggesting moderate impairment. <BR/>Review of Resident #4's comprehensive plan of care dated 7/18/22 revealed intervention administer medications and treatments as ordered.<BR/>Observation on 4/23/23 at 10:20 a.m. revealed Resident # 4's morning medication of four pills in a medicine cup on the top drawer of the medication cart. <BR/>Interview on 4/23/2023 at 10:55 a.m. with CMA B stated she had to pull medications early as she was tending to patient care and passing out medications. Therefore, she had pre-pulled her medications. She had signed the medication administration record as administered as she had pulled the medicine for resident # 4. She confirmed that she should not have pre-pulled medications as she risked a possible medication error by not following the medication rights. <BR/>Interview on 4/23/23 at 11:50 a.m. with the clinical nurse consultant revealed that LVN A should have stayed with Resident #288 until he swallowed all his medications. If Resident # 288 refused medications, LVN A should have marked medications on the electronic medical record as refused, not as administered. The clinical nurse consultant revealed that CMA B should not have pre-poured her morning medications for Resident # 4 and should not have marked medications on electronic medical record as administered; if she had not given them, she stated that both practices were not safe, and she would be in-servicing nursing staff, as this practice could lead to possible medication errors. <BR/>Review of the facility policy and procedure titled Administering medications dated 2001, revised December 2012, revealed, Medications shall be administered safely, timely, and as prescribed.

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access, for 1 of 1 Resident (#72) reviewed for medication storage, in that:<BR/>RN H left Resident #72's medication unattended and unsecured at Resident #72's bedside.<BR/>This deficient practice placed residents at risk for not receiving therapeutic effects of the medications as prescribed. <BR/>The findings are:<BR/>A record review of Resident #72's face sheet revealed an admission date of 9/15/2021 with diagnoses which included seizures, anxiety disorder, and paranoid schizophrenia [severe type, and a form of psychosis, paranoid schizophrenia is characterized by delusions and sometimes hallucinations].<BR/>A record review of Resident #72's Brief Interview for Mental Status score revealed 06 severe cognitive impairment.<BR/>A record review of Resident #72's care plan, dated 1/26/2022, revealed, revealed, Death and dying issues related to terminal condition, as evidenced by: Hospice services .administer medications and treatments as ordered monitor side effects and effectiveness.<BR/>A record review of Resident #72's physician's orders, dated 1/26/2022, revealed :<BR/>Aspirin, low dose tablet, delayed release, 81 milligrams, one tab oral, once a day at 8:00 AM.<BR/>Lorazepam, schedule IV [controlled narcotic] tablet, 0.5mg, one tab oral at 8:00 AM.<BR/>Oxcarbazepine, tablet 300 milligrams, one tab, oral, at 8:00 AM.<BR/>Phenobarbital, schedule IV [controlled narcotic] tablet, 16.2 milligrams, two tabs, oral at 8:00 AM.<BR/>Valproic acid capsule, 250 milligrams, two capsules, oral at 8:00 am.<BR/>Hyoscyamine tablet, 0.125mg, 1 tab, as needed for secretions. <BR/>During an observation on 1/23/22 at 9:09 am revealed Resident #72 was lying in bed, awake, with a bedside table next to the bed. Seven multicolored medication pills in a small plastic cup. There was not a nurse or Medication aid in the room. The medications were unattended and unsecured. <BR/>During an interview on 1/23/2022 at 9:11 am with Resident #72 stated, those are my pills, the nurse left them there .get the [expletive] out!<BR/>During an observation on 1/23/2022 at 9:14 AM ADON RN H was at the nurse's station, at the end of the hallway, away from Resident #72's room.<BR/>During an interview on 1/23/2022 at 9:15 am ADON RN H stated she prepared resident #72's medications at 9:00 am and left them at the bedside. ADON RN H stated Resident #72 is a difficult person to get medication compliance, so she left them there so he could take them at his leisure. ADON RN H stated her training and professional practice prohibit leaving medications at the bedside. <BR/>During an interview on 1/23/2022 at 4:11 pm the Regional DON stated the facility policy and training is for medication aides, and licensed nurses to administer medications to residents, on time as the physician ordered and to observe and verify the resident swallowed the oral medications without difficulty, and then document the administration.<BR/>The facility policy titled storage of Medications dated April 2007, stated, compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, boxes.) containing drugs and biologicals shall be locked when not in use; and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

.<BR/>Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>1. Employee A did not have a beard guard on to cover his facial hair during food preparation.<BR/>2. The handles of measuring utensils stored in the sugar, flour and rice bins touched the products stored in the bins instead of in an upright position.<BR/>3. Two and &frac12; cases of canned food (peaches, mashed potatoes, and sliced carrots) were stored on the floor in the dry storage room instead of 6 off the floor.<BR/>These deficient practices could place all residents who received meals/snacks from the kitchen at risk for food borne illness.<BR/>The findings were:<BR/>1. Observation on 1/23/22 at 9:08 a.m. revealed Employee A was standing by the 3-compartment sink washing pots and pans. Employee A had a beard about &frac14;-3/8 long and did not have a beard guard/restraint on. Employee A stated he was assisting in the kitchen because the dietary manager and several other dietary employees were out sick.<BR/>Observation on 1/23/22 at 9:27 a.m. revealed Employee A poured cake mix into a bowl and added milk to it while not wearing a beard guard/restraint to cover his facial hair. The surveyor asked Employee A if the kitchen had any beard guards/restraints, he responded hairnets were available and then asked the surveyor Why should I wear one?. Employee A then went to the dietary manager's office and placed a hair net over his beard.<BR/>Record review of the policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised December 2008, revealed 12. Hair nets or caps and/or beard restraints ust be worn to keep hair from contacting exposed food, clean equipment, utensils and linens.<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. <BR/>2. Observation on 1/23/22 at 9:26 a.m. of 3 large white storage bins revealed one was labeled flour, the second was labeled sugar and the third was labeled rice. Inside each storage bin was a plastic 2-cup measuring pitcher that was laying on the flour, rice, and sugar with the handle of each pitcher touching the flour, sugar, and rice. <BR/>Observation on 1/25/22 at 10:52 a.m. with the Dietary Manager of the 3 large white storage bins labeled flour, sugar, and rice revealed inside each storage bin was a plastic 2-cup measuring pitcher that was laying on the flour, rice, and sugar with the handle of each pitcher touching the flour, sugar, and rice. Interview with the Dietary Manager at this time confirmed the handles of the measuring pitchers should not touch the sugar, flour, and rice.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-304.12 In-Use Utensils, Between-Use Storage revealed During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .(B) In food that is not time/temperature control for safety food with their handles above the top of the food withing containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon;<BR/>3. Observation on 1/23/22 at 9:12 a.m. of the dry good storeroom revealed on the floor was a full case (6 #10-cans) of mashed potatoes, a full case of sliced carrots and an open case with 3 #10-cans of peaches.<BR/>In an interview on 1/25/22 at 10:55 a.m. the Dietary Manager reported cases of food should be put on the shelves as soon as possible and not left on the floor.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-305.11 Food Storage revealed (A) .Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.<BR/>Record review of the policy titled Food Receiving and Storage, revised December 2008, revealed Food shall be received and stored in a manner that complies with safe food handling practices. Under Policy Interpretation and Implementation was 5. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents.<BR/>Record review of the CMS 672 Resident Census and Conditions of Residents, completed by the facility on 1/26/22, revealed all residents in the facility received meals and snacks prepared and served from the kitchen.<BR/>.

Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 halls (100 hall) in that:<BR/>1. Men's unit (hot zone)- CNA K and LVN L not wearing eye protection in the hot zone hall.<BR/>a. CNA K walked from the hot zone to the cold zone to use the bathroom, without taking off her N95 mask. <BR/>b. LVN L pushed the lunch cart from the hot zone to the cold zone, a door was separating the zones. Observation of lunch cart had 10 trays and 10 plate tops that were not sanitized. <BR/>c. LVN L pushed the hydration cart with 3 tall plastic coffee pitchers, 3 1-gallon clear containers on 1st shelf, the 2nd shelf had a container with sugar, and the 3rd shelf had a metal wide container with ice and 3 resident plastic pitchers were not sanitized. This hydration cart was pushed from the hot zone to the cold zone.<BR/>2. Women's unit-LVN I was not wearing a N96 mask or eye protection when administering Resident #48's medications (hot zone room). <BR/>3. The 100-hall was not treated as a presumed COVID-19 hall after a COVID-19 exposure. Resident #81 resided on the 100-hall and was discovered COVID-19 positive and transferred to the COVID-10 unit. <BR/>4. The laundry department did not treat COVID-19 laundry per the CDC's guidelines for COVID-19. <BR/>These deficient practices could affect residents, visitors and staff and result in cross contamination and infections.<BR/>The findings were: <BR/>Interview on 1/23/22 at 10:52 a.m. with the Administrator stated the secure unit, 100 hall had a women's unit, (cold zone) on the left side of 100 hall and the right side of the 100 hall was the men's unit (hot zone) of the 100 hall-memory care unit. <BR/>1. Observation on 1/24/2022 at 11 a.m. revealed CNA K was in the hot zone, she took off her gown and gloves, opened the door to the cold zone to use the bathroom without taking off her N95 mask. <BR/>Observation on 1/24/2022 at 11:10 a.m. in the hot zone (right side of 100 hall) revealed CNA K and LVN L were not wearing eye protection and walked up and down the hall. (-no residents were observed near the door)<BR/>Interview on 1/24/2022 at 11:11 a.m. with CNA K, she stated she was told her prescription glasses were enough for the COVID-19 unit. CNA K stated she was told by the ADON she could use the bathroom in the women's cold zone. CNA K stated she was positive for COVID-19 and had no symptoms.<BR/>Interview on 1/24/2022 at 11:12 a.m. with LVN L, she stated the ADON (administrative staff) told her no eye protection was required in the hot zone, when aske by surveyor why she did not have her eye protection on in the hot zone.<BR/>Interview on 1/24/2022 at 12:37 p.m. with LVN I, she stated the lunch cart and hydration cart came to the women's unit (cold zone), staff opened the doors separating the two zones, to the hot zone (100 hall-men's unit), then came back to cold zone (women's unit) after being sanitized by staff. <BR/>Observation on 1/24/2022 at 1:21 p.m. in front of cold zone door that separated the hot zone and cold zone revealed the lunch cart (10 trays and plate tops) and hydration cart in the hot zone, then LVN L open the door and pushed the lunch cart and hydration tray cart ( 3 tall plastic coffee pitchers, 3 1-gallon clear containers on 1st shelf, the 2nd shelf had a container with sugar, and the 3rd shelf had a metal wide container with ice and 3 resident plastic pitchers) to the cold zone to CNA M. Staff LVN L sanitized the food tray and hydration cart frame but did not sanitize the items on the carts. Observed in the hot zone LVN L and CNA K in the hot zone and were not wearing eye protection. <BR/>Interview on 1/24/2022 at 1:30 p.m. LVN L stated she sanitized the frame of the carts. State Surveyor asked if she sanitized the items in lunch/hydration carts, she stated she did not know she had too. <BR/>Interview on 1/24/22 at 3:31 p.m. to 3:37 p.m. CNA M stated the staff in the hot zone sanitized the carts, then the lunch/hydration carts were rolled from the hot zone to the cold zone, by opening the doors, then CNA M got the lunch trays/plate guards and placed them in the lunch cart,from the women's side, then she rolled the carts down the opposite end of the hall, to the outside patio where the kitchen staff picked up the lunch/hydration cart. <BR/>Interview on 1/26/2022 at 10 a.m. with the ADON, she stated she never told staff in the hot zone that their prescription glasses counted as eye protection. ADON stated the staff in hot zone should wear full PPE, including eye protection (googles/face shield). (ADON left before I could ask more questions).<BR/>Record review of CNA K's positive COVID-19 test was on 1/20/202 and LVN L's positve COVID -19 test was on <BR/>2. Observation on 1/24/22 at 12:45 p.m. LVN I went into Resident #48's room (hot zone room), who tested positive for COVID-19 today and administered her medications without wearing a N95 mask or eye protection. LVN I was wearing a surgical mask, gown, and gloves. <BR/>Interview on 1/24/22 at 12:46 p.m. LVN I confirmed she entered Resident #48's room, who was positive for COVID-19, without a wearing N95 mask or face sheld/goggles. LVN I stated she had her prescription glasses on for her eye protection. Interview with LVN I stated she tested Resident #48 for COVID -19 that morning and LVN I stated she was positive. LVN I stated Resident #48 was quarantined to her room until the staff could move her to the hot zone. <BR/>Observation on 1/24/22 at 12:47 p.m. at the nurse's station, cold zone, women's hall, left side of 100 hall, a PPE posting on doffing/donning, staff wear gown, gloves, N95 mask and eye protection (goggles/face shield).<BR/>Interview on 1/24/22 at 1:16 p.m. LVN I stated she tested all residents in the women's secure unit, today. LVN I stated Resident #48 was the only resident who tested positive for COVID-19 this day. LVN I stated Resident #48 was in a quarantined room until they could move her to hot zone.<BR/>Interview on 1/25/22 at 2:56 p.m. the Regional Nurse, she stated she worked at the facility 1-2 days a week and from home on electronic records. She stated once staff worked in the hot zone, staff should not go to cold zone. The Regional Nurse stated staff in the hot zone should be wearing full PPE, to include N95 masks and eye protection (goggles/face shield) when working/caring for residents in the hot zone. The Regional Nurse stated the lunch and hydration cart should not go from hot zone to cold zone, staff should take it outside of the hot zone and take it to the kitchen for them to sanitize the carts. <BR/>Record review of Resident #48 and LVN I were vaccinated or not? <BR/>3.<BR/>Observation on 1/23/2022 at 10:00 am of the facility's memory care, 100 hall, revealed the hall separated from the facility by closed double doors, the doors presented with no signage to designate any quarantine or isolation precautions. The 100-hall memory care unit was further separated by a set of closed double smoke barrier doors, at the end of the hall. The women residents ambulated in the hallway, some residents wore masks and others did not, Resident #11 ambulated throughout the unit in her wheelchair and wore a surgical mask on her chin. LVN I attended to residents, LVN I wore a KN95 FFR as her only PPE. <BR/>During an interview on 1/23/2022 at 10:05 am LVN I stated the 100-hall memory care unit is separated by women and men. The women were in the part of the hall where she was, and the men resided behind the closed double barrier door. LVN I stated the men were COVID-19 positive and had dedicated staff, specifically, ADON O and COVID-19 positive CNA P. LVN I stated the women's area was not considered a COVID-19 area. LVN I stated the facility routinely tested residents for COVID-19 and on 1/17/2022 Resident #81 was COVID-19 positive and was transferred to the 200 hall COVID-19 unit. LVN I stated Resident #81 had a roommate Resident #11, and Resident #11 was attempted to be quarantined but due to her diagnosed dementia with wandering behavior she continued to ambulate throughout the unit. LVN I stated routine testing on 1/19/2022 revealed Resident #19 was COVID-19 positive. When asked if the 100-hall women's area was considered under any isolation / quarantine precautions, LVN I stated the women residents don't have COVID-19, therefore, there were no special isolation / quarantine precautions other than the facility had imposed all staff to wear KN95 FFR's. <BR/>During an interview on 1/24/2022 at 3:00 pm the Administrator stated the root cause analysis of the current COVID-19 outbreak revealed the outbreak started the week before Christmas 2021 and has spread throughout the facility into January 2022. The Administrator stated the outbreak triggered the facility's COVID-19 emergency testing protocols and the facility tested all staff and residents twice weekly on Mondays and Thursdays, the Administrator stated the testing initially revealed only staff were discovered COVID-19 positive and on January 17th, 2022, 7 residents who resided on the 100-hall were discovered COVID-19 positive; Of the 7, 6 were men and the men's area was developed into a COVID-19 unit. The female Resident (Resident #81) was transferred to the facility's newly developed COVID-19 unit at the end of 200 hall. The Administrator stated Resident #81 had a roommate Resident #11 and she was not successfully quarantined due to her diagnosed dementia and wandering behaviors and continued to ambulate throughout the unit. The Administrator stated the facility developed a COVID-19 unit at the end of 200 hall, specifically rooms 201 through 208. The Administrator stated continued daily testing revealed 100-hall memory care female Resident #19 tested COVID-19 positive on 1/19/2021 and she was transferred to the 200 hall COVID-19 unit.<BR/>4.<BR/>Observation on 1/25/2022 at 12:10 pm of Resident #77 room revealed a red sign which read, STOP Special Droplet / contact Precautions-in addition to standardized precautions only essential personnel should enter this room. When doing aerosolizing procedures fit tested N-95 with eye protection or higher required. Further observation revealed CNA Q wore full COVID-19 PPE N95, eye protection, gown gloves and exited Resident #77's room with 2 bags of soiled COVID-19 laundry and placed the soiled laundry bags into a 55-gallon trash can with a lid. CNA Q wheeled the can down the hall to the laundry department, CNA Q alerted Laundry Aide R to the 2 bags of COVID-19 soiled laundry stored in the soiled laundry room. CNA Q doffed her gown and gloves and provided hand hygiene, CNA Q exited to the cold zone and doffed the contaminated N95 FFR and donned a new fresh N95 FFR, CNA Q disinfected her face shield, and resumed CNA duties on 300 halls. <BR/>Observation on 1/25/2022 at 12:20 pm of Laundry Aide R revealed she wore a N95 FFR, eye goggles, gloves, and a gown, and wore a black neoprene apron over her gown, and black neoprene gloves over her gloves, Laundry Aide R picked up the 2 COVID-19 soiled laundry bags and placed the soiled COVID-19 laundry into the washing machine. Laundry Aide R doffed the black neoprene apron and disinfected the apron, doffed the black neoprene gloves, and disinfected the gloves, doffed the gown and gloves and provided hand hygiene, Laundry Aide R doffed the face shield and disinfected the face shield and then proceeded to handle clean laundry in the clean laundry area, while continuing to wear the same COVID-19 contaminated N95 FFR . <BR/>During an interview on 1/25/2022 at 12:33 pm with Laundry Aide R stated she was trained today by the Regional DON to don full COVID-19 PPE and to doff the gown and gloves after care with COVID-19 residents and their soiled laundry, and to then proceed to the facility's designated cold zone to doff the COVID-19 contaminated N95 FFR. Laundry Aide R stated she did not doff her COVID-19 contaminated N95 FFR because she was confused as to where the cold zone was. <BR/>During an interview on 1/25/2022 at 5:01 pm ADON H stated she was involved in the COVID-19 emergency outbreak planning on 1/17/2022 when 2 staff, and 11 residents were discovered COVID-19 positive. ADON O stated the Administrator, the regional Administrator, the Regional DON, and the ADON H were all participants in the meeting. The conclusion of the meeting resulted in the recognition of the difficulty to quarantine residents in the women's memory care 100 hall. The plan was developed and implemented to have the 100-hall women to be designated a presumed COVID-19 unit. ADON H stated the 100-hall presumed COVID-19 and COVID-19 units and the COVID 200-hall unit were in place prior to 1/23/2022 when surveyors entered the facility.<BR/>During an interview on 1/26/2022 at 9:00 am the Administrator and the Regional DON stated the the facility followed the Centers For Disease Prevention and Control concerning COVI-19. The Regional DON stated the facility's policy, training, and expectations were for staff to work soley in the covid-19 unit and not enter the facility, to wear PPE as per CDC guidelines in the COVID-19 unit (specifically a N95 FFR, eye protection, gown, and gloves) and to doff all the PPE when exiting the covid-19 unit. The Regional DON stated the facility's policy, training, and expectations were for staff who enter presumed (warm) COVID-19 rooms, was to wear PPE as per CDC guidelines in the COVID-19 unit (specifically a N95 FFR, eye protection, gown, and gloves) and to doff all the PPE when exiting the presumed (warm) COVID-19 room. The Regional DON stated the infection control breakdowns were the responsibility of each individual staff member to be held accountable for their individual adherance to the facility training and infection control policy. The Regional DON and the administrator stated the 1/2 of the 100-hall (the womens side) was deemed a presumed (warm) Covid-19 unit after the resident #81 was discovered COVID-19 positive and the other half of the 100-hall (the mens side was seperated by closed double doors and designated the Covid-19 (hot) unit with deicated staff (staff who solely work the covid unit). The Administrator and the Regional DON stated staff who are assigned to the Presumed (warm) unit are to utilize PPE and infection control measures as set by the CDC, (specifically a N95 FFR, eye protection, gown, and gloves) and to doff all the PPE when exiting the presumed covid-19 unit. The Regional DON and the administrator stated no PPE, equipment, or materials from the covid-19 units are to cross into the non- COVID-19 facility; if such durable equipment needs to cross the material is to be disinfected, such as meal delivery carts, and soiled laundry barrels. The training is provided by multi-leveled staff begining with the Regional DON, the ADON's, and the charge nurses; after which the responsibility is individualized. The Regional DON and the Administrator stated as of 1/25/2022 the whole facility is deemed presumed (warm) COVID-19 with individual COVID-19 rooms, and 2 seperate COVID units (100-hall and 200-hall) due to the continued COVID-19 outbreaks and staff infection control breakdowns.<BR/>Record review of the facility's, undated, PPE for facility 3 policy revealed Contact isolation rooms are identified with a red contact isolation sheet on the door. These rooms are considered hot zone. Upon exiting the room, you will doff (take Off) your gown, gloves, step through the door and put a new gown on, sanitize your hands and walk to the cold zone and replace your mask and disinfect your face shield. Examples of non-direct contact: b. Passing medications that are not crushed or administered through a g-tube.<BR/>A record review of the Centers for Disease Prevention and Control website titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 10, 2021 revealed, Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection, Personal Protective Equipment, HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).<BR/>A record review of the Centers for Disease Prevention and Control website titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 10, 2021 revealed, Source control options for HCP include: A NIOSH-approved N95 or equivalent or higher-level respirator . When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions), they should be removed and discarded after the patient care encounter and a new one should be donned.<BR/>Record review of the CDC website, accessed 1/26/2022, regarding face shields revealed the following:<BR/> https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html#anchor_1605043382236:<BR/>Conventional Capacity Strategies<BR/>Use eye protection according to product labeling and local, state, and federal requirements.<BR/>In healthcare settings, eye protection is used by HCP to protect their eyes from exposure to splashes, sprays, splatter, and respiratory secretions (e.g., for patients on Droplet Precautions and for all patient encounters when there is moderate to substantial community transmission of SARS-CoV-2). Disposable eye protection should be removed and discarded. Reusable eye protection should cleaned and disinfected after each patient encounter.<BR/>Record review of CDC website, accessed 1/26/2022, revealed the following instructions for cleaning and disinfection of face shields:<BR/> https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html#anchor_1605043382236:<BR/>Selected Options for Reprocessing Eye Protection<BR/>Adhere to recommended manufacturer instructions for cleaning and disinfection.<BR/>When manufacturer instructions for cleaning and disinfection are unavailable, such as for single use disposable face shields or goggles, consider:<BR/>1. While wearing a clean pair of gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe.<BR/>2. Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution.<BR/>3. Wipe the outside of face shield or goggles with clean water or alcohol to remove residue.<BR/>4. Fully dry (air dry or use clean absorbent towels).<BR/>5. Remove gloves and perform hand hygiene.<BR/>6. Cleaned and disinfected eye protection can be stored onsite, in a designated clean area within the facility.<BR/>A facility policy was requested on 1/26/2022 at 9:00 am, and the Administrator stated the facility followed CDC's COVID-19 guidelines.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 1 of 1 kitchen in that:<BR/>Mice and rats were seen in the facility's kitchen in the past.<BR/>This deficiency practice could affect residents who receive meals from the kitchen and could place them at risk of contracting food borne illnesses. The noncompliance was identified as PNC(past noncompliance). The noncompliance began on 12/29/23 and ended on 2/12/24. The facility had corrected the noncompliance before the survey began. <BR/>The findings included:<BR/>Observation on 3/12/24 from 2:30 PM to 3:00 PM of the kitchen revealed there were 13 dried mouse droppings near the pantry area underneath a metal cabinet. Two sticky mouse traps were present on the floor near the pantry. There was a live mouse trap in the ceiling of the kitchen near the ceiling leading to the pantry. As the Maintenance Director removed the ceiling tile near the pantry, five dried vermin droppings fell on a kitchen counter top. There were no fresh droppings in the food pantry or refrigerators. <BR/>Observation on 3/13/24 at 8:30 AM of kitchen revealed: staff were present and cleaning the kitchen to include the floors and underneath the cabinets and refrigerators and ice chest. There were no signs of vermin droppings. One rat trap was present outside the pantry area. Ceiling openings that could allow vermin entrance were sealed; the surveyor counted 6 areas in the ceiling that were sealed with epoxy. Epoxy sealant was also present in two areas on the kitchen floor near the pantry area There was not food on the floor and all foods were in containers. Food was not being prepared. The FSS stated that meals would be catered on 3/13/24 to allow tome to clean the kitchen. <BR/>Observation on 3/13/24 of meals for lunch, noon to 1 :00 PM, and dinner, 5:00 PM-6:00 PM revealed the meals were catered and the kitchen was closed for cleaning and removal of any vermin/rodent droppings. Likewise, observation on 3/14/24 at noon revealed the kitchen was closed and meals were catered for breakfast; and scheduled for catering during the lunch and dinner. <BR/>Observation on 3/13/24 at 8:30 PM of facility revealed: the facility was well lit. There were no signs of rodents in the hall or resident rooms. The kitchen was cleaned and lights were on. In the kitchen there were no signs of rodents or rodent noises in the ceiling. There were 5 traps on the floor with no rodents trapped. <BR/>Observation on 3/14/24 from 9:45 AM to 10:00 AM of the facility to include the kitchen revealed no signs of rodents; the kitchen was cleaned and staff were present providing further cleaning of the kitchen.<BR/>During a joint interview on 3/13/24 at 8:35 AM the FSS and the Maintenance Director stated the facility was thoroughly cleaning the kitchen and sealing any holes that could allow vermin/rodents to re-enter.<BR/>During an interview on 3/13/24 at 11:13 AM, the Maintenance Director stated that the outgoing Maintenance Director informed him of the vermin/rodent issue in the kitchen. The Maintenance Director stated, I addressed the issue by sticky pad traps .sealed holes .we contacted pest control .surveyed the outside for holes and filled in cracks .we have been at it since I arrived .I trapped about 7 mice .last trapping was the time I was employed, 2/26/24 .the live traps caught no mice a saw them [rodents] in the morning time in the kitchen a couple of weeks ago .never saw them in the residents rooms or hallways .not sure whether the local health department was informed .after [surveyor entrance on 3/13/24] deep cleaning of the kitchen .power washing .cleaning walls .sealing and corking .drywall the area that was opened in the ceiling and dry wall one of the entrance doors .AC units were corked .corked all the base boards in the pantry and still working on the kitchen to prevent any mice/rat re-entry .transferred all box foods in an non-working freezer .all walls checked and shelves powered washed .opened boxes have been sealed .and stored in the non-working freezer .only cans remain in the open pantry.<BR/>During an interview on 3/12/24 at 3:01 PM, the FSS stated that she was hired three weeks ago and had been addressing kitchen sanitation and pest control. The FSS stated that about three weeks ago 20 mice had been trapped; and the pest control company trapped 6 more mice. The FSS stated that there had been no other mice trapped in the past three weeks; and the facility had made a concerted effort to control pests in the kitchen. The FSS stated that food in the pantry had been taken off the floor; and pantry food put in sealed plastic containers. <BR/>During a joint interview on 3/13/24 at 8:35 AM the FSS and the Maintenance Director stated the facility was thoroughly cleaning the kitchen and sealing any holes that could allow vermin to re-enter.<BR/>During a telephone interview on 3/13/24 at 11:15 AM, Dietary Aide A, stated: she had been employed for the past year. She saw a live rat about a month ago in the kitchen and informed the previous FSS. The previous FSS informed her that the facility would buy traps. She had not seen any vermin in the past three weeks alive or dead in the kitchen. She stated that the vermin never got into the food or got into the pantry to chew on boxes in the past [last three weeks] or in the present. <BR/>During a telephone interview on 3/13/24 at 2:03 PM, the Dietician stated, I made a visit last month to orient the new [FSS] .I saw no droppings or food products ripped by vermin .I saw a sticky trap .they [the facility] had [hired] a pest control company .they were doing cleaning .there were traps .<BR/>During a telephone interview on 3/13/24 at 2:30 PM, the Medical Director stated that he participated in an Ad hoc QAPI meeting to discuss the vermin issue in the kitchen. The Medical Director stated he interviewed nursing staff on 02/06/24 and no nurse reported that residents were affected by the food coming from the kitchen due to the sighting or rodents. <BR/>During a telephone interview on 3/13/24 at 2:43 PM, Dietary Aide B, stated she notified the Maintenance Director on 1/12/24 that she saw a rat in the kitchen; her shift was from 1PM-8 PM. She also saw some droppings on the floor and the bread revealed signs that vermin had eaten some of the bread that was not in closed containers. Dietary Aide B stated the facility responded by putting out sticky traps, replacing the bread, and buying plastic bins. Dietary Aide B stated that after the incident on 1/12/24 she saw no other vermin or signs of vermin in the kitchen.<BR/>During a joint interview on 3/13/24 at 3:10 PM with the present Administrator, DON, and Cooperate Director of Quality revealed: the Administrator was aware on 1/12/24 of the vermin issue in the kitchen and started to address the issue and interventions included: sealing and exclusion of the building, traps, and notify staff to report any sightings, in-service on pest control, and contract with pest control. The Administrator stated that the health department report reflected that there were vermin droppings in the kitchen and needed to be resolved ASAP. The Administrator stated that no recommendation was made by the health department to close the kitchen. The Administrator stated as of 3/12/24 additional interventions included: total power washing and sanitization, more sealant and exclusion; and further re-education on cleaning items and the kitchen The DON and Administrator stated that no resident, visitor, or staff had alleged to seeing vermin in the halls or resident rooms. <BR/>During interviews on 03/13/24 from 8:56 AM to 9:57 AM with Residents #1, #2, #3, #4, #5 and #6 revealed no information that residents had seen signs of mice/rats or rodents in the halls or resident rooms. <BR/>During a telephone interview on 3/13/24 at 5:30 PM with the contracted pest control company the surveyor requested an assessment from the customer service representative as to whether the rodent/vermin issue in the facility's kitchen had been resolved. The customer service representative stated that she would check on the assessment and be in contact with the surveyor in the future. <BR/>Record review of Resident Council minutes for the months of January, February and March 2024 revealed no complaints about pest control or vermin/rodents seen in the kitchen on halls or resident rooms.<BR/>Record review of Facility's Ad-hoc QAPI: Pest Control meeting was held on 2/6/24 to discuss the Pest Control issue in the kitchen. Attendees were the Administrator, maintenance director and Medical Director.<BR/>Record review of facility's in-service sheets on Pest Control training from 3/5/24 to 3/13/24 revealed 63 signatures (100%); total paid staff was 63. <BR/>Record review of facility's Pest Control contact revealed one was present and was signed on 11/16/2018. <BR/>Record review of facility's pest control company invoices revealed: company made visits on 9/18/23, 10/16/23, 11/17/23, 12/18/23, 1/23/24, and 2/12/24 to address pest control issues in the facility and put in effect preventative measures.<BR/>Record review of facility's pest control report dated 2/12/24 revealed the pest control company assessed all possible entry points for vermin and rodent/vermin activity was not noticed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Resident #79) reviewed for personal hygiene. Resident #79 received 1 shower from the time of his admission on [DATE] to 07/24/2025. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections. The findings included: Record review of Resident #79's admission Record, dated 07/24/2025, reflected a [AGE] year-old resident with an initial admission date of 07/12/2025. No diagnoses were listed on Resident #79's admission Record. Record review of Resident #79's Comprehensive Person-Centered Care Plan, dated 07/24/2025, reflected no interventions or focus areas relating to ADL's or showers. Record review of Resident #79's initial MDS, dated [DATE], reflected a BIMS score of 0, indicating severe cognitive impairment. Further review reflected that Resident #79 required Partial/Moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort for, Tub/Shower transfer. There was no data entered to describe Resident #79's ability to Shower/bathe self. Record review of Resident #79's ADL Task in their POC titled, ADL - Bathing (Prefers: SPECIFY), dated 07/25/2025, reflected that Resident #79 was bathed on 07/20/2025 at 4:52 PM. No other bathing record was provided to the surveyor . Interview and observation on 07/25/2025 at 10:23 AM, CNA Z stated he primarily worked on the male's locked unit and when he worked, he was the CNA responsible for providing men on the locked unit with showers as scheduled. CNA Z stated he could not recall showering Resident #79 since he had been admitted on [DATE]. CNA Z stated there was a list of residents and their shower schedule on the door inside of the shower room. Observation and record review of the list did not reflect Resident #79 as being listed for showers at any time. CNA Z stated he did not see Resident #79 on the shower list inside of the shower room, and that it should be updated with any new admission. Interview and observation on 07/25/2025 at 10:35 AM, Resident #79 could not state whether he remembered if he had been showered since he had been at the facility . Resident #79's hair was observed to be greasy. Interview on 07/25/2025 at 10:42 AM, LVN AI stated she typically walks the hall to ensure each resident seems appropriately bathed. LVN AI stated the POC will flag when the showers are. LVN AI stated she was not certain if Resident #79 had been showered, but she was not confident he had not been showered . Interview on 07/25/2025 at 3:39 PM, the DON stated her expectation was for residents to receive showers as scheduled, at least 3 times a week, unless the resident refuses. The DON stated the only shower record was in the resident's electronic health record. The DON stated she could look into showers for Resident #79, but never followed up with the surveyor. Record review of facility policy titled, Resident Showers, dated 06/10/2025, reflected, Residents will be provided showers in accordance with the resident's preferences, care plan, and safety needs, as well as the facility's scheduled bathing protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents' right to personal privacy and confidentiality of his or her personal and medical records for 3 of 3 (Resident #1, #2 and #3) residents reviewed for privacy and confidentiality, in that:<BR/>The facility failed to prevent LVN A from having access and reviewing electronic medical records for Resident #1, #2, and #3's on [DATE] after she was removed from working from the facility on [DATE]. <BR/>These failures placed residents at risk for having personal medical information disclosed and placed them at risk for misuse of the information. <BR/>The findings included:<BR/>Record review of Resident #1's face sheet (undated) revealed an admission date of [DATE] and readmission date of [DATE] with diagnosis which included: unspecified dementia, epilepsy, and hallucinations. <BR/>Record review of Resident #2's face sheet (undated) revealed an admission date of [DATE] and a readmission date of [DATE] and a discharge date of [DATE] (expired) with diagnoses which included: cardiomegaly, unspecified dementia, and anxiety disorder. <BR/>Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS of 4 which indicated a severe cognitive impairment. <BR/>Record review of Resident #3's face sheet dated [DATE] revealed an admission date of [DATE] with readmission date of [DATE] with diagnoses which included: Alzheimer's disease, anxiety disorder due to known physiological condition, and depression. <BR/>Record review of Resident #3's MDS BIMS assessment dated [DATE] revealed a BIMS score of 99 which indicated the resident could not complete the assessment and had a severe cognitive impairment. <BR/>Record review of a screen shot of LVN A's electronic agency employee file dated [DATE] revealed the last date worked at the facility was Tuesday, [DATE]. <BR/>Record review of a text message from LVN A to the Administrator on [DATE] revealed LVN A wrote Hi [Administrator] .Did I get DNR'd (do not return)? .Did I do something wrong? I am very confused about what is going on and I would really appreciate it if someone told me what I did that caused me to get DNR'd? <BR/>During an observation on [DATE] at approximately 10:35 a.m., Resident #1's RP had an emotional outburst in the hallway near the nurses station with multiple staff and Administrator present. She was waving her cell phone in her hand and demanding to know who the anonymous staff member was who called her and upset her discussing personal information about her family member (Resident #1) who had just passed away a couple hours ago. <BR/>During an interview on [DATE] at 10:55 a.m., the Administrator stated Resident #1 passed away early this morning. She stated the resident had been on hospice and the death was expected. The Administrator expressed frustration that an anonymous person would stir up commotion on a day where the family should be allowed to grieve. She stated she notified the police of the incident and alleged allegations by the anonymous person and self-reported to HHSC. She stated she had also spoke at length to the family of Resident #1. The Administrator stated she would conduct a full investigation of the event. She stated since she had arrived at the facility as the Administrator there had been several disgruntled former staff members. <BR/>During an interview on [DATE] at 10:58 a.m. with Resident #1's RP and two additional family members revealed they were upset because an anonymous female had texted and called her on the phone moments after her mother (Resident #1) had passed away telling per personal information and events that allegedly occurred at the facility. The RP stated the anonymous female then sent her several text messages that included a picture of a bruise to a leg that was presumably Resident #1. The RP stated she immediately informed the Administrator about the call and text on [DATE] at approximately 8:30 a.m. and had spoken to the police. Resident #1's RP expressed that she had communicated well with the nursing staff at the facility all through her family members disease process and death and she had no concerns for the care Resident #1 had received. <BR/>During an interview on [DATE] at 12:31 p.m., anonymous stated she called Resident #1's RP this morning and informed her of several concerns she had about Resident #1, the Administrator and the facility. She stated she had received information from a former employee of the facility identified as LVN A and had no firsthand knowledge of events. She stated LVN A gave her personal information about several residents at the facility. Anonymous stated the information concerned her so she called and told Resident #1's RP about the concerns today ([DATE]). Anonymous stated although she was also a former employee of the facility, she did not notify the Administrator about the information. <BR/>During an interview on [DATE] at 1:01 p.m., LVN A answered the phone, when this surveyor identified the nature of the call, LVN A hung up the phone. She declined to answer on a second attempt to reach her. <BR/>During an interview on [DATE] at 2:42 p.m., the Administrator stated CNA's do not have access to resident information or family phone numbers. She stated the only way a staff could access this information was from a licensed nurse who had access. The Administrator stated she expected staff to have professional boundaries and protect HIPAA related information. She stated she was still working on identifying how someone (presumabably a former staff member), had access to this information. <BR/>During an interview on [DATE] at 3:16 p.m., the Administrator stated LVN A was not a current employee. She stated LVN A had worked at the facility several months ago as an agency nurse. The Administrator stated she made LVN A Do Not Return (DNR) and did not want her to return to the facility. The Administrator stated Resident #1 had been a resident on the secured unit where LVN A had worked. She stated she had been going through her mind, all the staff that had worked on the secured unit. The Administrator stated LVN A had become disgruntled and began a smear campaign against the facility since she was DNR'd. She stated she had blocked LVN A from her phone because LVN A had been calling her multiple times a day. She stated she had informed LVN A's agency not to send her back to the facility. <BR/>During an interview on [DATE] at 4:18 p.m., the Administrator stated she had run a PHI report on who had accessed electronic medical records of Resident #1 and determined there had been a HIPAA violation by LVN A. The Administrator stated she was still gathering information, but the PHI report indicated LVN A accessed the medical records of Resident #1 in [DATE] after she was DNR'd from the facility. The Administrator stated the PHI report also indicated LVN A had access Resident #2 and Resident #3's medical record at about the same time. She stated the report did not indicate when LVN A's computer access had been deactivated but she could tell LVN A did not currently have access. <BR/>During an interview on [DATE] at 3:06 p.m., ADON B stated her job duties included giving access to staff including agency to the electronic medical records. ADON B stated the ADON's are responsible for discontinuing access when staff no longer work in the facility although the duty is not assigned to any specific ADON. She stated they just knew who no longer worked there and took off their access by unassigning their username and password. ADON B stated LVN A had not worked in the facility for a while (date unknown) and was on the DNR list which meant she was not to return to the facility. She stated the facility did not have a specific profess of removal of staff from medical records, just when they are DNR'd they were to unassign. ADON B stated she did not know who had access to medical records. She stated the Administrator would have the ability to look to see who had access. <BR/>During an interview on [DATE] at 4:02 p.m., the DON stated on [DATE] she found out that a nurse, identified as LVN A, who the facility was no longer utilizing, had accessed medical records outside of when she should have been accessing them. The DON stated LVN A accessed multiple electronic charts that were outside of her work duties and after she had been DNR'd from the facility. The DON stated it was the ADONs or the person putting that person on the schedule who was responsible for removing access to medical records. The DON stated in this case she was unsure why the process of removing LVN A access had been delayed and she does not know when her access was finally cut. The DON stated all she knew was that LVN A did not have current access. The DON stated LVN A's last shift was [DATE] and she accessed into the system for the last time on [DATE]. The DON stated last night ([DATE]) they had completed a full audit of their electronic medical records including pharmacy records, narcotic records, and physician orders and to ensure LVN A had not made any changes, which she had not. The DON stated it was important for staff who no longer worked at the facility to have no access to medical records because they were no longer providing care to the residents, it was a huge liability, it was unethical, and it was a violation of HIPAA. <BR/>During an interview on [DATE] at 4:49 p.m., the Administrator stated she held staff to a high standard. She stated the staff may not always agree with her, but it was her job/duty to keep the residents safe. The Administrator stated after Resident #1's RP received the anonymous call, her wheels started turning on who had access to the information. She stated it was something she wanted to investigate. The Administrator stated LVN A was DNR'd on [DATE]. She stated on [DATE], LVN A sent her (administrator) a text asking why she was DNR'd. The Administrator stated after a review, she determined LVN A accessed medical records one time on [DATE] which impacted 11 residents, all on the secured unit. The Administrator stated the facility used a SSO management (single sign on user) module/portal to provide usernames and security profiles. She stated sometimes agency staff go to multiple facilities and their usernames are tied to multiple facilities. The Administrator stated the administrative team would terminate access by telling the SSO module to cut contact. The Administrator stated LVN A access had already been terminated when she ran the audit on [DATE]. She stated there had been a small lapse of time before it was shut off from LVN A's last date working until [DATE]. The Administrator stated the ADON's provided and terminated that access. She stated the ADON's would know someone had been DNR'd by a conversation with the management team or a document. The Administrator stated she believes this happened because the facility was in transition with ADON's and there was a lapse of time between. The Administrator stated HIPAA compliance was important so that the correct person employed by the facility had the correct information. <BR/>Record review of a PHI Audit log dated [DATE] revealed LVN A accessed the following medical records. <BR/>Resident #1: face sheet, contact page, progress notes. <BR/>Resident #4, face sheet, POC (point of care), MDS responses page, message history page, medication administration page.<BR/>Resident #2, #3, #4, #5, #6, #7. #8, #9, #10, and #11: face sheet and progress notes. <BR/>And a global search of medication administration history. <BR/>Record review of a facility policy, titled Electronic Medical Records last revised [DATE] revealed; 3. Only authorized persons who have been issued a password and user ID code will be permitted access to the electronic medical records system. 4. The facility will make reasonable efforts to limit the use or disclosure of protected health information to only the minimum necessary to accomplish the intended purpose of the use or disclosure. 6. When personnel changes occur, or there is reason to believe that unauthorized access to protect information has occurred, the HIPAA Compliance Office, Administrator and Director of Nursing Services shall review the security of the information and change user ID codes if necessary.

.<BR/>Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>1. Employee A did not have a beard guard on to cover his facial hair during food preparation.<BR/>2. The handles of measuring utensils stored in the sugar, flour and rice bins touched the products stored in the bins instead of in an upright position.<BR/>3. Two and &frac12; cases of canned food (peaches, mashed potatoes, and sliced carrots) were stored on the floor in the dry storage room instead of 6 off the floor.<BR/>These deficient practices could place all residents who received meals/snacks from the kitchen at risk for food borne illness.<BR/>The findings were:<BR/>1. Observation on 1/23/22 at 9:08 a.m. revealed Employee A was standing by the 3-compartment sink washing pots and pans. Employee A had a beard about &frac14;-3/8 long and did not have a beard guard/restraint on. Employee A stated he was assisting in the kitchen because the dietary manager and several other dietary employees were out sick.<BR/>Observation on 1/23/22 at 9:27 a.m. revealed Employee A poured cake mix into a bowl and added milk to it while not wearing a beard guard/restraint to cover his facial hair. The surveyor asked Employee A if the kitchen had any beard guards/restraints, he responded hairnets were available and then asked the surveyor Why should I wear one?. Employee A then went to the dietary manager's office and placed a hair net over his beard.<BR/>Record review of the policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised December 2008, revealed 12. Hair nets or caps and/or beard restraints ust be worn to keep hair from contacting exposed food, clean equipment, utensils and linens.<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. <BR/>2. Observation on 1/23/22 at 9:26 a.m. of 3 large white storage bins revealed one was labeled flour, the second was labeled sugar and the third was labeled rice. Inside each storage bin was a plastic 2-cup measuring pitcher that was laying on the flour, rice, and sugar with the handle of each pitcher touching the flour, sugar, and rice. <BR/>Observation on 1/25/22 at 10:52 a.m. with the Dietary Manager of the 3 large white storage bins labeled flour, sugar, and rice revealed inside each storage bin was a plastic 2-cup measuring pitcher that was laying on the flour, rice, and sugar with the handle of each pitcher touching the flour, sugar, and rice. Interview with the Dietary Manager at this time confirmed the handles of the measuring pitchers should not touch the sugar, flour, and rice.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-304.12 In-Use Utensils, Between-Use Storage revealed During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .(B) In food that is not time/temperature control for safety food with their handles above the top of the food withing containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon;<BR/>3. Observation on 1/23/22 at 9:12 a.m. of the dry good storeroom revealed on the floor was a full case (6 #10-cans) of mashed potatoes, a full case of sliced carrots and an open case with 3 #10-cans of peaches.<BR/>In an interview on 1/25/22 at 10:55 a.m. the Dietary Manager reported cases of food should be put on the shelves as soon as possible and not left on the floor.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-305.11 Food Storage revealed (A) .Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.<BR/>Record review of the policy titled Food Receiving and Storage, revised December 2008, revealed Food shall be received and stored in a manner that complies with safe food handling practices. Under Policy Interpretation and Implementation was 5. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents.<BR/>Record review of the CMS 672 Resident Census and Conditions of Residents, completed by the facility on 1/26/22, revealed all residents in the facility received meals and snacks prepared and served from the kitchen.<BR/>.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 1 of 1 kitchen in that:<BR/>Mice and rats were seen in the facility's kitchen in the past.<BR/>This deficiency practice could affect residents who receive meals from the kitchen and could place them at risk of contracting food borne illnesses. The noncompliance was identified as PNC(past noncompliance). The noncompliance began on 12/29/23 and ended on 2/12/24. The facility had corrected the noncompliance before the survey began. <BR/>The findings included:<BR/>Observation on 3/12/24 from 2:30 PM to 3:00 PM of the kitchen revealed there were 13 dried mouse droppings near the pantry area underneath a metal cabinet. Two sticky mouse traps were present on the floor near the pantry. There was a live mouse trap in the ceiling of the kitchen near the ceiling leading to the pantry. As the Maintenance Director removed the ceiling tile near the pantry, five dried vermin droppings fell on a kitchen counter top. There were no fresh droppings in the food pantry or refrigerators. <BR/>Observation on 3/13/24 at 8:30 AM of kitchen revealed: staff were present and cleaning the kitchen to include the floors and underneath the cabinets and refrigerators and ice chest. There were no signs of vermin droppings. One rat trap was present outside the pantry area. Ceiling openings that could allow vermin entrance were sealed; the surveyor counted 6 areas in the ceiling that were sealed with epoxy. Epoxy sealant was also present in two areas on the kitchen floor near the pantry area There was not food on the floor and all foods were in containers. Food was not being prepared. The FSS stated that meals would be catered on 3/13/24 to allow tome to clean the kitchen. <BR/>Observation on 3/13/24 of meals for lunch, noon to 1 :00 PM, and dinner, 5:00 PM-6:00 PM revealed the meals were catered and the kitchen was closed for cleaning and removal of any vermin/rodent droppings. Likewise, observation on 3/14/24 at noon revealed the kitchen was closed and meals were catered for breakfast; and scheduled for catering during the lunch and dinner. <BR/>Observation on 3/13/24 at 8:30 PM of facility revealed: the facility was well lit. There were no signs of rodents in the hall or resident rooms. The kitchen was cleaned and lights were on. In the kitchen there were no signs of rodents or rodent noises in the ceiling. There were 5 traps on the floor with no rodents trapped. <BR/>Observation on 3/14/24 from 9:45 AM to 10:00 AM of the facility to include the kitchen revealed no signs of rodents; the kitchen was cleaned and staff were present providing further cleaning of the kitchen.<BR/>During a joint interview on 3/13/24 at 8:35 AM the FSS and the Maintenance Director stated the facility was thoroughly cleaning the kitchen and sealing any holes that could allow vermin/rodents to re-enter.<BR/>During an interview on 3/13/24 at 11:13 AM, the Maintenance Director stated that the outgoing Maintenance Director informed him of the vermin/rodent issue in the kitchen. The Maintenance Director stated, I addressed the issue by sticky pad traps .sealed holes .we contacted pest control .surveyed the outside for holes and filled in cracks .we have been at it since I arrived .I trapped about 7 mice .last trapping was the time I was employed, 2/26/24 .the live traps caught no mice a saw them [rodents] in the morning time in the kitchen a couple of weeks ago .never saw them in the residents rooms or hallways .not sure whether the local health department was informed .after [surveyor entrance on 3/13/24] deep cleaning of the kitchen .power washing .cleaning walls .sealing and corking .drywall the area that was opened in the ceiling and dry wall one of the entrance doors .AC units were corked .corked all the base boards in the pantry and still working on the kitchen to prevent any mice/rat re-entry .transferred all box foods in an non-working freezer .all walls checked and shelves powered washed .opened boxes have been sealed .and stored in the non-working freezer .only cans remain in the open pantry.<BR/>During an interview on 3/12/24 at 3:01 PM, the FSS stated that she was hired three weeks ago and had been addressing kitchen sanitation and pest control. The FSS stated that about three weeks ago 20 mice had been trapped; and the pest control company trapped 6 more mice. The FSS stated that there had been no other mice trapped in the past three weeks; and the facility had made a concerted effort to control pests in the kitchen. The FSS stated that food in the pantry had been taken off the floor; and pantry food put in sealed plastic containers. <BR/>During a joint interview on 3/13/24 at 8:35 AM the FSS and the Maintenance Director stated the facility was thoroughly cleaning the kitchen and sealing any holes that could allow vermin to re-enter.<BR/>During a telephone interview on 3/13/24 at 11:15 AM, Dietary Aide A, stated: she had been employed for the past year. She saw a live rat about a month ago in the kitchen and informed the previous FSS. The previous FSS informed her that the facility would buy traps. She had not seen any vermin in the past three weeks alive or dead in the kitchen. She stated that the vermin never got into the food or got into the pantry to chew on boxes in the past [last three weeks] or in the present. <BR/>During a telephone interview on 3/13/24 at 2:03 PM, the Dietician stated, I made a visit last month to orient the new [FSS] .I saw no droppings or food products ripped by vermin .I saw a sticky trap .they [the facility] had [hired] a pest control company .they were doing cleaning .there were traps .<BR/>During a telephone interview on 3/13/24 at 2:30 PM, the Medical Director stated that he participated in an Ad hoc QAPI meeting to discuss the vermin issue in the kitchen. The Medical Director stated he interviewed nursing staff on 02/06/24 and no nurse reported that residents were affected by the food coming from the kitchen due to the sighting or rodents. <BR/>During a telephone interview on 3/13/24 at 2:43 PM, Dietary Aide B, stated she notified the Maintenance Director on 1/12/24 that she saw a rat in the kitchen; her shift was from 1PM-8 PM. She also saw some droppings on the floor and the bread revealed signs that vermin had eaten some of the bread that was not in closed containers. Dietary Aide B stated the facility responded by putting out sticky traps, replacing the bread, and buying plastic bins. Dietary Aide B stated that after the incident on 1/12/24 she saw no other vermin or signs of vermin in the kitchen.<BR/>During a joint interview on 3/13/24 at 3:10 PM with the present Administrator, DON, and Cooperate Director of Quality revealed: the Administrator was aware on 1/12/24 of the vermin issue in the kitchen and started to address the issue and interventions included: sealing and exclusion of the building, traps, and notify staff to report any sightings, in-service on pest control, and contract with pest control. The Administrator stated that the health department report reflected that there were vermin droppings in the kitchen and needed to be resolved ASAP. The Administrator stated that no recommendation was made by the health department to close the kitchen. The Administrator stated as of 3/12/24 additional interventions included: total power washing and sanitization, more sealant and exclusion; and further re-education on cleaning items and the kitchen The DON and Administrator stated that no resident, visitor, or staff had alleged to seeing vermin in the halls or resident rooms. <BR/>During interviews on 03/13/24 from 8:56 AM to 9:57 AM with Residents #1, #2, #3, #4, #5 and #6 revealed no information that residents had seen signs of mice/rats or rodents in the halls or resident rooms. <BR/>During a telephone interview on 3/13/24 at 5:30 PM with the contracted pest control company the surveyor requested an assessment from the customer service representative as to whether the rodent/vermin issue in the facility's kitchen had been resolved. The customer service representative stated that she would check on the assessment and be in contact with the surveyor in the future. <BR/>Record review of Resident Council minutes for the months of January, February and March 2024 revealed no complaints about pest control or vermin/rodents seen in the kitchen on halls or resident rooms.<BR/>Record review of Facility's Ad-hoc QAPI: Pest Control meeting was held on 2/6/24 to discuss the Pest Control issue in the kitchen. Attendees were the Administrator, maintenance director and Medical Director.<BR/>Record review of facility's in-service sheets on Pest Control training from 3/5/24 to 3/13/24 revealed 63 signatures (100%); total paid staff was 63. <BR/>Record review of facility's Pest Control contact revealed one was present and was signed on 11/16/2018. <BR/>Record review of facility's pest control company invoices revealed: company made visits on 9/18/23, 10/16/23, 11/17/23, 12/18/23, 1/23/24, and 2/12/24 to address pest control issues in the facility and put in effect preventative measures.<BR/>Record review of facility's pest control report dated 2/12/24 revealed the pest control company assessed all possible entry points for vermin and rodent/vermin activity was not noticed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 1 Resident (Resident #38) reviewed for coordination with the State Agency, in that;<BR/>The facility did not submit the Nursing Facility Specialized Services (NFSS) form to the State Agency.<BR/>This deficient practice placed the resident at risk for not receiving specialized services provided by the State Agency.<BR/>The findings include:<BR/>A record review of Resident #38's face sheet, dated 1/24/2022, revealed an admission date of 4/14/2021, with diagnoses which included moderate intellectual disabilities, cognitive communication deficit, and major depressive disorder. <BR/>A record review of Resident #38's Brief interview for Mental Status (BIMS) score, dated 1/24/2022, revealed 03, severe intellectual disability.<BR/>A record review of Resident #38's Pre-admission Screening and Resident Review (PASRR) dated June 8th, 2021, revealed a positive finding her intellectual disabilities.<BR/>A record review of Resident #38's Care Plan , dated 3/3/2022, revealed goals, Will have behavior identified so that staff may intervene quickly with listed interventions daily through next review date; will have decreased behavioral episodes and feel safe within the facility environment with dignity intact; will have knowledge of potential for harm related to refusal to participate in recommended treatments / specialized services through the next quarter; resident self-inflicted scratches will heal without complication.<BR/>A record review of Resident #38's care plan conference meeting note, dated 6/8/2021, documented by ADON O, revealed IDT meeting for PASRR resident meeting held in conference room resident is doing well at the facility he states I'm happy here and I want to stay here discuss services related to PASRR that he is eligible for at the facility. [Resident #38's family] provided with information on community living at group homes if he chooses in the future, discussed that he would like to have job training and would like to attend day hab services once the facilities reopen .will be evaluated by all three services physical therapy, occupational therapy, speech therapy.<BR/>During an interview on 1/25/2021 at 9:22 am the Minimum Data Set (MDS) Nurse stated she was responsible for uploading the Nursing Facility Specialized Services form in the Texas Mental Health Partnership website portal, however, she was not employed in this position until November 2021. MDS Nurse stated she had access to the facilities PASRR records and Resident #38 had an Interdisciplinary Team (IDT) Meeting, on June 8th, 2021, which included the occupational therapist, regarding a positive finding for level II PASRR. MDS Nurse stated the facility's MDS nurse would be the person responsible for taking the therapist's information and completing the NFSS form in the TMHP website to alert the state the need for services for a PASRR positive Resident. MDS Nurse stated the facility has 20 days after the PASRR IDT meeting to complete the NFSS form in the TMHP website portal. MDS Nurse stated she could not find any evidence the form was completed and submitted.<BR/>During an interview on 1/26/2022 at 9:50 am ADON O stated she attended the PASRR care plan meeting for Resident #38 on 6/8/2021 where the IDT in collaboration with Resident #38 and family agreed Resident #38 did not want / need specialized services from the state agency. ADON O stated the MDS nurse would have submitted the NFSS form to the state agency, however the portal did not allow submission for an entry of no services and / or refusal of services. ADON O stated she had no knowledge if the state agency for PASRR services was contacted for assistance with the NFSS form submission. <BR/>During an interview on 1/26/2022 at 11:10 am the Regional DON stated the facility did not submit the NFSS form in the TMHP portal due to the Resident refused / did not need specialized services from the state agency. The Regional DON stated the facility could not submit the NFSS form in the TMHP website portal due to the form did not provide for the option of no services needed. The Regional DON stated she had no knowledge if the state agency for PASRR services was contacted for assistance with the NFSS form submission. The Regional DON stated the MDS Nurse would be responsible to enter the information into the NFSS form in the TMHP portal website in coordination with the therapist's evaluation. The MDS nurse would also be the person responsible for reviewing alerts regarding the lack of NFSS submissions. <BR/>During an interview on 1/26/2022 at 11:47 am with the state agency's PASRR Unit- Program Specialist stated, regarding the facility's statements, the Resident did not need any services or the resident's family refused services, There is no documentation [in the TMHP] that the services were refused. They are continuing to be out of compliance today. They still haven't had an update meeting to document changes (including changes for refusals or services not needed) and/or submitted NFSS requests. I am able to verify this in the portal. Nothing is in there.<BR/>During an interview on 1/26/2022 at 11:10 am a facility policy for submission of PASRR positive residents, regarding the NFSS form was requested from the Regional DON. A policy wasnot provided. The Regional DON stated the facility follows all HHSC guidelines.<BR/>A record review of the Texas Health and Human Services document titled Detailed Item by Item Guide for Completing the Authorization Request for PASRR Nursing Facility Specialized Services (NFSS) form April 2021, revealed, Initiating PASRR nursing facility specialized services the nursing facility has 20 business days from the date of the initial ID T or a specialized services review meeting to initiate all PASRR nursing facility specialized services for those with a positive PE for ID / DD recommended and agreed to at the meeting. And NFSS form assistance call TMHP at [PHONE NUMBER] option 1 for general inquiries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 7 of 7 residents (Resident #'s 1-7) reviewed for neglect, in that:<BR/>Resident #'s 1-7 were occupying rooms in 100 Hall (Male Secured Unit) and 200 Hall without functioning HVAC/Heating Systems which resulted in these residents being subjected to enduring cold temperatures during cold winter weather. The facility did not report this to the state agency.<BR/>This deficiency placed residents at risk for harm by a diminished quality of life, specifically, sleep deprivation and cold-related injuries (hypothermia) for residents.<BR/>The findings included:<BR/>Observation on 01/17/24 at 2:15 PM, when entering the facility, revealed it was noticeably cold and residents/staff were still wearing winter clothing (jackets/gloves/scarfs/ski caps) while in the building. <BR/>Record review of website: Past Weather in [city] Texas, USA - Yesterday or Further Back (timeanddate.com) of the air temperatures for [city], Texas revealed the following air temperatures and corresponding dates for the city this facility was located:<BR/>Date: Low High<BR/>1/12/2024 29 F 59 F<BR/>1/13/2024 24 F 61 F<BR/>1/14/2024 16 F 28 F<BR/>1/15/2024 14 F 30 F <BR/>1/16/2024 15 F 34 F<BR/>1/17/2024 13 F 52 F<BR/>Interview on 1/16/2024 at 2:34 PM, the administrator stated the facility's heating units for 100 Hall (Male Secured Unit) and 200 Hall were not functioning and pending replacement. The administrator stated 2 portable heating units had been placed at both ends of the 100 Hall (Male Secured Unit) and one large space heater was placed at the end of 200 Hall until the facility's permanent heating units could be replaced. The Administrator also said portable heaters were purchased and offered to residents who wanted one in their room in response to staff and residents complaining of cold temperatures within the building on the night of 1/13/2024.<BR/>Observation on 1/16/2024 at 3:06 PM of 100 Hall (Secured Men's) revealed 2 temporary heating units (THU) located at both ends of the hall. Further observation revealed the THU at the beginning of 100 Hall was running at a setting of 80 F and indicated room temperature (Hallway) of 69 F. Observation of the THU at the end of 100 Hall revealed the THU was not running. <BR/>Observation and interview on 1/16/2024 at 3:09 PM, Resident #1 was observed walking 100 Hall (Secured Men's) and lead this investigator his room. Resident #1 indicated his room was cold and would get colder at night. Resident #1 proceeded to show this investigator 4 blankets on his bed he was utilizing in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. <BR/>Observation and interview on 1/16/2024 at 3:14 PM, Resident #2 (100 Hall Secured Men's) was observed lying in his bed. Resident #2 was observed wearing gloves and when asked why, Resident #2 responded, because I like them! When asked if the resident was cold at night, he responded, Yes! When asked how the resident was doing in an attempt to stay warm, he responded, The blankets. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation and interview on 1/16/2024 at 3:16 PM, Resident #3 (100 Hall Secured Men's) was observed sitting in the secured dining area in his wheelchair. During the interview, Resident #3 said that this week had been, really cold. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation on 1/16/2024 at 3:38 PM revealed a space heater at the end of Hall 200.The space heater was on and glowing. The room temperature in this hall felt uncomfortably cold while wearing a jacket. <BR/>Observation and interview on 1/16/2024 at 3:40 PM, Resident #4 (200 Hall). Resident #4 was asked about the temperature of her room and indicated she had been, Very cold, and said she had been using multiple blankets in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation and interview on 1/17/2024 at 7:38 AM, facility staff were observed wearing winter-clothing in the building which consisted of extra layers and ski hats. At this time, an unknown staff shouted, It's cold in there, 50 degrees.<BR/>Observation and interview on 1/17/2024 at 7:44 AM, Resident, Resident #1 was observed lying in his bed with a blanket over his head. A reading of the room's temperature revealed a temperature of 56 F. During an interview that this time, Resident #1 was asked if he was cold and responded, Yes The resident stated he did not sleep well because his room was cold. <BR/>Observation and interview on 1/17/2024 at 7:57 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #1's bed which revealed a temperature reading of 56 F. LVN B confirmed the temperature in Resident #1's room was 56 F and responded, Oh wow, that's cold.<BR/>Observation and interview on 1/17/2024 at 7:44 AM, Resident #5 was observed lying in bed with a navy blue blanket over his head (photo taken). A reading of the room's temperature revealed a temperature of 51 F. During an interview at this time, Resident #5 was asked how he was doing and responded, Cold. When asked if the Resident #5 felt tired, he responded, Yeah, I can't sleep. <BR/>Observation and interview on 1/17/2024 at 7:58 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #5's bed which revealed a temperature reading of 51 F. During an interview at this time, LVN B was asked what the temperature should be to be considered comfortable to which she responded, Around 70 F.<BR/>Observation and interview on 1/17/2024 at 8:07 AM with Staff C, this investigator pointed a thermal thermometer laser at the wall closest to Resident #4's bed which revealed a temperature reading of 51 F. Staff C confirmed the temperature for Resident #4's room was 51 F. <BR/>During an interview at this time, Staff C said Resident #4 had requested to be moved to a new location due to feeling cold in her room. Staff C mentioned another Resident, Resident #7 (Hall 200) had also requested to be moved because she was cold in her room. <BR/>Interview and observation on 1/17/2024 at 9:50 PM, the Maintenance Supervisor and this investigator compared thermal temperature guns and confirmed their readings matched within +/-.3 degrees F. The Maintenance Supervisor's thermal temperature gun was orange and black ([NAME] Tools IR1 Infrared Thermometer), The Maintenance Director was asked what the room temperatures should be and responded, Around 75 F in the winter and around 70 F in the summer.<BR/>Interview and observation on 1/17/2024 at 10:00 AM, the Maintenance Supervisor measured Resident #1's room (100 Hall - Secured Men's Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 61 F. During an interview at this time, the Maintenance Supervisor said, It feels chili in here, I would need more blankets and double socks.<BR/>Interview and observation on 1/17/2024 at 10:04 AM, the Maintenance Supervisor measured Resident #5's room (100 Hall - Secured Men's Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #5's which revealed a temperature of 61 F. Resident #5 was observed still lying in bed with blankets over his head. A space heater was observed in this resident's room and was emitting heat but the room still felt cold. During an interview at this time, Resident #5 was asked if he was still cold to which he responded, Ya. At this time, the Maintenance Director said, Even with a space heater the room still feels cold. I don't see why the main heating unit (for 100 Hall) wasn't fixed before the cold weather.<BR/>Interview on 1/17/2024 at 10:15 AM, the administrator stated she had moved all but 1 resident on 200 Hall from the second half of 200 Hall to other locations including the first half of 200 Hall. The Administrator also stated she had closed the smoke barrier doors located in the middle of 200 Hall in an effort to prevent cold air coming down the first half of the 200 hall. Additionally, the Administrator said all residents on the 100 Hall (Male Secured unit) were moved to the 100 Hall (Female Secured unit) and indicated that section of 100 Hall had a HVAC. <BR/>Interview and observation on 1/17/2024 at 10:29 AM, the Maintenance Supervisor measured Resident #7's room (200 Hall) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 57.7 F. Resident #6 was observed lying in her bed under layers of blankets. During an interview at this time, Resident #6 was asked how she was doing to which she responded, I'm cold. The Maintenance Director then said, Ya, it's cold, I wouldn't want to be in there. The Maintenance Director then confirmed Resident #7's room was on the first half of 200 Hall that was supposed to be the side residents were moved to because it was warmer than the second half of 200 Hall. The Maintenance Supervisor agreed it felt much colder in the resident's room than in the hall. <BR/>A record review of the facility's Abuse/Neglect - Clinical Protocol revised 12/2016, stated, Assessment and Recognition - 2. Neglect is defined as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional destress . 4. If there is concern related to possible abuse and/or neglect of a resident, a nurse will assess the individual and document findings. Further review stated, The facility management and staff will comply with applicable laws and regulations pertaining to the documentation and management of abuse and neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 (Resident #57, #66, and #138) residents reviewed for Medicare/Medicaid services. <BR/>1. Resident #57 was not given a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) when discharged from skilled services prior to her covered days being exhausted.<BR/>2. Resident #66 was not given a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) when discharged from skilled services prior to her covered days being exhausted.<BR/>3. Resident #138 was not given a Skilled Nursing Facility Notice of Medicare Non-Coverage (NOMNC) when discharged from skilled services prior to his covered days being exhausted.<BR/>These failures could place residents at risk of not being fully informed about services not covered by Medicare and their financial responsibilities.<BR/>The findings include:<BR/>1. Record review of Resident #57's Face Sheet dated 4/27/2023 revealed the resident was admitted on [DATE] and had diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), essential hypertension (abnormally high blood pressure that was not the result of a medical condition), and cerebral infarction (a disrupted blood flow to the brain due to problems with the blood vessels that supply it, which can cause parts of the brain to die).<BR/>Review of information provided by the facility revealed Resident #57's was discharged from Medicare Part A services on 2/19/2023, prior to using up her 100 days of skilled services. The resident remained in the facility on Medicaid services.<BR/>2. Record review of Resident #66's Face Sheet dated 4/27/2023 revealed the resident was admitted on [DATE] and had diagnoses that included diabetes mellitus due to underlying condition with ketoacidosis (when the pancreas does not produce enough insulin into the body, complicated by the body producing excessive blood acids), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), essential hypertension (abnormally high blood pressure that was not the result of a medical condition) , and cerebrovascular disease (a condition which affects blood flow and the blood vessels in the brain).<BR/>Review of information provided by the facility revealed Resident #66's was discharged from Medicare Part A services on 3/24/2023, prior to using up her 100 days of skilled services. The resident remained in the facility on Medicaid services.<BR/>3. Record review of Resident #138's Face Sheet dated 4/27/2023 revealed the resident was admitted on [DATE] and had diagnoses that included diabetes mellitus due to underlying condition with diabetic neuropathy (when the body does not produce enough insulin in the body, causing nerve damage), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and the heart), dysphagia (difficulty swallowing food and fluids) , and cognitive communication deficit (deficits result in difficulty thinking and how someone uses language).<BR/>Review of information provided by the facility revealed Resident #138's was discharged from Medicare Part A services on 1/6/2023, prior to using up his 100 days of skilled services. The resident was discharged to the community.<BR/>During an interview 4/27/2023 at 10:15 a.m. with the Administrator revealed he was not able to locate an SNF ABN (issued if the beneficiary intends to continue services and the skilled nursing facility believes the services may not be covered under Medicare, informing the option to continue services with the beneficiary accepting financial liability for those services) or NOMNC (given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending) on any of the 3 residents that had discharged from Medicare Part A services. The Administrator reported he recently took over as the Administrator for the facility and was not aware who was responsible for completing the forms prior to his employment. The Administrator reported if the forms were not provided to the residents discharging from Medicare services, they would not be aware when their payee sources have changed.<BR/>During an interview on 4/27/2023 at 10:15 a.m., the Administrator said the facility did not have a policy and procedure for providing NOMNC or ABN to residents and/or resident's responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 38 residents (Residents #8, #57) whose assessments were reviewed, in that:<BR/>1. Resident #8's Annual MDS dated [DATE] incorrectly documented the resident was on an anticoagulant.<BR/>2. Resident #57 Quarterly MDS did not have depression listed under active diagnoses. <BR/>This failure could place residents at-risk for inadequate care due to inaccurate assessments. <BR/>1. Review of Resident #8's face sheet dated 4/24/2023 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included vascular dementia (problems with reasoning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain) with behavioral disturbance, mild protein-calorie malnutrition (inadequate of food as a source of protein, calories, and other essential nutrients occurring in the absence of significant inflammation, injury or another condition), hyperkalemia (high potassium) and chronic pain. <BR/>Review of Resident #8's April 2023 physician orders revealed an order for aspirin (an antiplatelet that prevent blood cells called platelets from clumping together to form a blood clot) tablet, 81 mg, 1 tablet daily at 8:00 a.m. with a start date of 10/13/2022. Further review of the resident's physician orders revealed she was not receiving an anticoagulant.<BR/>Review of Resident #8's care plan with a start date of 3/14/2022 revealed the resident had a Potential for complications, injury related to anticoagulant or antiplatelet medication.<BR/>Review of Resident #8's Annual MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 3, which indicated she had a severely impaired cognition. Further review of Resident #8's Annual revealed, under section N, Medications, option E., Anticoagulant, the resident was receiving an anticoagulant (used to prevent the formation of blood clots that inhibit circulation) 7 days a week. <BR/>Review of the CMS Minimum Data Set (MDS) 3.0 Instructor Guide dated May 2010, N-18 revealed, 2. Do not code antiplatelet medications such as aspirin/extended release, dipyridamole (used to treat the symptoms of prophylaxis against blood clots after heart valve replacement surgery), or clopidogrel (an antiplatelet medication that prevents platelets from sticking together) under option E. Anticoagulant.<BR/>In an interview on 4/25/2023 at 9:12 a.m. with MDS Coordinator and ADON LVN reported aspirin should not be coded as an anti-coagulant n the MDS.<BR/>In an interview on 4/25/2023 at 9:30 a.m. with the MDS Coordinator revealed she had reviewed Resident #8's medical record and could not find that the resident had been prescribed an anticoagulant. The MDS Coordinator reported the former MDS Coordinator coded aspirin as an anticoagulant on the MDS. The MDS Coordinator reported the MDS described the resident and what needs, or services would be required and determined the amount received from Medicaid for a resident's care. The MDS Coordinator revealed if the coding was wrong then the billing would be wrong. <BR/>2. Review of Resident #57's electronic face sheet dated 04/23/2023 revealed the resident was admitted to the facility on [DATE] and again on 04/14/2023 with diagnoses of pneumonia (an infection that inflames the air sacs in one or both lungs), dysphagia (a condition with difficulty in swallowing food or liquid), major depressive disorder (mental health disorder having episodes of psychological depression; symptoms include feelings of sadness, low esteem, hopelessness), anxiety disorder (Feeling nervous, restless or tense; having a sense of impending danger, panic or doom). <BR/>Review of Resident #57's quarterly MDS assessment dated [DATE] revealed the resident did not have depression listed under active diagnoses. Resident #57's BIMS was 10/15, indicating moderate cognitive impairment.<BR/>Review of Resident #57's Active Orders revealed an order for: Buspirone tablet; 10 mg; amt: 2 tablets; oral. Twice a day - 07:00 AM, 04:00 PM for Depression. Start date: 07/15/2022, End date: Open Ended.<BR/>Review of Resident #57's MAR for April 2023 revealed Resident #57 received Buspirone as prescribed.<BR/>Interview on 04/27/23 at 12:27 p.m. with the MDS coordinator revealed the diagnosis of depression was not properly checked off on Resident #57's quarterly MDS dated [DATE]. The MDS coordinator stated she had been in the job for one week at the facility but had been a MDS Coordinator for two years, and it was critical that all a residents' diagnoses be indicated on the MDS because if a diagnosis was not listed in a resident's MDS, it would likely not be noted in the resident's comprehensive care plan and the staff would not know to look for disease symptoms, progression and assist the resident with disease management.<BR/>Review of the facility policy, Resident Assessment Instrument, revised September 2010 revealed, 3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity.

**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 2 of 38 Residents (Resident #55 and #57) reviewed for care plans, in that: <BR/>1. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #55 to address hospice information, details of hospice care provided and coordination of services.<BR/>2. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #57 to address the resident's diagnosis of depression and use of psychotropic medications.<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/>1. Review of Resident #55's face sheet dated 4/24/2023 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's disease (a type of dementia that effects memory, thinking and behavior which eventually grows severe enough to interfere with daily tasks), moderate protein-calorie malnutrition (deficiency of energy, protein and nutrients that result in a person's weight to be 70-80% of ideal body weight and/or Body Mass Index is -2 to -2.9 below ideal body weight based on the weight and height of the person), dysphagia (difficulty swallowing food or liquids) and anxiety disorder.<BR/>Review of a physician order for Resident #55, with a start date of 1/25/2023, revealed the resident was on hospice services for her diagnosis of protein-calorie malnutrition.<BR/>Review of Resident #55s Significant Change in Status MDS dated [DATE] revealed the resident was on hospice services.<BR/>Review of Resident #55's care plan, with the last review date of 4/20/23 revealed there was not a care plan for hospice services.<BR/>In an interview on 4/25/2023 at 9:08 a.m. with the MDS Coordinator started that Resident #55 was on hospice services but did not have a hospice care plan in her medical record. The MDS Coordinator reported the care plan described the care the resident was receiving and without the care plan the being provided by hospice may be missed. <BR/>2. Review of Resident 57's face sheet dated 04/23/2023 revealed the resident was admitted to the facility on [DATE] and again on 04/14/2023 with diagnoses of pneumonia (an infection that inflames the air sacs in one or both lungs), dysphagia (a condition with difficulty in swallowing food or liquid), major depressive disorder (mental health disorder having episodes of psychological depression; symptoms include feelings of sadness, low esteem, hopelessness), anxiety disorder (Feeling nervous, restless or tense; having a sense of impending danger, panic or doom). <BR/>Review of Resident #57's quarterly MDS assessment dated [DATE] the resident's BIMS was 10/15, indicating moderate cognitive impairment.<BR/>Review of Resident #57's Active Orders for April 2023 revealed the following orders : Ativan (lorazepam) - Schedule IV tablet; 0.5 mg; amt: 1 tab; oral, three times a day, 07:00 AM, 01:00 PM, 07:00 PM for Anxiety. Start date: 06/07/2022, End date: Open Ended. Buspirone tablet; 10 mg; amt: 2 tablets; oral. Twice a day - 07:00 AM, 04:00 PM for Depression. Start date: 07/15/2022, End date: Open Ended.<BR/>Review of Resident #57's MAR for April 2023 revealed Resident #57 received the medications Ativan and Buspirone as ordered.<BR/>Review of Resident #57's comprehensive care plan, last revised 12/07/2022 and accessed on 04/23/2023 revealed there was no care plan for Resident #57'ss diagnosis of depression or for Resident #57's orders for psychotropic medications.<BR/>Interview on 04/27/23 at 12:27 with the MDS coordinator revealed Resident #57's diagnosis of depression and psychotropic medications were not documented in Resident #57's care plan and should have been. The MDS coordinator stated she had been in the job for one week but had been a MDS Coordinator for two years, and if a diagnosis or use of psychotropic medications were not listed in a resident's care plan, staff would not know to look for disease symptoms and/or progression or side effects of the medication.<BR/>Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed, 8. The comprehensive, person-centered care plan will: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and j. Reflect the resident's expressed wishes regarding care and treatment goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, the physicians' orders, and the residents' choices for 1 of 7 residents (Resident #7) reviewed for quality of care in that:<BR/>The facility failed to provide Resident #7 with adequate and timely wound care to treat a wound to the resident's stomach.<BR/>This failure could place residents at risk for not receiving appropriate care and treatment resulting in infection, delayed healing, and diminished quality of life. <BR/>The findings included:<BR/>Record Review of Resident #7's face sheet, dated 4/25/2023, reflected Resident #7 was a [AGE] year-old female admitted on [DATE] with diagnosis including Chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), Morbid obesity (excessive body fat that increases the risk of health problems), rash, and cellulitis of abdominal wall (skin infection). <BR/>Record review of Resident #7's MDS assessment, dated 4/7/2023, reflected a BIMS of 11, indicating moderately impaired cognitive status. The MDS stated the resident had moisture related skin damage and skin tears, but did not specify location.<BR/>Record Review of Resident #7's Orders, dated 4/22/2023, reflected three separate orders, for three areas under the stomach that needed wound care, to be completed daily and PRN wound care dressing change once a day during the hours between 6:00 AM - 6:00 PM. <BR/>Interview on 4/25/2023 at 11:45 AM, Resident #7 stated she had not received wound care to the area below her stomach after her shower on 4/24/2023 at approximately 4:00 or 5:00 PM. Resident #7 stated she still had not received wound care, and that her wound dressing had been removed right before her shower. Resident #7 stated she preferred her wound care to be performed after her showers, and that she currently has a towel sitting below her stomach to keep the wound away from her clothing and dry. <BR/>Interview and Observation on 4/25/2023 at 1:20 PM, Resident #7 stated that her wound to below her stomach was uncomfortable and that it hurt. She stated it made her feel unwanted at the facility because she was not being provided wound care. Resident #7 stated she informed CNA G on 4/24/2023 that her wound care had not been performed since it had been removed before her shower. Observation of the wound revealed red skin on her stomach, with wounds that were red and had yellow fluid leaking from them. <BR/>Interview on 4/25/2023 at 2:26 PM with the facilities Wound Care Doctor, he stated he came to the facility weekly on Tuesday and was always available by phone if necessary. The doctor stated he had not received notification of any residents not receiving wound care in the last 72 hours. The wound care doctor stated the expectation for the facility to notify him if there was a change in condition, or if wound care was not provided as ordered, and if wound care had not been done properly, he would ask the nurses at the facility to conduct a telemedicine appointment with him so that he would be able to assess the wound. <BR/>Interview on 4/25/2023 at 2:58 PM, LVN D stated she provided wound care to residents as needed depending on orders. LVN D stated she was aware of wound care not being performed on Resident #7 as she had not completed it before leaving for the day. LVN D stated she was not able to provide wound care on Monday, 4/24/2023, because the resident showered around 5:00 PM, and the LVN must pass out dinner trays to residents and get ready for reporting to the next shift before she leaves at 6:00 PM. LVN D stated she had completed wound care on 4/25/2023 during the visit with the wound care doctor at approximately 2:40 PM, and the wound had not looked different. LVN D stated the risk of not completing wound care could include infection and increased treatment. <BR/>Observation on 4/25/2023 at 3:15 PM revealed wound care had been completed to include debridement of wound.<BR/>Interview on 4/25/2023 at 3:44 PM, CNA G stated she took off Resident #7's wound dressing prior to her shower on 4/24/2023. CNA G stated she helped Resident #7 shower on 4/24/2023 at approximately 4:30 PM or 5:00 PM and stated the wound did not look different during the shower than it normally did, but was not able to state what the wound looked like. CNA G stated the last time she saw the wound was approximately a week prior. CNA G stated she did not inform LVN D the resident needed to be provided with wound care, as CNA G saw Resident #7 tell LVN D she was ready for wound care after her shower. CNA G stated she informed nurses immediately when a resident needed wound care and would ask them about it frequently if she noticed the wound care was not provided. CNA G stated she did not know Resident #7 did not receive wound care on the day of 4/24/2023, as she knew LVN D was aware of Resident #7's need for wound care after her shower. <BR/>Interview on 4/25/2023 at 4:27 PM, the ADON stated the charge nurse or LVN is to provide wound care. The ADON stated her expectation is that if someone is unable to complete treatment, staff is informed so that either the next shift or the ADON can complete the treatment. ADON stated she was not aware of any wound care treatments that had not been completed in the previous days. The ADON stated that the residents wish for wound care to be provided after showers should be honored. The ADON stated that if a wound is not dressed as ordered, their next step would be to notify the physician to ensure they are aware. <BR/>Interview on 4/25/2023 at 4:44 PM, the regional nurse stated that her expectation is that if the daytime shift charge nurse is not able to complete wound care and reports it to night shift nurse, the regional nurse would want to know why and what happened that caused the nurse to not complete it. The regional nurse stated that nurses should be able to always contact the doctor. The regional nurse stated that if wound care was not completed on a resident, it would depend on the wound, but that if there is an order to change it every day and it is not, they should inform the doctor. The regional nurse stated that she, the ADON, as well as the marketing director are all able to provide wound care if necessary and if the charge nurse is not available or able to. <BR/>Record review of Resident #7's Treatment Administration Record from 4/1/2023 through 4/27/2023 indicate 3 orders for wound care once daily. The Treatment Administration Record for the three wound care orders is blank for the day of 4/24/2023. <BR/>Record review of the 24-hour nursing report dated 4/24/2023 does not indicate information about wound care for Resident #7. <BR/>Record review of the facility's policy on Wound Care, dated October 2010, stated that before wound care is completed, physician orders must be verified, and care plan must be reviewed to ensure wound care is being performed properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure incontinent bladder residents received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 2 out of 36 residents reviewed reviewed for indwelling catheters , (Resident # 12 and 41)<BR/>The facility failed to ensure Resident # 12 and Resident # 41 indwelling catheter was attached to prevent pulling or tugging to the urethra. <BR/>These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections.<BR/>Findings included:<BR/>1.Record review of Resident's # 12 face sheet dated 4/23/23 revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis of [Dysphagia] Difficulty swallowing. [Dementia] impaired ability to remember, think, or make decisions that interfere with everyday activities. [Hypothyroidism] when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs. <BR/>Record review of Resident #12's quarterly MDS, dated [DATE], revealed a BIMS score of 4 suggesting severe impairment. <BR/>Record review of Resident # 12's quarterly MDS, dated [DATE], revealed under section H Bowel and Bladder, indwelling catheter not marked. <BR/>Record review of Residents #12's quarterly MDS , dated 4/11/23 , revealed under section H (bowel and bladder) , section 2 selected indicating resident had no indewing cathater . <BR/>Record review of Resident#12's's care plan, updated on 04/05/2023, revealed no interventions for catheter care. <BR/>Record review of residents' orders dated 4/23/23 revealed no orders for Foley catheter care. <BR/>Observation on 4/23/2023 at 11:20 a.m. revealed that Resident #12's indwelling catheter anchor was not in place. <BR/>2.Record review of Resident 41's face sheet dated 4/23/2023 revealed that a [AGE] year-old male was admitted on [DATE] and readmitted on [DATE] with a diagnosis of [paraplegia], impairment in motor or sensory function of the lower extremities. [Dysphagia] taking more time and effort to move food or liquid from your mouth to your stomach. [ Muscle wasting] lack of muscle strength. <BR/>Record review of Resident # 41 quarterly MDS, dated [DATE], revealed a BIMS score of 15, suggesting the patient is cognitively intact. <BR/>Record review of Resident # 41 quarterly MDS, dated [DATE], revealed under section H Bowel and Bladder, indwelling catheter marked. <BR/>Record review of Resident # 41 care plan updated, 4/4/23 revealed interventions; catheter care each shift but no interventions for anchor catheter to prevent impairment. <BR/>Record review of residents' orders dated 4/23/23 revealed orders start date 4/4/23 check and secure catheter with a tube holder each shift. <BR/>In an interview on 4/23/23 at 11:30 a.m., LVN D stated she was the charge nurse for both Resident # 12 and 41 and Licensed nurses were responsible for putting a Foley stat lock anchor on the resident as sometimes the resident can lay on it, get coiled, or get pulled without one. The stat lock for the Foley catheter should be on to stabilize the Foley and prevent tugging; if the balloon comes out, it would be painful for the resident. LVN D stated that the CNAs were expected to tell nurses when a new stat lock was needed. He stated she had not gotten a chance to see Resident# 41 and Resident 12 this morning. She said he was in the middle of meds pass and had not yet reached the patient's rooms. <BR/>In an interview on 04/24/23 at 2:00 p.m., the Clinical nurse consultant stated that all residents with indwelling urinary catheters needed a leg strap or securing device so the catheter tubing was not pulled, which could irritate the urethra. The Clinical nurse consultant said the charge nurse should have secured the urinary catheter tubing to the resident's leg. She does not know why it was not done but would investigate it. <BR/>Record review of Catheter care, urinary policy dated 2001, revised September 2014 revealed Ensure that catheter remains secured with leg strap '.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure residents who use psychotropic drugs, PRN orders for psychotropic drugs are limited to 14 days for 1 of 20 Residents , Resident (# 41) reviewed for unnecessary psychotropic medications.<BR/>The Facility failed to address as needed order for Alprazolam that exceeded the 14-day limit for as-needed psychotropic medications.<BR/>This deficient practice could affect 1 resident who receives Alprazolam in the facility and put them at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status.<BR/>The findings were:<BR/>Record review of Resident 41's face sheet dated 4/23/2023 revealed that a [AGE] year-old male was admitted on [DATE] and readmitted on [DATE] with a diagnosis of [paraplegia], impairment in motor or sensory function of the lower extremities. [Dysphagia] taking more time and effort to move food or liquid from your mouth to your stomach. [ Muscle wasting] lack of muscle strength. <BR/>Record review of Resident # 41 quarterly MDS, dated [DATE], revealed a BIMS score of 15, suggesting the patient is cognitively intact.<BR/>Record review of Resident # 41's consolidated physician orders for April 2023 revealed orders for Lorazepam (an antianxiety medication) 1 mg, take one tablet orally twice daily every 12 hours as needed for anxiety, order date 4/18/2023 end date 7/18/2023. <BR/>Further review of consolidated physician orders revealed an order for Clonazepam (an antianxiety medication) 0.5 mg, one tablet orally twice daily at 08:00 AM and 4:00 PM (order date 7/2/2022).<BR/> Record review of Resident # 41's Medication Administration history dated 4/1/23-4/23/23 revealed Resident # 41 received 10 as-needed doses of lorazepam 1 mg (an antianxiety medication) on 4/2/23 , 4/5/2023 , 4/6/2023 , 4/8/2023 , 4/10/2023 , 4/11/2023 , 4/13/2023 , 4/18/2023 , 4/19/2023 and 4/21/2023 <BR/>Record review of Resident #41's Scheduled, and as-needed medication history revealed Resident # 41 was administered an as-needed dose of lorazepam on 4/15/ 2023 at 6:22 AM and a scheduled dose clonazepam at 9:31 a.m. and on 4/21/23 at 2:27 PM, then received a scheduled dose at 4:14 PM.<BR/>During an interview on 4/23/23 at 10:29 AM with LVN D, she revealed she was not aware that antianxiety medications were one of the psychotropic as-needed medications that needed to be limited to 14 days. <BR/>During an interview with a Clinical nurse consultant on 4/24/2023 at 10:35 a.m. confirmed that Resident # 41 was receiving two antianxiety agents and that she would have the charge nurse investigate this. She stated that the resident risked respiratory distress by being on both antianxiety agents. <BR/>The facility could not provide a copy of the policy for unnecessary medications related to antianxiety agents. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents are free of any significant medication errors and that accepted professional standards and principles which apply to administration were followed for 2 (Resident #288 and Resident # 4) of 15 Residents observed and reviewed for medication administration in that:<BR/>1. <BR/>Resident # 288's medications were in a medicine cup in the top drawer of the medication cart.<BR/>2. <BR/>Resident #4's medications were in the medicine cup in the top drawer of the medication cart. <BR/>This deficient practice could affect residents who receive medications, resulting in needed medications not being taken and documented as taken. <BR/>The findings were:<BR/>1.Review of Resident # 288's electronic face sheet dated 4/23/23 revealed he was admitted on [DATE] with a diagnosis of [Acute Respiratory Distress] when fluid builds up in the tiny, elastic air sacs in the lungs. [Muscle Weakness] Lack of muscle strength. [ Essential Hypertension] abnormally high blood pressure that's not the result of a medical condition. <BR/>Review of Resident 288's electronic medication administration record dated 4/23/23 revealed that resident # 288 had seven medications scheduled for 0:800 a.m. Amlodipine 10 mg, one tablet by mouth daily for hypertension, B-12 Complex, for vitamin supplementation; Divalproex 250 mg, one capsule by mouth daily for dementia; Omeprazole 40 mg, one capsule by mouth daily, for reflux, Potassium Chloride 10 MEQ, one tablet daily for hypertension, Pyridostigmine bromide60 mg, one tablet by mouth daily for myasthenia gravis, Seroquel 25 mg, one tablet by mouth daily for dementia. <BR/>Review of Resident 288's admission MDS dated [DATE], revealed BIMS left blank, indicating resident # 288 could not complete the interview and suggesting severe impairment. <BR/>Review of Resident #288's comprehensive plan of care dated 4/17/23 revealed intervention administer medications and treatments as ordered.<BR/>Observation on 4/23/23 at 10:15 am revealed Resident # 288's morning medication of seven pills was in a medication cup on the top drawer of the medication cart. <BR/>Interview on 4/23/23 at 10:45 a.m., LVN A stated, I attempted to give him his medication earlier, but he refused and was going to try again later; I signed the electronic administration record as administered since medications had been pulled. LVN A stated, She knows that storing medications in cups in a medication drawer is not the best practice, as they should be disposed of if a resident refuses. LVN A stated resident risked the possibility of a medication error.<BR/>2.Review of Resident # 4's electronic face sheet dated 4/23/23 revealed resident was admitted on [DATE] with a diagnosis of [schizophrenia], a serious mental disorder in which people interpret reality abnormally. [Dementia] condition characterized by progressive or persistent loss of intellectual functioning. Cognitive Communication Deficit] difficulty with thinking and how someone uses language. <BR/>Review of resident # 4's electronic medication administration record dated 4/23/23 revealed that resident # 4 had four medications scheduled for 0:800. Lexapro 10 mg, one tablet daily by mouth for schizophrenia, Lipitor 20 mg, one tablet daily by mouth for hyperlipidemia, Metformin 1000 mg take one tablet daily by mouth for diabetes mellitus, Risperdal 2mg one tablet daily by mouth for schizophrenia. <BR/>Review of Resident # 4 Quarterly MDS dated [DATE] revealed a BIMS of 8, suggesting moderate impairment. <BR/>Review of Resident #4's comprehensive plan of care dated 7/18/22 revealed intervention administer medications and treatments as ordered.<BR/>Observation on 4/23/23 at 10:20 a.m. revealed Resident # 4's morning medication of four pills in a medicine cup on the top drawer of the medication cart. <BR/>Interview on 4/23/2023 at 10:55 a.m. with CMA B stated she had to pull medications early as she was tending to patient care and passing out medications. Therefore, she had pre-pulled her medications. She had signed the medication administration record as administered as she had pulled the medicine for resident # 4. She confirmed that she should not have pre-pulled medications as she risked a possible medication error by not following the medication rights. <BR/>Interview on 4/23/23 at 11:50 a.m. with the clinical nurse consultant revealed that LVN A should have stayed with Resident #288 until he swallowed all his medications. If Resident # 288 refused medications, LVN A should have marked medications on the electronic medical record as refused, not as administered. The clinical nurse consultant revealed that CMA B should not have pre-poured her morning medications for Resident # 4 and should not have marked medications on electronic medical record as administered; if she had not given them, she stated that both practices were not safe, and she would be in-servicing nursing staff, as this practice could lead to possible medication errors. <BR/>Review of the facility policy and procedure titled Administering medications dated 2001, revised December 2012, revealed, Medications shall be administered safely, timely, and as prescribed.

.<BR/>Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>1. Employee A did not have a beard guard on to cover his facial hair during food preparation.<BR/>2. The handles of measuring utensils stored in the sugar, flour and rice bins touched the products stored in the bins instead of in an upright position.<BR/>3. Two and &frac12; cases of canned food (peaches, mashed potatoes, and sliced carrots) were stored on the floor in the dry storage room instead of 6 off the floor.<BR/>These deficient practices could place all residents who received meals/snacks from the kitchen at risk for food borne illness.<BR/>The findings were:<BR/>1. Observation on 1/23/22 at 9:08 a.m. revealed Employee A was standing by the 3-compartment sink washing pots and pans. Employee A had a beard about &frac14;-3/8 long and did not have a beard guard/restraint on. Employee A stated he was assisting in the kitchen because the dietary manager and several other dietary employees were out sick.<BR/>Observation on 1/23/22 at 9:27 a.m. revealed Employee A poured cake mix into a bowl and added milk to it while not wearing a beard guard/restraint to cover his facial hair. The surveyor asked Employee A if the kitchen had any beard guards/restraints, he responded hairnets were available and then asked the surveyor Why should I wear one?. Employee A then went to the dietary manager's office and placed a hair net over his beard.<BR/>Record review of the policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised December 2008, revealed 12. Hair nets or caps and/or beard restraints ust be worn to keep hair from contacting exposed food, clean equipment, utensils and linens.<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. <BR/>2. Observation on 1/23/22 at 9:26 a.m. of 3 large white storage bins revealed one was labeled flour, the second was labeled sugar and the third was labeled rice. Inside each storage bin was a plastic 2-cup measuring pitcher that was laying on the flour, rice, and sugar with the handle of each pitcher touching the flour, sugar, and rice. <BR/>Observation on 1/25/22 at 10:52 a.m. with the Dietary Manager of the 3 large white storage bins labeled flour, sugar, and rice revealed inside each storage bin was a plastic 2-cup measuring pitcher that was laying on the flour, rice, and sugar with the handle of each pitcher touching the flour, sugar, and rice. Interview with the Dietary Manager at this time confirmed the handles of the measuring pitchers should not touch the sugar, flour, and rice.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-304.12 In-Use Utensils, Between-Use Storage revealed During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .(B) In food that is not time/temperature control for safety food with their handles above the top of the food withing containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon;<BR/>3. Observation on 1/23/22 at 9:12 a.m. of the dry good storeroom revealed on the floor was a full case (6 #10-cans) of mashed potatoes, a full case of sliced carrots and an open case with 3 #10-cans of peaches.<BR/>In an interview on 1/25/22 at 10:55 a.m. the Dietary Manager reported cases of food should be put on the shelves as soon as possible and not left on the floor.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-305.11 Food Storage revealed (A) .Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.<BR/>Record review of the policy titled Food Receiving and Storage, revised December 2008, revealed Food shall be received and stored in a manner that complies with safe food handling practices. Under Policy Interpretation and Implementation was 5. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents.<BR/>Record review of the CMS 672 Resident Census and Conditions of Residents, completed by the facility on 1/26/22, revealed all residents in the facility received meals and snacks prepared and served from the kitchen.<BR/>.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 1 of 1 kitchen in that:<BR/>Mice and rats were seen in the facility's kitchen in the past.<BR/>This deficiency practice could affect residents who receive meals from the kitchen and could place them at risk of contracting food borne illnesses. The noncompliance was identified as PNC(past noncompliance). The noncompliance began on 12/29/23 and ended on 2/12/24. The facility had corrected the noncompliance before the survey began. <BR/>The findings included:<BR/>Observation on 3/12/24 from 2:30 PM to 3:00 PM of the kitchen revealed there were 13 dried mouse droppings near the pantry area underneath a metal cabinet. Two sticky mouse traps were present on the floor near the pantry. There was a live mouse trap in the ceiling of the kitchen near the ceiling leading to the pantry. As the Maintenance Director removed the ceiling tile near the pantry, five dried vermin droppings fell on a kitchen counter top. There were no fresh droppings in the food pantry or refrigerators. <BR/>Observation on 3/13/24 at 8:30 AM of kitchen revealed: staff were present and cleaning the kitchen to include the floors and underneath the cabinets and refrigerators and ice chest. There were no signs of vermin droppings. One rat trap was present outside the pantry area. Ceiling openings that could allow vermin entrance were sealed; the surveyor counted 6 areas in the ceiling that were sealed with epoxy. Epoxy sealant was also present in two areas on the kitchen floor near the pantry area There was not food on the floor and all foods were in containers. Food was not being prepared. The FSS stated that meals would be catered on 3/13/24 to allow tome to clean the kitchen. <BR/>Observation on 3/13/24 of meals for lunch, noon to 1 :00 PM, and dinner, 5:00 PM-6:00 PM revealed the meals were catered and the kitchen was closed for cleaning and removal of any vermin/rodent droppings. Likewise, observation on 3/14/24 at noon revealed the kitchen was closed and meals were catered for breakfast; and scheduled for catering during the lunch and dinner. <BR/>Observation on 3/13/24 at 8:30 PM of facility revealed: the facility was well lit. There were no signs of rodents in the hall or resident rooms. The kitchen was cleaned and lights were on. In the kitchen there were no signs of rodents or rodent noises in the ceiling. There were 5 traps on the floor with no rodents trapped. <BR/>Observation on 3/14/24 from 9:45 AM to 10:00 AM of the facility to include the kitchen revealed no signs of rodents; the kitchen was cleaned and staff were present providing further cleaning of the kitchen.<BR/>During a joint interview on 3/13/24 at 8:35 AM the FSS and the Maintenance Director stated the facility was thoroughly cleaning the kitchen and sealing any holes that could allow vermin/rodents to re-enter.<BR/>During an interview on 3/13/24 at 11:13 AM, the Maintenance Director stated that the outgoing Maintenance Director informed him of the vermin/rodent issue in the kitchen. The Maintenance Director stated, I addressed the issue by sticky pad traps .sealed holes .we contacted pest control .surveyed the outside for holes and filled in cracks .we have been at it since I arrived .I trapped about 7 mice .last trapping was the time I was employed, 2/26/24 .the live traps caught no mice a saw them [rodents] in the morning time in the kitchen a couple of weeks ago .never saw them in the residents rooms or hallways .not sure whether the local health department was informed .after [surveyor entrance on 3/13/24] deep cleaning of the kitchen .power washing .cleaning walls .sealing and corking .drywall the area that was opened in the ceiling and dry wall one of the entrance doors .AC units were corked .corked all the base boards in the pantry and still working on the kitchen to prevent any mice/rat re-entry .transferred all box foods in an non-working freezer .all walls checked and shelves powered washed .opened boxes have been sealed .and stored in the non-working freezer .only cans remain in the open pantry.<BR/>During an interview on 3/12/24 at 3:01 PM, the FSS stated that she was hired three weeks ago and had been addressing kitchen sanitation and pest control. The FSS stated that about three weeks ago 20 mice had been trapped; and the pest control company trapped 6 more mice. The FSS stated that there had been no other mice trapped in the past three weeks; and the facility had made a concerted effort to control pests in the kitchen. The FSS stated that food in the pantry had been taken off the floor; and pantry food put in sealed plastic containers. <BR/>During a joint interview on 3/13/24 at 8:35 AM the FSS and the Maintenance Director stated the facility was thoroughly cleaning the kitchen and sealing any holes that could allow vermin to re-enter.<BR/>During a telephone interview on 3/13/24 at 11:15 AM, Dietary Aide A, stated: she had been employed for the past year. She saw a live rat about a month ago in the kitchen and informed the previous FSS. The previous FSS informed her that the facility would buy traps. She had not seen any vermin in the past three weeks alive or dead in the kitchen. She stated that the vermin never got into the food or got into the pantry to chew on boxes in the past [last three weeks] or in the present. <BR/>During a telephone interview on 3/13/24 at 2:03 PM, the Dietician stated, I made a visit last month to orient the new [FSS] .I saw no droppings or food products ripped by vermin .I saw a sticky trap .they [the facility] had [hired] a pest control company .they were doing cleaning .there were traps .<BR/>During a telephone interview on 3/13/24 at 2:30 PM, the Medical Director stated that he participated in an Ad hoc QAPI meeting to discuss the vermin issue in the kitchen. The Medical Director stated he interviewed nursing staff on 02/06/24 and no nurse reported that residents were affected by the food coming from the kitchen due to the sighting or rodents. <BR/>During a telephone interview on 3/13/24 at 2:43 PM, Dietary Aide B, stated she notified the Maintenance Director on 1/12/24 that she saw a rat in the kitchen; her shift was from 1PM-8 PM. She also saw some droppings on the floor and the bread revealed signs that vermin had eaten some of the bread that was not in closed containers. Dietary Aide B stated the facility responded by putting out sticky traps, replacing the bread, and buying plastic bins. Dietary Aide B stated that after the incident on 1/12/24 she saw no other vermin or signs of vermin in the kitchen.<BR/>During a joint interview on 3/13/24 at 3:10 PM with the present Administrator, DON, and Cooperate Director of Quality revealed: the Administrator was aware on 1/12/24 of the vermin issue in the kitchen and started to address the issue and interventions included: sealing and exclusion of the building, traps, and notify staff to report any sightings, in-service on pest control, and contract with pest control. The Administrator stated that the health department report reflected that there were vermin droppings in the kitchen and needed to be resolved ASAP. The Administrator stated that no recommendation was made by the health department to close the kitchen. The Administrator stated as of 3/12/24 additional interventions included: total power washing and sanitization, more sealant and exclusion; and further re-education on cleaning items and the kitchen The DON and Administrator stated that no resident, visitor, or staff had alleged to seeing vermin in the halls or resident rooms. <BR/>During interviews on 03/13/24 from 8:56 AM to 9:57 AM with Residents #1, #2, #3, #4, #5 and #6 revealed no information that residents had seen signs of mice/rats or rodents in the halls or resident rooms. <BR/>During a telephone interview on 3/13/24 at 5:30 PM with the contracted pest control company the surveyor requested an assessment from the customer service representative as to whether the rodent/vermin issue in the facility's kitchen had been resolved. The customer service representative stated that she would check on the assessment and be in contact with the surveyor in the future. <BR/>Record review of Resident Council minutes for the months of January, February and March 2024 revealed no complaints about pest control or vermin/rodents seen in the kitchen on halls or resident rooms.<BR/>Record review of Facility's Ad-hoc QAPI: Pest Control meeting was held on 2/6/24 to discuss the Pest Control issue in the kitchen. Attendees were the Administrator, maintenance director and Medical Director.<BR/>Record review of facility's in-service sheets on Pest Control training from 3/5/24 to 3/13/24 revealed 63 signatures (100%); total paid staff was 63. <BR/>Record review of facility's Pest Control contact revealed one was present and was signed on 11/16/2018. <BR/>Record review of facility's pest control company invoices revealed: company made visits on 9/18/23, 10/16/23, 11/17/23, 12/18/23, 1/23/24, and 2/12/24 to address pest control issues in the facility and put in effect preventative measures.<BR/>Record review of facility's pest control report dated 2/12/24 revealed the pest control company assessed all possible entry points for vermin and rodent/vermin activity was not noticed.

Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 halls (100 hall) in that:<BR/>1. Men's unit (hot zone)- CNA K and LVN L not wearing eye protection in the hot zone hall.<BR/>a. CNA K walked from the hot zone to the cold zone to use the bathroom, without taking off her N95 mask. <BR/>b. LVN L pushed the lunch cart from the hot zone to the cold zone, a door was separating the zones. Observation of lunch cart had 10 trays and 10 plate tops that were not sanitized. <BR/>c. LVN L pushed the hydration cart with 3 tall plastic coffee pitchers, 3 1-gallon clear containers on 1st shelf, the 2nd shelf had a container with sugar, and the 3rd shelf had a metal wide container with ice and 3 resident plastic pitchers were not sanitized. This hydration cart was pushed from the hot zone to the cold zone.<BR/>2. Women's unit-LVN I was not wearing a N96 mask or eye protection when administering Resident #48's medications (hot zone room). <BR/>3. The 100-hall was not treated as a presumed COVID-19 hall after a COVID-19 exposure. Resident #81 resided on the 100-hall and was discovered COVID-19 positive and transferred to the COVID-10 unit. <BR/>4. The laundry department did not treat COVID-19 laundry per the CDC's guidelines for COVID-19. <BR/>These deficient practices could affect residents, visitors and staff and result in cross contamination and infections.<BR/>The findings were: <BR/>Interview on 1/23/22 at 10:52 a.m. with the Administrator stated the secure unit, 100 hall had a women's unit, (cold zone) on the left side of 100 hall and the right side of the 100 hall was the men's unit (hot zone) of the 100 hall-memory care unit. <BR/>1. Observation on 1/24/2022 at 11 a.m. revealed CNA K was in the hot zone, she took off her gown and gloves, opened the door to the cold zone to use the bathroom without taking off her N95 mask. <BR/>Observation on 1/24/2022 at 11:10 a.m. in the hot zone (right side of 100 hall) revealed CNA K and LVN L were not wearing eye protection and walked up and down the hall. (-no residents were observed near the door)<BR/>Interview on 1/24/2022 at 11:11 a.m. with CNA K, she stated she was told her prescription glasses were enough for the COVID-19 unit. CNA K stated she was told by the ADON she could use the bathroom in the women's cold zone. CNA K stated she was positive for COVID-19 and had no symptoms.<BR/>Interview on 1/24/2022 at 11:12 a.m. with LVN L, she stated the ADON (administrative staff) told her no eye protection was required in the hot zone, when aske by surveyor why she did not have her eye protection on in the hot zone.<BR/>Interview on 1/24/2022 at 12:37 p.m. with LVN I, she stated the lunch cart and hydration cart came to the women's unit (cold zone), staff opened the doors separating the two zones, to the hot zone (100 hall-men's unit), then came back to cold zone (women's unit) after being sanitized by staff. <BR/>Observation on 1/24/2022 at 1:21 p.m. in front of cold zone door that separated the hot zone and cold zone revealed the lunch cart (10 trays and plate tops) and hydration cart in the hot zone, then LVN L open the door and pushed the lunch cart and hydration tray cart ( 3 tall plastic coffee pitchers, 3 1-gallon clear containers on 1st shelf, the 2nd shelf had a container with sugar, and the 3rd shelf had a metal wide container with ice and 3 resident plastic pitchers) to the cold zone to CNA M. Staff LVN L sanitized the food tray and hydration cart frame but did not sanitize the items on the carts. Observed in the hot zone LVN L and CNA K in the hot zone and were not wearing eye protection. <BR/>Interview on 1/24/2022 at 1:30 p.m. LVN L stated she sanitized the frame of the carts. State Surveyor asked if she sanitized the items in lunch/hydration carts, she stated she did not know she had too. <BR/>Interview on 1/24/22 at 3:31 p.m. to 3:37 p.m. CNA M stated the staff in the hot zone sanitized the carts, then the lunch/hydration carts were rolled from the hot zone to the cold zone, by opening the doors, then CNA M got the lunch trays/plate guards and placed them in the lunch cart,from the women's side, then she rolled the carts down the opposite end of the hall, to the outside patio where the kitchen staff picked up the lunch/hydration cart. <BR/>Interview on 1/26/2022 at 10 a.m. with the ADON, she stated she never told staff in the hot zone that their prescription glasses counted as eye protection. ADON stated the staff in hot zone should wear full PPE, including eye protection (googles/face shield). (ADON left before I could ask more questions).<BR/>Record review of CNA K's positive COVID-19 test was on 1/20/202 and LVN L's positve COVID -19 test was on <BR/>2. Observation on 1/24/22 at 12:45 p.m. LVN I went into Resident #48's room (hot zone room), who tested positive for COVID-19 today and administered her medications without wearing a N95 mask or eye protection. LVN I was wearing a surgical mask, gown, and gloves. <BR/>Interview on 1/24/22 at 12:46 p.m. LVN I confirmed she entered Resident #48's room, who was positive for COVID-19, without a wearing N95 mask or face sheld/goggles. LVN I stated she had her prescription glasses on for her eye protection. Interview with LVN I stated she tested Resident #48 for COVID -19 that morning and LVN I stated she was positive. LVN I stated Resident #48 was quarantined to her room until the staff could move her to the hot zone. <BR/>Observation on 1/24/22 at 12:47 p.m. at the nurse's station, cold zone, women's hall, left side of 100 hall, a PPE posting on doffing/donning, staff wear gown, gloves, N95 mask and eye protection (goggles/face shield).<BR/>Interview on 1/24/22 at 1:16 p.m. LVN I stated she tested all residents in the women's secure unit, today. LVN I stated Resident #48 was the only resident who tested positive for COVID-19 this day. LVN I stated Resident #48 was in a quarantined room until they could move her to hot zone.<BR/>Interview on 1/25/22 at 2:56 p.m. the Regional Nurse, she stated she worked at the facility 1-2 days a week and from home on electronic records. She stated once staff worked in the hot zone, staff should not go to cold zone. The Regional Nurse stated staff in the hot zone should be wearing full PPE, to include N95 masks and eye protection (goggles/face shield) when working/caring for residents in the hot zone. The Regional Nurse stated the lunch and hydration cart should not go from hot zone to cold zone, staff should take it outside of the hot zone and take it to the kitchen for them to sanitize the carts. <BR/>Record review of Resident #48 and LVN I were vaccinated or not? <BR/>3.<BR/>Observation on 1/23/2022 at 10:00 am of the facility's memory care, 100 hall, revealed the hall separated from the facility by closed double doors, the doors presented with no signage to designate any quarantine or isolation precautions. The 100-hall memory care unit was further separated by a set of closed double smoke barrier doors, at the end of the hall. The women residents ambulated in the hallway, some residents wore masks and others did not, Resident #11 ambulated throughout the unit in her wheelchair and wore a surgical mask on her chin. LVN I attended to residents, LVN I wore a KN95 FFR as her only PPE. <BR/>During an interview on 1/23/2022 at 10:05 am LVN I stated the 100-hall memory care unit is separated by women and men. The women were in the part of the hall where she was, and the men resided behind the closed double barrier door. LVN I stated the men were COVID-19 positive and had dedicated staff, specifically, ADON O and COVID-19 positive CNA P. LVN I stated the women's area was not considered a COVID-19 area. LVN I stated the facility routinely tested residents for COVID-19 and on 1/17/2022 Resident #81 was COVID-19 positive and was transferred to the 200 hall COVID-19 unit. LVN I stated Resident #81 had a roommate Resident #11, and Resident #11 was attempted to be quarantined but due to her diagnosed dementia with wandering behavior she continued to ambulate throughout the unit. LVN I stated routine testing on 1/19/2022 revealed Resident #19 was COVID-19 positive. When asked if the 100-hall women's area was considered under any isolation / quarantine precautions, LVN I stated the women residents don't have COVID-19, therefore, there were no special isolation / quarantine precautions other than the facility had imposed all staff to wear KN95 FFR's. <BR/>During an interview on 1/24/2022 at 3:00 pm the Administrator stated the root cause analysis of the current COVID-19 outbreak revealed the outbreak started the week before Christmas 2021 and has spread throughout the facility into January 2022. The Administrator stated the outbreak triggered the facility's COVID-19 emergency testing protocols and the facility tested all staff and residents twice weekly on Mondays and Thursdays, the Administrator stated the testing initially revealed only staff were discovered COVID-19 positive and on January 17th, 2022, 7 residents who resided on the 100-hall were discovered COVID-19 positive; Of the 7, 6 were men and the men's area was developed into a COVID-19 unit. The female Resident (Resident #81) was transferred to the facility's newly developed COVID-19 unit at the end of 200 hall. The Administrator stated Resident #81 had a roommate Resident #11 and she was not successfully quarantined due to her diagnosed dementia and wandering behaviors and continued to ambulate throughout the unit. The Administrator stated the facility developed a COVID-19 unit at the end of 200 hall, specifically rooms 201 through 208. The Administrator stated continued daily testing revealed 100-hall memory care female Resident #19 tested COVID-19 positive on 1/19/2021 and she was transferred to the 200 hall COVID-19 unit.<BR/>4.<BR/>Observation on 1/25/2022 at 12:10 pm of Resident #77 room revealed a red sign which read, STOP Special Droplet / contact Precautions-in addition to standardized precautions only essential personnel should enter this room. When doing aerosolizing procedures fit tested N-95 with eye protection or higher required. Further observation revealed CNA Q wore full COVID-19 PPE N95, eye protection, gown gloves and exited Resident #77's room with 2 bags of soiled COVID-19 laundry and placed the soiled laundry bags into a 55-gallon trash can with a lid. CNA Q wheeled the can down the hall to the laundry department, CNA Q alerted Laundry Aide R to the 2 bags of COVID-19 soiled laundry stored in the soiled laundry room. CNA Q doffed her gown and gloves and provided hand hygiene, CNA Q exited to the cold zone and doffed the contaminated N95 FFR and donned a new fresh N95 FFR, CNA Q disinfected her face shield, and resumed CNA duties on 300 halls. <BR/>Observation on 1/25/2022 at 12:20 pm of Laundry Aide R revealed she wore a N95 FFR, eye goggles, gloves, and a gown, and wore a black neoprene apron over her gown, and black neoprene gloves over her gloves, Laundry Aide R picked up the 2 COVID-19 soiled laundry bags and placed the soiled COVID-19 laundry into the washing machine. Laundry Aide R doffed the black neoprene apron and disinfected the apron, doffed the black neoprene gloves, and disinfected the gloves, doffed the gown and gloves and provided hand hygiene, Laundry Aide R doffed the face shield and disinfected the face shield and then proceeded to handle clean laundry in the clean laundry area, while continuing to wear the same COVID-19 contaminated N95 FFR . <BR/>During an interview on 1/25/2022 at 12:33 pm with Laundry Aide R stated she was trained today by the Regional DON to don full COVID-19 PPE and to doff the gown and gloves after care with COVID-19 residents and their soiled laundry, and to then proceed to the facility's designated cold zone to doff the COVID-19 contaminated N95 FFR. Laundry Aide R stated she did not doff her COVID-19 contaminated N95 FFR because she was confused as to where the cold zone was. <BR/>During an interview on 1/25/2022 at 5:01 pm ADON H stated she was involved in the COVID-19 emergency outbreak planning on 1/17/2022 when 2 staff, and 11 residents were discovered COVID-19 positive. ADON O stated the Administrator, the regional Administrator, the Regional DON, and the ADON H were all participants in the meeting. The conclusion of the meeting resulted in the recognition of the difficulty to quarantine residents in the women's memory care 100 hall. The plan was developed and implemented to have the 100-hall women to be designated a presumed COVID-19 unit. ADON H stated the 100-hall presumed COVID-19 and COVID-19 units and the COVID 200-hall unit were in place prior to 1/23/2022 when surveyors entered the facility.<BR/>During an interview on 1/26/2022 at 9:00 am the Administrator and the Regional DON stated the the facility followed the Centers For Disease Prevention and Control concerning COVI-19. The Regional DON stated the facility's policy, training, and expectations were for staff to work soley in the covid-19 unit and not enter the facility, to wear PPE as per CDC guidelines in the COVID-19 unit (specifically a N95 FFR, eye protection, gown, and gloves) and to doff all the PPE when exiting the covid-19 unit. The Regional DON stated the facility's policy, training, and expectations were for staff who enter presumed (warm) COVID-19 rooms, was to wear PPE as per CDC guidelines in the COVID-19 unit (specifically a N95 FFR, eye protection, gown, and gloves) and to doff all the PPE when exiting the presumed (warm) COVID-19 room. The Regional DON stated the infection control breakdowns were the responsibility of each individual staff member to be held accountable for their individual adherance to the facility training and infection control policy. The Regional DON and the administrator stated the 1/2 of the 100-hall (the womens side) was deemed a presumed (warm) Covid-19 unit after the resident #81 was discovered COVID-19 positive and the other half of the 100-hall (the mens side was seperated by closed double doors and designated the Covid-19 (hot) unit with deicated staff (staff who solely work the covid unit). The Administrator and the Regional DON stated staff who are assigned to the Presumed (warm) unit are to utilize PPE and infection control measures as set by the CDC, (specifically a N95 FFR, eye protection, gown, and gloves) and to doff all the PPE when exiting the presumed covid-19 unit. The Regional DON and the administrator stated no PPE, equipment, or materials from the covid-19 units are to cross into the non- COVID-19 facility; if such durable equipment needs to cross the material is to be disinfected, such as meal delivery carts, and soiled laundry barrels. The training is provided by multi-leveled staff begining with the Regional DON, the ADON's, and the charge nurses; after which the responsibility is individualized. The Regional DON and the Administrator stated as of 1/25/2022 the whole facility is deemed presumed (warm) COVID-19 with individual COVID-19 rooms, and 2 seperate COVID units (100-hall and 200-hall) due to the continued COVID-19 outbreaks and staff infection control breakdowns.<BR/>Record review of the facility's, undated, PPE for facility 3 policy revealed Contact isolation rooms are identified with a red contact isolation sheet on the door. These rooms are considered hot zone. Upon exiting the room, you will doff (take Off) your gown, gloves, step through the door and put a new gown on, sanitize your hands and walk to the cold zone and replace your mask and disinfect your face shield. Examples of non-direct contact: b. Passing medications that are not crushed or administered through a g-tube.<BR/>A record review of the Centers for Disease Prevention and Control website titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 10, 2021 revealed, Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection, Personal Protective Equipment, HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).<BR/>A record review of the Centers for Disease Prevention and Control website titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 10, 2021 revealed, Source control options for HCP include: A NIOSH-approved N95 or equivalent or higher-level respirator . When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions), they should be removed and discarded after the patient care encounter and a new one should be donned.<BR/>Record review of the CDC website, accessed 1/26/2022, regarding face shields revealed the following:<BR/> https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html#anchor_1605043382236:<BR/>Conventional Capacity Strategies<BR/>Use eye protection according to product labeling and local, state, and federal requirements.<BR/>In healthcare settings, eye protection is used by HCP to protect their eyes from exposure to splashes, sprays, splatter, and respiratory secretions (e.g., for patients on Droplet Precautions and for all patient encounters when there is moderate to substantial community transmission of SARS-CoV-2). Disposable eye protection should be removed and discarded. Reusable eye protection should cleaned and disinfected after each patient encounter.<BR/>Record review of CDC website, accessed 1/26/2022, revealed the following instructions for cleaning and disinfection of face shields:<BR/> https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html#anchor_1605043382236:<BR/>Selected Options for Reprocessing Eye Protection<BR/>Adhere to recommended manufacturer instructions for cleaning and disinfection.<BR/>When manufacturer instructions for cleaning and disinfection are unavailable, such as for single use disposable face shields or goggles, consider:<BR/>1. While wearing a clean pair of gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe.<BR/>2. Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution.<BR/>3. Wipe the outside of face shield or goggles with clean water or alcohol to remove residue.<BR/>4. Fully dry (air dry or use clean absorbent towels).<BR/>5. Remove gloves and perform hand hygiene.<BR/>6. Cleaned and disinfected eye protection can be stored onsite, in a designated clean area within the facility.<BR/>A facility policy was requested on 1/26/2022 at 9:00 am, and the Administrator stated the facility followed CDC's COVID-19 guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all residents were free from abuse for 2 of 6 residents (Residents #1 and #5) reviewed for abuse in that:<BR/>The facility staff failed to implement adequate interventions to ensure Resident #1 did not enter other resident rooms, which caused him to be abused by Resident #2 and Resident #3. Eventually, Resident #1 was pushed by Resident #3 and Resident #1 broke his right hip and his left index finger. Resident #1 was no longer independent after breaking his hip.<BR/>The facility failed to implement adequate interventions to ensure Resident #5 felt safe at the facility after he was pushed by resident #3.<BR/>This failure resulted in identification of an Immediate Jeopardy (IJ) on 3/17/23. While the IJ was removed on 3/19/23, the facility remained out of compliance level of actual harm with a scope identified as isolated until interventions were put in place to ensure residents were free from abuse. <BR/>This failure could place residents at risk for abuse from other residents.<BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated 3/15/23, revealed Resident #1 was originally admitted to the facility on [DATE] with diagnoses of unspecified dementia [a general term for impaired ability to remember, think, or make decisions], unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, pain, unspecified, and hypocalcemia (History of) [low levels of calcium in the blood.]<BR/>Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 did not have a BIMS score because Resident #1 was rarely/never understood. <BR/>Record review of Resident #1's care plan, obtained 3/15/23, revealed the following:<BR/>- Problem last updated 11/2/22: Behavior problem related to: Dementia AEB [As Evidenced By:] Roams into others rooms. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review date. One of the interventions was last updated on 11/2/22 read: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. <BR/>- Problem last updated 1/18/23: Resident resides in secure unit and is at risk for injury from wandering in an unsafe environment R/T [related to] impaired safety awareness. Resident is at risk for injury from others while residing in secure unit D/T [due to] altered cognition. This problem area had the following goal: Dignity will be maintained and resident will wander about unit without occurrence of any injury over the next quarter. One of the interventions last updated on 1/18/23 was: Keep environment free from possible hazards. This problem area also had the following goal dated 1/18/23: Activities director to monitor/discuss activity preference. This problem area also had the following goal dated 1/18/23: Allow resident to choose activities inside and outside that don't pose a safety risk. <BR/>Record review of activities documentation from 2/1/23 to 3/14/23 revealed Resident #1 had outside activity, which was outside (walk), as early as 2/2/23. Other activities that took place outside of the locked unit, like bingo were seen documented as early as 2/6/23 and a coffee social on 2/15/23.<BR/>Record review of Resident #2's face sheet, dated 3/15/23, revealed Resident #2 was originally admitted to the facility on [DATE] with diagnosis of dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, depression, unspecified, Type 2 diabetes mellitus without complications, and unspecified dementia with behavioral disturbance. Further record review of this document revealed Resident #2 was discharged on 3/10/23.<BR/>Record review of Resident #2's Discharge MDS, dated [DATE], revealed Resident #2 had a BIMS score of 3, signifying severe cognitive impairment.<BR/>Record review of Resident #2's care plan, obtained 3/15/23, revealed the following: <BR/>- Problem last updated 11/17/22: [Resident #2] is territorial of room/personal belongings r/t: Dementia with Behaviors. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review date. This problem area had the following intervention dated 11/3/22: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. <BR/>- Problem area last updated 1/4/23: Behavior problem related to: Dementia with behaviors AEB: Physical and Verbal aggression towards others. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review date. This problem area had the following interventions dated 1/4/23: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed.<BR/>Record review Resident #3's face sheet, dated 3/15/23, revealed Resident #3 was admitted to the facility on [DATE] with diagnosis of other lack of coordination, unspecified dementia, unspecified severity, with other behavioral disturbance, anxiety disorder, unspecified, unspecified psychosis not due to a substance of known physiological condition, and persistent mood [affective] disorder [a persistent and usually fluctuating disorders of mood which can last for many years that involve considerable distress and disability], unspecified.<BR/>Record review of Resident #3's 5-day MDS, dated [DATE], revealed Resident #3 had a BIMS score of 9, signifying moderate cognitive impairment.<BR/>Record review of Resident #3's care plan, obtained 3/15/23, revealed the following:<BR/>- Problem dated 3/10/23: Behavior problem related to: Dementia AEB: Physical Aggression/Verbal aggression. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily through next review date. This problem area had the following interventions dated 3/10/23: intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed.<BR/>Record review of Resident #5's face sheet, dated 3/15/23, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease [a progressive disease that affects memory and other important mental functions], unspecified, other abnormalities of gait and mobility, other lack of coordination, weakness, other malaise, and muscle wasting and atrophy not elsewhere classified, unspecified site. <BR/>Record review of Resident #1's incident report, dated 2/15/23 and written by LVN E, revealed the following: Brief Description of Incident: hit by another resident [Resident #2] in the head Description of injury: laceration [cut] over left eye . At 2:25 pm this nurse heard loud voices coming from . another resident's room, this resident [Resident #1] came out of the room, this nurse asked the other resident [Resident #2] what was the problem, the other resident [Resident #2] stated that he [Resident #2] hit this [sic] because he repeatedly told him [Resident #1] to get out of his [Resident #2's] room but he [Resident #1] refused. [sic]<BR/>Record review of Resident #2's nursing progress note, dated 2/15/23 and written by LVN E, revealed the following: this nurse heard loud voices coming from this resident's [Resident #2's] room, another resident [Resident #1] . came out of the room, this nurse asked the resident [Resident #2] what was the problem, resident [Resident #2] stated he hit the other [Resident #1] because he [Resident #2] repeatedly told him [Resident #1] to get out of his [Resident #2's] room but he refused.<BR/>Record review of Resident #1's incident report, dated 3/9/23 and written by LVN F, revealed the following: Patient went into another patient room when the Aggressor Punched other patient in the nose . Nurse was notified by CNA Patient was seen walking up and down hall with Excessive bleeding coming down from nose and another patient verbalized to her he came into his room and 'he got what he deserved.'<BR/>Record review of Resident #2's nursing progress note, dated 3/9/23 and written by LVN F, revealed the following: Nurse was notified by CNA Patient admitted to hitting another patient in the nose verbalized He got what he deserved because he walked into his room. <BR/>Record review of Resident #2's electronic health record revealed no 30-day discharge notice dated prior to his discharge on [DATE]. <BR/>Record review of Resident #5's nursing progress note, dated 3/11/23 at 10:31 a.m. and written by LVN F, revealed the following: Patient requested to [NAME] [sic] to nurse out in 'secret' He feels unsafe around another resident and would like for him to leave him alone. Nurse spoken [sic] to other resident and separated the two nurse will continue to monitor patients.<BR/>Record review of Resident #5's nursing progress note, dated 3/11/23 and written at 10:31 a.m. by LVN F, revealed Rm changed to 116B. <BR/>Record review of Resident #3's nursing progress note, dated 3/11/23 at 10:42 a.m. and written by LVN F, revealed the following: Patient seen trying to shove roommate into his room. When asked patient to please leave other patient alone he does not want to be in the room he shouted, 'I didn't touch him, I don't have blood on my hands.' Nurse talked to patient about keeping his hands to himself and patient understood.<BR/>Record review of Resident #3's nursing progress note, dated 3/11/23 at 4:06 p.m. and written by LVN F, revealed the following: Patient arguing and yelling at other patients in the hall, Nurse instructed patient to sit at nurse station for 1:1 Observation. For behavior problems. <BR/>Record review of Resident #1's incident report, dated 3/12/23 and written by LVN C, revealed the following: Brief description of incident: wandered to another resident room, pushed to the floor by another resident [Resident #3] . 3/12/23 at 9:29 a.m This hour resident [Resident #1] sent out to ER to evaluate/tx [treat.] Pushed to floor by another resident [Resident #3.] <BR/>Record review of Resident #3's nursing progress note, dated 3/12/23 and written by LVN C, revealed the following: This am [a.m., meaning morning,] Resident voiced 'I didn't do it. I have no blood on my hands' A commotion could be heard during resident smoke hour. This resident shouted, 'get outta my room'! Then a slapping noise. This writer check the hall another resident [Resident #1] on the floor. That resident [Resident #1] is unable to communicate the incident related to DX.<BR/>Record review of Resident #1's hospital physician progress note, dated 3/13/23, revealed the following: Presents after was wondering about other patients room, was pushed, fall, subsequent inability to stand up, brought to the ED [Emergency Department] which showed nondisplaced fracture of right femoral neck [right broken hip] as well as fracture of [left] proximal second digit [broken index finger.] He is scheduled to have surgical correction his afternoon.<BR/>Record review of Resident #1's hospital X-ray results, dated 3/13/23, revealed total right hip arthroplasty [hip replacement] without hardware complication.<BR/>Record review of Resident #1's Physical Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following short-term goals:<BR/>-Patient able to perform sit &lt;&gt;[to] stand 3x [3 times] mod A [Moderate Assistance] to improve safety with transfers . PLOF [Prior Level of Function] (prior to onset) Independent. Baseline (3/15/23) dependent.<BR/>-Patient able to stand with BUE [Bilateral Upper Extremities, meaning both arms] 1 minute min A [minimal assistance] to improve safety with transfers . PLOF (prior to onset) independent for most of the day. Baseline (3/15/23) unable limited by pain.<BR/>Further record review of this same Physical Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following long-term goals: <BR/>-Patient able to perform supine [lying on bed face-up] &lt;&gt; [to] sit supervision to decrease caregiver assistance . PLOF (prior to onset) independent. Baseline (3/15/23) dependent.<BR/>-Patient able to transfer bed &lt;&gt; [to] W/C [wheelchair] supervision to decrease caregiver assistance and risk for falls . PLOF (prior to onset) independent. Baseline (3/15/23) unable. Admit on stretcher to facility. Limited by pain.<BR/>-Patient able to ambulate [walk] with FWW [four wheel walker] 150' [150 feet] with supervision to decrease risk for falls . PLOF (prior to onset) independent no device. Baseline (3/15/23) unable.<BR/>Record review of Resident #1's Occupational Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following short-term goals:<BR/>-Patient will increase activity tolerance for functional activities of choice to 20 min in order to w/o [without] signs/symptoms of physical exertion increased participation with ADL tasks . PLOF Prior to onset) 20 min. Baseline (3/15/23) 30-60 seconds.<BR/>-Patient will safely perform self feeding tasks with Set-up (A) with use of for initiation/termination of tasks in order to facilitate self esteem through increased independence with tasks . PLOF (prior to onset) S/U [set up.] Baseline (3/15/23) Min (A) [Minimal Assistance]<BR/>-Patient will complete toilet/commode transfers with Modified Independence for clothing management with recognition of safety hazards . PLOF (prior to onset) MI [Modified Independence.] Baseline: Max (A) [Max Assistance].<BR/>Further record review of this same Occupational Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following long-term goals:<BR/>-Patient will complete hygiene and grooming tasks while standing at sink with Modified Independence for initiate/termination of tasks with recognition of safety hazards in order to facilitate ability to live in environment with least amount of supervision and assistance . PLOF (prior to onset) Modified Independence. Baseline (3/15/23) Max (A).<BR/>-Patient will safely perform toileting tasks using grab bars with Modified Independence for clothing management with recognition of safety hazards . PLOF (prior to onset) MI. Baseline (3/15/23) Max (A).<BR/>-Patient will safely and efficiently perform LB [Lower Body] Dressing with Modified Independence with use of for initiation/termination of tasks in order to be able to return to prior level of living . PLOF (prior to onset) MI. Baseline (3/15/23) Max (A)<BR/>Record review of Daily Schedule, dated 3/12/23, revealed the facility had 1 LVN, 1 CMA, and 1 CNA on 3/12/23. A second CNA was seen noted for the locked unit, but the second CNA's name scratched out and moved to another unit.<BR/>Record review of the facility's current staff roster, provided on 3/15/23, revealed the facility had 17 CNAs, 11 Nurse Aides, 4 CMAs, 9 LVNs, and 1 RN. Including the non-clinical staff, the facility had 65 total employees.<BR/>Record review of the facility's uploaded files from TULIP for Intake #411419 (which was the incident involving Resident #1 and Resident #2 on 3/9/23), revealed the following in-services conducted on the following dates:<BR/>-On 3/9/23, the facility educated 14 staff members on Falls and Unmanageable Residents. <BR/>-On 3/9/23, the facility also educated 22 staff members on Prevention of Abuse and Neglect. However, of the 22 staff members, 2 staff members signed their names twice for a total of 20 staff members. Of these now 20 staff members, 14 were the same staff members educated on Falls and Unmanageable residents. Only 6 new staff members received this education. <BR/>-On 3/13/23, the facility also educated 13 staff members on Abuse Reporting. <BR/>-On 3/13/23, the facility also educated 13 staff members on Managing Fall Risk. The 13 staff members on this in-service were the same 13 staff members who were educated on Abuse Reporting.<BR/>During an observation and interview on 3/15/23 at 1:11 p.m., Resident #1 was seen in bed, awake, alert, and fully-dressed. CO H was at Resident #1's bedside and CO H stated Resident #1 may not be able to answer questions due to his diagnosis of dementia. An interview was attempted with Resident #1. When asked if he had any issues with other residents, Resident #1 answered, yes, but he did not elaborate on his answer when this surveyor prompted Resident #1 to elaborate. CO H stated Resident #1 was attacked 3 times last week and stated Resident #1's last attack was on Sunday, 3/12/23. CO H stated she received a call from CO J and they both went to a local emergency department. CO H stated, the story they told [CO J] is that the nurse was out on the patio and she heard someone yell 'get out of here.' She [the nurse] went to investigate and [Resident #1] was on the floor. And that's when the hip was broken . They [the facility] promised me they were going to keep [Resident #1 and Resident #2] separate and keep [Resident #1] safe.<BR/>During an interview on 3/15/23 at 3:11 p.m., NA G stated if [Resident #3] sees anyone walking by, he'll try to pick a fight. Usually Resident #5 is afraid of Resident #3.<BR/>In a follow-up interview on 3/15/23 at 3:20 p.m., NA G stated she had heard [Resident #2] had struck [Resident #1.] NA G stated Resident #2 was no longer in the facility. <BR/>During an interview on 3/17/23 at 9:21 a.m., Resident #5 stated he did not feel safe in the facility. Resident #5 stated the other residents make him feel unsafe and have hurt him before. Resident #5 did not provide the names of the other residents who had hurt him. <BR/>During an interview on 3/17/23 at 9:22 a.m., LVN C stated she ensured the safety of residents in the facility's locked unit by frequently monitoring the residents. LVN C stated she currently had 2 CNAs, but she was supposed to have a 3rd CNA that was supposed to come in later. When asked how they ensured Resident #1's safety, LVN C stated frequent re-direction all the time . to the best of our ability educate the residents that it's not intentional on his part to invade their space. LVN C stated [Resident #2] could go for a good amount of time [without being aggressive] and then slowly start to show the signs and then explode. When asked how they managed Resident #2's aggressive behavior, LVN C stated they spoke with [Resident #2] firmly. LVN C stated after Resident #2 struck Resident #1 they had temporarily moved Resident #1 to the women's side until lunch the next day, 3/10/23, after Resident #2 was discharged . LVN C stated only new interventions she was aware of for [Resident #1] was to consider alternative placement but it was difficult to find alternative placement for Resident #1 due to his wandering. <BR/>Continuing the interview on 3/17/23 at 9:22 a.m., LVN C stated Resident #3's aggressive behavior was new for Resident #3. LVN C stated she believed Resident #3 may be mimicking Resident #2's aggressive behavior. LVN C stated, [Resident #3] somehow got attached to him and he was always calling out for [Resident #2.] And I found that extremely odd because [Resident #3] was becoming dependent on [Resident #2.] [Resident #3] felt safe around him. LVN C stated prior to 3/12/23, Resident #3 was approaching other residents with the intent to push them over, but when [Resident #3] was aware he was being watched by the facility staff, he would leave the other residents alone. LVN C confirmed she was working on 3/12/23, the day Resident #3 pushed Resident #1. LVN C stated, We were short [a staff member] that day. I remember because I had to take them out to smoke because usually a CNA would do it. So to keep the [other residents] calm I went and initiated the smoke [smoke break.] So I let them [the residents] out and then it happened. LVN C stated after Resident #3 pushed over Resident #1 and caused Resident #1 to break his hip they made sure [Resident #3] stayed away from the others.<BR/>During an interview on 3/17/23 at 10:48 a.m., LVN I stated he was currently the primary nurse for Resident #1. LVN I stated Resident #1 was currently on physical therapy and occupational therapy, which was new for Resident #1. LVN I stated Resident #1 could previously walk independently and currently cannot bear weight on his broken hip.<BR/>During an interview on 3/17/23 at 12:28 p.m., the DOR stated Resident #1 was currently on physical therapy and occupational therapy for his broken right hip. The DOR stated Resident #1 never required therapy before because he was ambulatory [able to walk] without any device and was independent with ADLs prior to his broken hip. The DOR stated Resident #1 was currently bed-bound at this point. He was independent, but now he's dependent. <BR/>During an interview on 3/17/23 at 1:34 p.m., the Director of Marketing LVN stated his current role at the facility was a Nurse Manager due to the fact the facility did not have a DON and ADON. The Director of Marketing LVN stated the facility ensured the safety of residents in the locked unit by frequent monitoring. The Director of Marketing LVN stated if 2 residents had a physical altercation the staff would ensure the altercation doesn't happen again by monitoring continuously. When asked about the incident involving Resident #1 and Resident #2 on 2/15/23, the Director of Marketing stated he could not recall much about the incident as that was around the time he began to become more involved in nurse management. The Director of Marketing LVN stated after the incident we did our frequent monitoring and then our redirection and then provided activities on the unit. <BR/>Continuing the interview on 3/17/23 at 1:34 p.m., the Director of Marketing LVN stated a resident was considered unmanageable when medication management failed to manage a resident's behavior and once that was identified the facility would find alternative placement. The Director of Marketing LVN stated Resident #2 was very nice . but he would have his spurts where if an individual invaded his space too closely, he might get a little aggressive . He was more of a verbal yelling and screaming. Just whenever his personal space was invaded. The Director of Marketing LVN stated to manage Resident #2's aggression they provided activities for him. We have an activity assistant back there [in the unit] to encourage to do activities throughout the day. The Director of Marketing LVN stated the facility had attempted to discharge Resident #2 to other nursing homes but was denied. The Director of Marketing LVN stated he was unsure if the facility ever issued a 30 day discharge notice to Resident #2. When asked about what happened between Resident #1 and Resident #2 on 3/9/23, the Director of Marketing LVN stated the facility sent out Resident #2 to the hospital for medical clearance but Resident #2 was sent back. The facility then scheduled Resident #2 to be sent out to another local hospital and when transportation arrived Resident #2 became combative, law enforcement was involved, Resident #2 was arrested and was currently not in the facility. The Director of Marketing LVN stated afterwards the facility initiated in-services on abuse, neglect, and resident-to-resident altercation. The Director of Marketing LVN stated the facility continued their current interventions from 2/15/23 for Resident #1 which included redirection, music therapy, providing more staff in the locked unit, and posting an identification marker on his Resident #1's room to help Resident #1 find where his room is.<BR/>Continuing the interview on 3/17/23 at 1:34 p.m., the Director of Marketing LVN stated Resident #3 had a diagnosis of dementia, anxiety, unspecified psychosis, and persistent mood disorder. The Director of Marketing LVN stated from admission until these recent events he's been very pleasant and after Resident #3 pushed Resident #1 the facility provided redirection, a calming environment, and scheduled a psychiatric evaluation for Resident #3 after he returned to the facility on 3/12/23. The Director of Marketing LVN stated the ideal staffing in the locked unit was 1 nurse and 2 CNAs, but on 3/12/23, the locked unit was short 1 CNA. The Director of Marketing LVN stated he did not feel the short-staffing contributed to Resident #1's incident on 3/12/23. When asked about the incident on 3/12/23, the Director of Marketing LVN stated the initial report was not made to him but to the facility's former MDS Nurse who was no longer employed at the facility. The Director of Marketing LVN stated, the only thing I remember is that the resident stated he didn't do it. I know [the former MDS Nurse] set up for [Resident #3] to be sent to [a local hospital] to be evaluated for psychiatric treatment and he came back. When asked if the facility implemented new interventions for Resident #3, the Director of Marketing LVN stated, just our general intervention. Just to provide a calm environment, redirection, and continuous monitoring. When asked if they implemented anything new for the staff, the Director of Marketing LVN stated, I know they did some in-services on abuse and neglect. The Director of Marketing LVN stated Resident #1 was independent before his incident on 3/12/23. When asked if they implemented anything new for Resident #1, the Director of Marketing LVN stated, we did incorporate a lot of activities that were off the unit to change his environment for him. The Director of Marketing LVN stated, I think they did everything they could have done to ensure the safety of all residents in this facility. They followed the procedures meant to be implemented in these situations.<BR/>During an interview on 3/17/23 at 3:05 p.m., the Administrator stated he had been the Administrator at the facility since early February 2023 and was currently the abuse coordinator. The Administrator stated they ensured the safety of residents in their locked unit by supervision and increased activities. The Administrator stated he did not recall if the facility had implemented any interventions for the locked unit after the incident involving Resident #1 and Resident #2 on 2/15/23. The Administrator stated he was not too familiar with Resident #2 beyond the incident between Resident #1 and Resident #2 on 3/9/23. The Administrator stated he was not aware of any new interventions for Resident #2 prior to 3/9/23. The Administrator stated he was aware the facility had attempted to discharge Resident #2 before 3/9/23 but with no success. The Administrator stated aside from in-servicing, the facility did not make any major changes after the incident between Resident #1 and Resident #2 on 3/9/23. <BR/>Continuing the interview on 3/17/23 at 3:05 p.m., the Administrator stated he heard Resident #3 became aggressive towards Resident #5 prior to Resident #3 pushing over Resident #1 on 3/12/23. The Administrator stated on 3/12/23 he was notified of the incident between Resident #3 and Resident #1 and he came on-site the same day to conduct safe surveys with other residents. When asked if there were any interventions in place to ensure Resident #1's safety, the Administrator stated, just the 15-minute check thing that we've done. I'll tell you what the problem is, it's the size of the hall . Most everyone has dementia and some of those guys get into people's personal space and some people don't like it. And [Resident #1] does that. He'll enter people's personal space and these guys-they have dementia too and I assume they don't like it. The Administrator stated he was unsure if there were any considerations to place Resident #1 in another facility. When asked if he felt the facility had done everything they could to ensure Resident #1's safety, the Administrator stated, I don't think I could have done anything to make that not happen. An updated education for the facility's incident report on 3/12/23 was requested at this time. <BR/>In a follow-up interview on 3/17/23 at 5:47 p.m., the Marketing Director LVN stated the facility's education on 3/9/23 carried over to the incident on 3/12/23. <BR/>During an interview on 3/18/23 at 10:45 a.m. with the Administrator, this surveyor requested for a copy of a 30-day discharge for Resident #2, if one was available.<BR/>In a follow-up interview on 3/18/23 at 11:03 a.m., LVN C stated she was aware Resident #3 attempted to push Resident #5 before and heard Resident #3 raised a fist at Resident #5. LVN C stated Resident #5 felt unsafe around Resident #3 and wanted to change rooms.<BR/>In a follow-up interview on 3/18/23 at 11:15 a.m. with CO H, CO H stated, [Resident #1] walks and always has. That honestly is my biggest concern . He used to sit up by himself and stand and now he can't do that . Something that he's never done before that's really concerned me is that I went to move his hair out of his eyes and he flinched. And that broke my heart. He knows I'd never lay a hand on him . He sleeps a lot more. He never used to sleep during the day. He was always up and walking.<BR/>During an interview on 3/18/23 at 11:59 a.m., the Assistant Activities Director stated she conducted activities for the locked unit. The Assistant Activities Director stated she was told to do more activities with the men's locked unit, but added, I'm still making it work because she was trying to balance doing activities for the men and women's locked unit. When asked about any new changes to their activities schedule, the Assistant Activities Director stated the facility started having weekly outings on Thursdays since 3/2/23. The Assistant Activities Director stated off-unit activities had been implemented since October 2022. The Assistant Activities Director state the facility's off-unit activities included coffee socials on Tuesday, and bingo on Tuesdays and Thursdays. When asked about Resident #1, the Assistant Activities Director stated the resident liked to go for walks and she would take him to walk through the dining hall and outside at least 2 or 3 times per week for 30 minutes. <BR/>During an interview and record review on 3/18/23 at 12:28 p.m., the Assistant Activities Director stated she was asked to pass to this surveyor a print-out of Resident #2'nursing and physician progress notes with highlighted portions indicating the facility's unsuccessful attempts to discharge Resident #2. No 30-day discharge notice was provided with this print-out and there was no documentation in the progress notes that indicated a 30-day discharge notice was provided.<BR/>Record review of a facility policy titled, Preventing Resident Abuse, dated February 2014, revealed the following, Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse . The facility's goal is to achieve and maintain an abuse-free environment. <BR/>Record review of Resident #1's signed admission agreement, dated 10/19/23, revealed the following: Each Resident has the right to be free from verbal, sexual, mental and physical abuse, corporal punishment, and involuntary seclusion.<BR/>The Administrator was notified of an IJ on 3/17/23 at 5:48 p.m. and was given a copy of the IJ Tem[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nurses had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 2 out of 9 LVNS (LVN G and LVN H) reviewed for the administration of medications via and caring for a central line. <BR/>As of 12/08/2023, 2 LVNs (LVN G and LVN H) operated outside their scope of practice by administering medications via Resident #1's PICC.<BR/>These failures could place residents at risk for adverse outcomes to resident care and/or services and may also include the potential for physical and psychosocial harm.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet, dated 12/08/23, revealed the resident was admitted on [DATE] with the following diagnosis: Acute hematogenous osteomyelitis (infection in the bone caused by bacteria), left tibia (anterior bone of the lower leg) and fibula (bone located next to the tibia) <BR/>Record review of Resident #1's MDS assessment, dated 12/04/2023, revealed the resident had a BIMS score of 15 (suggesting intact cognition). <BR/>Record review of Resident #1's Care Plan, dated 11/30/2023, revealed the following: Problem: resident has amputation to: L AKA. Receiving antibiotics Cefazolin 2gm/100 mL Q8 IV via PICC line to R arm. <BR/>Record review of Resident #1's Prescription Order, dated 11/27/2023, revealed Normal Saline Flush (sodium chloride 0.9 % (flush) syringe; a.m.t: 10 mL; injection. Special Instructions: Flush with 10 mL before each dose, 20 mL after each dose and Q shift to maintain patency. <BR/>Record review of Resident #1's Prescription Order, dated 11/28/2023, revealed cefazolin (antibiotic) in dextrose piggyback (An IV piggyback is a small bag of solution attached to a primary infusion line or intermittent venous access device to deliver medication over a specified period of time); 2 gram./100 mL; a.m.t: 1 unit; intravenous. Every 8hrs times 35 days. <BR/>Record review of Resident #1's MAR, dated 12/01/2023 - 12/10/2023 revealed saline flush was administered on:<BR/>12/07/2023 night shift by LVN H and<BR/>12/08/2023 day shift by LVN G<BR/>Record review of Resident #2's Face Sheet, dated 12/11/23, revealed the resident was re-admitted on [DATE] with the following diagnosis: Osteomyelitis (infection in the bone caused by bacteria), and methicillin resistant staphylococcus aureus infection (infection difficult to treat due to resistance to antibiotics). <BR/>Record review of Resident #2's MDS, dated [DATE], revealed the resident had a BIMS score of 11 (suggesting moderate impairment). <BR/>Record review of Resident #2's Prescription Order, dated 12/08/2023, revealed levofloxacin solution; 25 mg/mL; a.m.t: 750mg; intravenous; once a day. <BR/>Record review of Resident #2's MAR, dated 12/01/2023 - 12/11/2023 revealed levofloxacin was administered on:<BR/>12/08/2023 at 12:00 a.m. by LVN H and <BR/>12/08/2023 at 08:00 a.m. by LVN G<BR/>During an interview on 12/08/23 at 11:00 a.m., the Administrator was asked for personnel records, including competencies and certifications, for LVN H and LVN G. <BR/>During an interview 12/08/23 at 02:00 p.m. the RNC said the facility did not have a policy for medication administration via IV. <BR/>During an interview on 12/08/2023 at 02:43 p.m., LVN G confirmed she had administered cefazolin to Resident #1 at 02:00 p.m. <BR/>During observation and interview on 12/08/2023 at 01:45 p.m., Resident #1 was sitting on his bed, clean and groomed, he had no visible injuries, PICC was noted to the right upper arm with dressing initialed by the DON, dated 12/05/2023 which was clean dry and intact and surgical wound was noted to the left leg s/p AKA. Resident #1 said the PICC was doing fine, no infections, the dressing was changed on 12/5/23, and he received his medication 3 times a day.<BR/>During an interview on 12/08/2023 at 3:24 p.m., the DON said any licensed nurse was able to administer medications via a central line. She said the LVNs did have competency evaluations completed prior to her hire and was looking for them but was unable to find any. She added the ADONs might have some. The DON said she did not know if the facility had a policy regarding central lines. <BR/>During an interview on 12/08/2023 at 03:28 p.m., LVN H said she was not aware of any policy regarding medication administration via central lines and did not know if the LVNs had had competency evaluations because the facility did not have residents with PICCs in the past. <BR/>During observation and interview on 12/08/2023 at 05:27 p.m., Resident #2 was sitting up in bed, clean and groomed, he had no visible injuries, PICC was noted to right upper arm with dressing that was clean, dry and intact. Resident #2 said he was doing well. He said he received his medications on time and had no issues with the PICC. <BR/>Record review of the facility policy dated May 2019 and titled Competency of Nursing Staff revealed: .1. All nursing staff must meet the specific requirements of their respective licensure and certification requirements defined by State law. 2. I addition, licensed nurses .employed (or contracted) by the facility will .b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of resident, as identified through resident assessments and described in the plans of care. <BR/>Record review of Texas Board of Nursing Position Statement 15.27, The Licensed Vocational Nurse Scope of Practice revealed Position Statement 15.27, The Licensed Vocational Nurse Scope of Practice, provides additional clarification of the Standards of Nursing Practice Rule as it applies to LVN scope of practice. Instruction and skill evaluation relating to LVNs performing insertion of peripheral IV catheters and/or administering IV fluids and medications as prescribed by an authorized practitioner may allow an LVN to expand his/her scope of practice to include IV therapy.<BR/>It is the opinion of the Board that the LVN shall not engage in IV therapy related to either peripheral or central venous catheters, including venipuncture, administration of IV fluids, and/or administration of IV push medications, until successful completion of a validation course that instructs the LVN in the knowledge and skills applicable to the LVN's IV therapy practice. The BON does not define or set qualifications for an IV Validation Course or for LVN IV certification. The LVN who chooses to engage in IV therapy must first have been instructed in the principles of IV therapy congruent with prevailing nursing practice standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure for accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 residents (Resident #14) reviewed for medications and pharmacy services. The facility failed to ensure Resident #14 morning meds were disposed of appropriately when the resident refused the medications on 9/06/2025 by MA P. The facility failed to ensure Resident #1's hydrocodone was appropriately wasted and documented when it was removed from original container on 8/29/2025 by LVN A. These deficient practices could put residents at risk for medication errors. The findings included: Record review of Resident #14's face sheet, dated 9/06/2025 revealed an [AGE] year-old male admitted on [DATE] with diagnoses which included severe dementia, anxiety disorder, restlessness and agitation. Record review of Resident #14's modified quarterly MDS dated [DATE] revealed a BIMs score of 4 which indicated a severe cognitive impairment with no behavior symptoms. His ADL function was listed as set up assistance. Record review of Resident #14's care plan revealed was on hospice care with interventions which included administer medications and treatments as ordered. A plan of care for behavior problems with intervention which included administer medications as ordered and behavior monitoring. A plan of care for resistance to care such as care refusals related to dementia with interventions which included: if resident resists with ADL's, reassure resident, leave and return 5-10 minutes later and try again. Record review of Resident #14's September MAR revealed the following medications were marked as refused by MA P: Fluoxetine 20 mg-give 2 capsules by mouth one time a day for depressionLisinopril 2.5 mg-give one tablet by mouth in the morning for hypertension.Provera 2.5 mg-give one tablet by mouth one time a day for lower testosterone levels related to dementia. Depakote Sprinkles delayed release 125 mg-give 3 capsules by mouth two times a day related to dementiaLorazepam 0.5 mg-give one tablet by mouth three times a day for anxiety and agitations related to anxiety disorder. During an observation on 9/06/2025 at 4:05 pm of the medication cart on 100 hallway assigned to MA P revealed a medication cup with pudding and crushed meds mixed with the pudding in the second drawer of the medication cart. The medication cup had the Resident #14's first name handwritten on the cup. During an interview on 9/06/2025 at 4:11 p.m., MA P stated the medication in the pudding belonged to Resident #14 and it was his morning medications. She stated Resident #14 had allowed her to take his vital signs this morning but when she went to administer the medication he refused, pushed it away and tried to hit her. She stated she put it in the medication cart to give it later. MA P stated the medication included Depakote, fluoxetine, lisinopril, Provera and lorazepam 0.5mg (controlled substance). She stated she had signed the medication off in the medical record. MA P stated she had received the in-service training on medication administration. She stated she thought as long as the name was on the cup it was okay to keep it. MA P stated she told LVN C what she was doing and the LVN said it was fine. MA P stated she learned in training as long as the resident name was on the cup that it was fine to keep and hold on to. During an interview on 9/06/2025 at 4:22 p.m., LVN C stated MA P had informed her Resident #14 had refused medication. She stated she did not know MA P held the meds mixed in pudding in the cart. She stated she should have had MA P and herself wasted (disposed) the medications together because of the risk for medication error with pre-dispensed medications. 2. Record review of Resident #1's face sheet dated 9/03/2025 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: epilepsy, hypotension (low blood pressure), cardiomyopathy (disease of the heart muscle) and schizophrenia (serious mental health condition that affects how people think feel and behave). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicated a severe cognitive impairment with behaviors that included rejection of care less than daily. Resident #1's functional status was listed partial assistance showering/bathing and supervision for oral care and eating. Record review of Resident #1's care plan dated 7/15/2025 revealed she was on hospice care with interventions to observe for pain and administer pain medications as ordered by a physician. Record review of Resident #1's BIMS evaluation dated 9/02/2025 revealed a score of 15 which indicated the resident was cognitively intact. Record review of Resident #1's physician order summary for August 2025 revealed the following medication order: Hydrocodone-acetaminophen oral tablet 10/325 mg, give 0.5 tablet by mouth every 8 hours as needed for pain with a start date 8/29/2025. Record review of Resident #1's Narcotic Administration Record for hydrocodone-acetaminophen 10/325 mg revealed LVN A signed out one dosage (0.5 mg) of the narcotic on 8/29/2025 at 8 p.m. Record review of Resident #1's August 2025 MAR revealed hydrocodone-acetaminophen 10/325 mg tablet, give 0.5 tablet every 8 hours as needed was not documented as administered. Record review of Resident #1's hospital records dated 8/31/2025 revealed the resident was admitted to the hospital due to inadvertent administration of another patient's medication while at her nursing facility. The hospital MD called the nursing facility and confirmed medications which included eight medications and a question mark for hydrocodone. Nursing facility staff stated this (hydrocodone) may not have been administered as it was a later dose for this patient. Urine drug screen noted positive for opioids, TCA's (tricyclic antidepressants) and benzos (benzodiazepines). During an interview on 9/03/2025 at 1:45 p.m., Resident #1 stated on Friday 8/29/2025 she was approached by an unknown staff member and given medications two times in a short period of time. She stated she was not sure what she was given as she trusted the staff and just took the medications. During an interview on 9/04/2025 at 1:30 p.m., LVN A stated she signed Resident #1's hydrocodone out on the narcotic record. She stated she does not believe she administered the hydrocodone to the resident. She stated pulled the hydrocodone and intended to give it when she made a medication error with Resident #1. She stated she was more worried about caring for Resident #1 than she was about documentation or the disposal of medication. She stated she threw the hydrocodone in the sharps container but did not have another staff member witness the wasting of the medication as required for a narcotic or correct any documentation. She stated she was trained to have another nurse witness the waste (disposal) with her and then document the medication waste with double signatures. During an interview on 9/04/2025 at 1:39 p.m. the DON stated she had reviewed the narcotic record for Resident #1's hydrocodone which indicated the medication was documented as removed at 8:00 pm on 8/29/2025. The DON stated she does not believe the hydrocodone was given to Resident #1 and the time did not match when it was actually pulled. She stated LVN A documented on the narcotic record when the time it was supposed to be given rather than the time it was given. The DON stated she had reviewed with LVN A. The DON stated LVN A should document the medication at the actual time the medication was given. During an interview on 9/07/2025 at 3:01 p.m., the DON stated medications should be wasted and discarded if not administered to avoid confusion. Record review of a facility policy, titled Medication Administration last revised 5/07/2025 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.3. Identify resident 10. Ensure that the six rights of medication administration are followed. a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation. 11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form dose, route and time. 14. Remove medication from source.15. Administer medication as ordered in accordance with manufacturer specifications 19. Observe resident consumption of medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the required abuse training for all employees for 3 of 3 abuse incidents reviewed for abuse training, in that: <BR/>The facility failed to address allegations of abuse for Resident #s 4, 5, and 3 by in servicing all staff on abuse definition and reporting.<BR/>This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. <BR/>Findings included:<BR/>1. Record review of Resident #5's Face Sheet, dated 12/08/2023 revealed Resident #5 was an [AGE] year-old male, initially admitted to the facility on [DATE] with diagnoses of dementia (a general term for impaired ability to remember, think, or make decisions), Alzheimer's disease (a progressive disease that affects memory and other important mental functions), and muscle wasting and atrophy (shrinking of muscle or nerve tissue). <BR/>Record review of Resident #5's MDs, assessment date 09/21/2022 revealed Resident #5 had a BIMS score of 05 and was severely cognitively impaired. <BR/>Record review of facility Provider Investigation Report signed 12/11/2023 revealed the facility ADMIN reported an incident involving Resident #5 to HHSC on 12/04/2023. The report revealed Resident #5 was found to have a bruise of unknown origin to his right inner thigh. The report revealed Resident #5 was unable to recall how the bruise occurred. The report revealed staff were interviewed and unable to identify the cause of the bruise. The report revealed the investigation findings were inconclusive and staff training on abuse and neglect, and bed positioning and transferring were conducted. <BR/>Record reviews of facility Employee Roster dated as generated 12/05/2023 revealed the facility had 70 employees. Record review of in-service training report dated 12/04/2023, topic noted as Abuse & Neglect/ Bed Positioning/ Transferring revealed 23 signatures. Comparison of legible typed and signed names on the in-service training report to the facility Employee Roster indicated 22 of 70 facility staff were trained, including 14 of the 43 clinical staff. One name typed and signed on the in-service document was illegible. <BR/>2. Record review of Resident #4's Face Sheet, dated 12/11/2023 revealed Resident #4 was a [AGE] year-old female, initially admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, bipolar type (a chronic mental illness involving symptoms of schizophrenia and bipolar disorder and characterized by symptoms such as delusions, hallucinations, depression, and high-energy mood), diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), and nightmare disorder (a sleep disorder that involves frequent and disturbing dreams that cause anxiety, fear, or sleep disturbance).<BR/>Record review of Resident #4's MDS, assessment date 09/21/2023 revealed Resident #4 had a BIMS score of 10 and was moderately cognitively impaired. <BR/>Record review of facility Provider Investigation Report signed 12/14/2023 revealed the facility ADMIN reported an incident involving Resident #4 to HHSC on 12/07/2023. The report revealed Resident #4 reported an allegation of abuse to the ADMIN on 12/07/2023, reporting CNA C had pushed her into the wall of her room around 10:00 p.m. on 12/06/2023. The report revealed the ADMIN interviewed CNA C, who denied the alleged interaction with Resident #4 and suspended CNA C pending the investigation into the incident. The report revealed Resident #4 had no noted bruising from alleged incident. The investigation findings were noted as unconfirmed. The report revealed the ADMIN continued ongoing abuse and neglect staff training and that CNA C decided to not return to the facility following the suspension. <BR/>Record review of facility in-service training report dated 12/09/2023, topic noted as Red Events & Notifications and Abuse & Neglect & Reporting revealed 28 signatures. Comparison of legible typed and signed names on the in-service training report to the facility Employee Roster, dated as generated 12/05/2023 indicated 22 of 70 staff were trained, including 18 of 43 clinical staff. Additional names were noted as agency staff with one illegible typed and signed name. <BR/>During an interview with Resident #4's RP on 12/14/2023 at 03:25 p.m., he revealed that Resident #4 had told him that she had reported the incident that occurred 12/06/2023 p.m. to the night charge nurse but that nothing was done following her report. Resident #4's RP stated that he came to the facility on [DATE] to raise hell. He stated that he was excited that they contacted the state and reported the incident but was upset that the police department did not interview Resident #4 even though she cannot make a cognizant report. Resident #4's RP stated that Resident #4 does not feel safe living in the facility due to another resident that stalks her and comes into her room at night but that the incident on 12/06/2023 was the first time something of that nature had occurred. Resident #4's RP stated he was delighted with how the facility had addressed the incident. <BR/>3. Record review of Resident #3's Face Sheet, dated 12/11/2023 revealed Resident #3 was a [AGE] year-old male, admitted to the facility on [DATE]. Resident #3's preferred language was English. Resident #3's diagnoses included dementia (a general term for impaired ability to remember, think, or make decisions), chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and cognitive communication deficit (difficulty communicating due to injury to the brain).<BR/>Record review of Resident #3's MDS, assessment date 11/04/2023 revealed Resident #3 had a BIMS score of 06 severe cognitive impairment.<BR/>During an interview with Resident #3 on 12/07/2023, Resident #3 stated that one staff member talks to me bad, she said that I have to stay in my room, that she can get me locked up in jail or get me committed. He revealed that staff told him he was stupid because he had COVID-19. He stated that the staff are not gods, to talk to him like that. He continued to state that we are just like them and should be spoken to as such. Resident #3 was unable to identify the staff but said he thought she was a nurse and he had not reported this to the facility. <BR/>Record review of facility Provider Investigation Report signed 12/15/2023 revealed the facility ADMIN reported an incident involving Resident #3 to HHSC on 12/08/2023. The report revealed the ADMIN on 12/07/2023 witnessed LVN J tell Resident #3 that she was going to hit him and observed LVN J pointing directly at Resident #3, which caused him to back away from her. The report revealed the ADMIN terminated LVN J's employment, contacted the police regarding the incident, notified the Texas Board of Nursing, and continued ongoing abuse and neglect staff training. The investigation findings were noted as confirmed.<BR/>Record review of facility in-service training report dated 12/18/2023, topic noted as Abuse & Neglect & Abuse Prevention revealed 12 signatures. Comparison of legible typed and signed names on the in-service training report to the facility Employee Roster, dated as generated 12/05/2023, to the in-service training report dated 12/04/2023, and to the in-service training report dated 12/09/2023 revealed two (2) staff were trained on 12/18/2023 that were not trained on 12/04/2023 or 12/09/2023, one (1) additional new legible name was not identified on the facility employee roster, and one (1) name was illegible typed and signed.<BR/>During an interview with Resident #3 on 12/19/2023, he revealed at the time of the incident on 12/07/2023, he had felt threatened and fearful. <BR/>Record review of facility policy Abuse Prevention Program, dated as revised 12/2026, revealed the policy statement, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms . As part of the resident abuse prevention, the administration will: 4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse .<BR/>Record review of facility policy Abuse and Neglect- Clinical Protocol, dated as revised March 2018, revealed the following, .Treatment/Management 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect.

Based on observation, interview, and record review, the facility failed to provide a comfortable and safe temperature levels for 1 of 1 kitchen reviewed for environmental temperatures.<BR/>The Facility's kitchen air temperature readings exceeded the maximum of 81 degrees Fahrenheit; temperature reading was 84 degrees Fahrenheit.<BR/>This failure could lead kitchen staff preparing meals in a hot environment, the air conditioner was not working and the cooking area measurd 87 F, impacting the time and quality of meals served to residents; and residents experiencing a diminished quality of life. <BR/>The findings included:<BR/>Initial observation on 05/17/23 from 1:05 PM-1:20 PM of facility's kitchen air temperatures, measured by [NAME] B's temperature gauge, revealed: the pots and pan area measured 83F; the AC was not working; the cooking area measured 87 F; the dishwashing area measured 83 F; and the thermostat was not working.<BR/>During an interview on 05/17/23 at 2:43 PM, the Administrator stated: he was not aware the kitchen thermostat was not working; and that some areas in the kitchen air temperatures were above 81 degrees F. He stated he was not aware of any workorders associated with the kitchen air temperature readings. The administrator stated the FSS was responsible for putting in work orders and notifying the Maintenance Supervisor.<BR/>During an interview on 05/17/23 at 2:57 PM, the FSS stated the kitchen had been hot since August 2022; and no work orders were filed by kitchen staff. The AC had not been working since August 2022. The kitchen staff had complained to the previous management team (Administrator and Maintenance Supervisor ). The FSS stated, I did not say anything .I did not want to create waves .this is my last day here (05/17/23) . <BR/>During an interview on 05/17/21 at 3:03 PM, Dishwasher A , stated, it has been hot for the last three weeks .especially when the stove and oven are on .the AC is not working .I did not complain because I did not want to cause problems . <BR/>During an interview on 05/17/23 at 3:05 PM, [NAME] B, stated: .the kitchen has been hot since the past 6 months .I complained to the old maintenance guy .and the old administrator .the parts never came, and the AC never got fixed .the AC is not working today . [NAME] B added that every day he enters the freezer to cool down because of the heat in the kitchen.<BR/>Observation on 05/17/23 at 4:20 PM of kitchen revealed: the air temperature was 84 F.<BR/>During an interview on 05/18/23 at 8:30 AM, the Administrator stated the temperature readings were not taken by Maintenance staff of the kitchen from 04/10/23 (Administrator's date to hiring) to the present (05/17/23) <BR/>During an interview on 05/18/23 at 8:36 AM, the assistant Maintenance Supervisor , stated he had not taken air temperature readings of the kitchen from 04/10/23 to the present (05/17/23); The assistant Maintenance Director stated: he knew the AC in the kitchen was not working and was waiting on corporate approval for an AC contractor assessment and approval of work. The assistant Maintenance Supervisor stated, No formal work-order was documented in the Maintenance Work Log. <BR/>Record review of facility's temperature logs from April to May 2023 revealed no documentation of readings of air temperatures of the kitchen. <BR/>Record review of Administrator's personal temperature log notes revealed he took air temperatures on: 05/15/23-05/18/23 of Hall 100 (secured unit-Men's section) only. No temperature readings were listed for the kitchen for the latter period. <BR/>Record review of facility's Quality of Life-Homelike Environment dated revised February 2014 read: .Characteristics of a Personalized, Homelike Setting .g. Comfortable temperatures .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all residents were free from abuse for 2 of 6 residents (Residents #1 and #5) reviewed for abuse in that:<BR/>The facility staff failed to implement adequate interventions to ensure Resident #1 did not enter other resident rooms, which caused him to be abused by Resident #2 and Resident #3. Eventually, Resident #1 was pushed by Resident #3 and Resident #1 broke his right hip and his left index finger. Resident #1 was no longer independent after breaking his hip.<BR/>The facility failed to implement adequate interventions to ensure Resident #5 felt safe at the facility after he was pushed by resident #3.<BR/>This failure resulted in identification of an Immediate Jeopardy (IJ) on 3/17/23. While the IJ was removed on 3/19/23, the facility remained out of compliance level of actual harm with a scope identified as isolated until interventions were put in place to ensure residents were free from abuse. <BR/>This failure could place residents at risk for abuse from other residents.<BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated 3/15/23, revealed Resident #1 was originally admitted to the facility on [DATE] with diagnoses of unspecified dementia [a general term for impaired ability to remember, think, or make decisions], unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, pain, unspecified, and hypocalcemia (History of) [low levels of calcium in the blood.]<BR/>Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 did not have a BIMS score because Resident #1 was rarely/never understood. <BR/>Record review of Resident #1's care plan, obtained 3/15/23, revealed the following:<BR/>- Problem last updated 11/2/22: Behavior problem related to: Dementia AEB [As Evidenced By:] Roams into others rooms. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review date. One of the interventions was last updated on 11/2/22 read: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. <BR/>- Problem last updated 1/18/23: Resident resides in secure unit and is at risk for injury from wandering in an unsafe environment R/T [related to] impaired safety awareness. Resident is at risk for injury from others while residing in secure unit D/T [due to] altered cognition. This problem area had the following goal: Dignity will be maintained and resident will wander about unit without occurrence of any injury over the next quarter. One of the interventions last updated on 1/18/23 was: Keep environment free from possible hazards. This problem area also had the following goal dated 1/18/23: Activities director to monitor/discuss activity preference. This problem area also had the following goal dated 1/18/23: Allow resident to choose activities inside and outside that don't pose a safety risk. <BR/>Record review of activities documentation from 2/1/23 to 3/14/23 revealed Resident #1 had outside activity, which was outside (walk), as early as 2/2/23. Other activities that took place outside of the locked unit, like bingo were seen documented as early as 2/6/23 and a coffee social on 2/15/23.<BR/>Record review of Resident #2's face sheet, dated 3/15/23, revealed Resident #2 was originally admitted to the facility on [DATE] with diagnosis of dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, depression, unspecified, Type 2 diabetes mellitus without complications, and unspecified dementia with behavioral disturbance. Further record review of this document revealed Resident #2 was discharged on 3/10/23.<BR/>Record review of Resident #2's Discharge MDS, dated [DATE], revealed Resident #2 had a BIMS score of 3, signifying severe cognitive impairment.<BR/>Record review of Resident #2's care plan, obtained 3/15/23, revealed the following: <BR/>- Problem last updated 11/17/22: [Resident #2] is territorial of room/personal belongings r/t: Dementia with Behaviors. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review date. This problem area had the following intervention dated 11/3/22: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed. <BR/>- Problem area last updated 1/4/23: Behavior problem related to: Dementia with behaviors AEB: Physical and Verbal aggression towards others. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily, through next review date. This problem area had the following interventions dated 1/4/23: Intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed.<BR/>Record review Resident #3's face sheet, dated 3/15/23, revealed Resident #3 was admitted to the facility on [DATE] with diagnosis of other lack of coordination, unspecified dementia, unspecified severity, with other behavioral disturbance, anxiety disorder, unspecified, unspecified psychosis not due to a substance of known physiological condition, and persistent mood [affective] disorder [a persistent and usually fluctuating disorders of mood which can last for many years that involve considerable distress and disability], unspecified.<BR/>Record review of Resident #3's 5-day MDS, dated [DATE], revealed Resident #3 had a BIMS score of 9, signifying moderate cognitive impairment.<BR/>Record review of Resident #3's care plan, obtained 3/15/23, revealed the following:<BR/>- Problem dated 3/10/23: Behavior problem related to: Dementia AEB: Physical Aggression/Verbal aggression. This problem area had the following goal: Will have behavior identified so that staff may intervene quickly with listed interventions, daily through next review date. This problem area had the following interventions dated 3/10/23: intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to another location as needed.<BR/>Record review of Resident #5's face sheet, dated 3/15/23, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease [a progressive disease that affects memory and other important mental functions], unspecified, other abnormalities of gait and mobility, other lack of coordination, weakness, other malaise, and muscle wasting and atrophy not elsewhere classified, unspecified site. <BR/>Record review of Resident #1's incident report, dated 2/15/23 and written by LVN E, revealed the following: Brief Description of Incident: hit by another resident [Resident #2] in the head Description of injury: laceration [cut] over left eye . At 2:25 pm this nurse heard loud voices coming from . another resident's room, this resident [Resident #1] came out of the room, this nurse asked the other resident [Resident #2] what was the problem, the other resident [Resident #2] stated that he [Resident #2] hit this [sic] because he repeatedly told him [Resident #1] to get out of his [Resident #2's] room but he [Resident #1] refused. [sic]<BR/>Record review of Resident #2's nursing progress note, dated 2/15/23 and written by LVN E, revealed the following: this nurse heard loud voices coming from this resident's [Resident #2's] room, another resident [Resident #1] . came out of the room, this nurse asked the resident [Resident #2] what was the problem, resident [Resident #2] stated he hit the other [Resident #1] because he [Resident #2] repeatedly told him [Resident #1] to get out of his [Resident #2's] room but he refused.<BR/>Record review of Resident #1's incident report, dated 3/9/23 and written by LVN F, revealed the following: Patient went into another patient room when the Aggressor Punched other patient in the nose . Nurse was notified by CNA Patient was seen walking up and down hall with Excessive bleeding coming down from nose and another patient verbalized to her he came into his room and 'he got what he deserved.'<BR/>Record review of Resident #2's nursing progress note, dated 3/9/23 and written by LVN F, revealed the following: Nurse was notified by CNA Patient admitted to hitting another patient in the nose verbalized He got what he deserved because he walked into his room. <BR/>Record review of Resident #2's electronic health record revealed no 30-day discharge notice dated prior to his discharge on [DATE]. <BR/>Record review of Resident #5's nursing progress note, dated 3/11/23 at 10:31 a.m. and written by LVN F, revealed the following: Patient requested to [NAME] [sic] to nurse out in 'secret' He feels unsafe around another resident and would like for him to leave him alone. Nurse spoken [sic] to other resident and separated the two nurse will continue to monitor patients.<BR/>Record review of Resident #5's nursing progress note, dated 3/11/23 and written at 10:31 a.m. by LVN F, revealed Rm changed to 116B. <BR/>Record review of Resident #3's nursing progress note, dated 3/11/23 at 10:42 a.m. and written by LVN F, revealed the following: Patient seen trying to shove roommate into his room. When asked patient to please leave other patient alone he does not want to be in the room he shouted, 'I didn't touch him, I don't have blood on my hands.' Nurse talked to patient about keeping his hands to himself and patient understood.<BR/>Record review of Resident #3's nursing progress note, dated 3/11/23 at 4:06 p.m. and written by LVN F, revealed the following: Patient arguing and yelling at other patients in the hall, Nurse instructed patient to sit at nurse station for 1:1 Observation. For behavior problems. <BR/>Record review of Resident #1's incident report, dated 3/12/23 and written by LVN C, revealed the following: Brief description of incident: wandered to another resident room, pushed to the floor by another resident [Resident #3] . 3/12/23 at 9:29 a.m This hour resident [Resident #1] sent out to ER to evaluate/tx [treat.] Pushed to floor by another resident [Resident #3.] <BR/>Record review of Resident #3's nursing progress note, dated 3/12/23 and written by LVN C, revealed the following: This am [a.m., meaning morning,] Resident voiced 'I didn't do it. I have no blood on my hands' A commotion could be heard during resident smoke hour. This resident shouted, 'get outta my room'! Then a slapping noise. This writer check the hall another resident [Resident #1] on the floor. That resident [Resident #1] is unable to communicate the incident related to DX.<BR/>Record review of Resident #1's hospital physician progress note, dated 3/13/23, revealed the following: Presents after was wondering about other patients room, was pushed, fall, subsequent inability to stand up, brought to the ED [Emergency Department] which showed nondisplaced fracture of right femoral neck [right broken hip] as well as fracture of [left] proximal second digit [broken index finger.] He is scheduled to have surgical correction his afternoon.<BR/>Record review of Resident #1's hospital X-ray results, dated 3/13/23, revealed total right hip arthroplasty [hip replacement] without hardware complication.<BR/>Record review of Resident #1's Physical Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following short-term goals:<BR/>-Patient able to perform sit &lt;&gt;[to] stand 3x [3 times] mod A [Moderate Assistance] to improve safety with transfers . PLOF [Prior Level of Function] (prior to onset) Independent. Baseline (3/15/23) dependent.<BR/>-Patient able to stand with BUE [Bilateral Upper Extremities, meaning both arms] 1 minute min A [minimal assistance] to improve safety with transfers . PLOF (prior to onset) independent for most of the day. Baseline (3/15/23) unable limited by pain.<BR/>Further record review of this same Physical Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following long-term goals: <BR/>-Patient able to perform supine [lying on bed face-up] &lt;&gt; [to] sit supervision to decrease caregiver assistance . PLOF (prior to onset) independent. Baseline (3/15/23) dependent.<BR/>-Patient able to transfer bed &lt;&gt; [to] W/C [wheelchair] supervision to decrease caregiver assistance and risk for falls . PLOF (prior to onset) independent. Baseline (3/15/23) unable. Admit on stretcher to facility. Limited by pain.<BR/>-Patient able to ambulate [walk] with FWW [four wheel walker] 150' [150 feet] with supervision to decrease risk for falls . PLOF (prior to onset) independent no device. Baseline (3/15/23) unable.<BR/>Record review of Resident #1's Occupational Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following short-term goals:<BR/>-Patient will increase activity tolerance for functional activities of choice to 20 min in order to w/o [without] signs/symptoms of physical exertion increased participation with ADL tasks . PLOF Prior to onset) 20 min. Baseline (3/15/23) 30-60 seconds.<BR/>-Patient will safely perform self feeding tasks with Set-up (A) with use of for initiation/termination of tasks in order to facilitate self esteem through increased independence with tasks . PLOF (prior to onset) S/U [set up.] Baseline (3/15/23) Min (A) [Minimal Assistance]<BR/>-Patient will complete toilet/commode transfers with Modified Independence for clothing management with recognition of safety hazards . PLOF (prior to onset) MI [Modified Independence.] Baseline: Max (A) [Max Assistance].<BR/>Further record review of this same Occupational Therapy Evaluation & Plan of Treatment, dated 3/15/23, revealed Resident #1 had the following long-term goals:<BR/>-Patient will complete hygiene and grooming tasks while standing at sink with Modified Independence for initiate/termination of tasks with recognition of safety hazards in order to facilitate ability to live in environment with least amount of supervision and assistance . PLOF (prior to onset) Modified Independence. Baseline (3/15/23) Max (A).<BR/>-Patient will safely perform toileting tasks using grab bars with Modified Independence for clothing management with recognition of safety hazards . PLOF (prior to onset) MI. Baseline (3/15/23) Max (A).<BR/>-Patient will safely and efficiently perform LB [Lower Body] Dressing with Modified Independence with use of for initiation/termination of tasks in order to be able to return to prior level of living . PLOF (prior to onset) MI. Baseline (3/15/23) Max (A)<BR/>Record review of Daily Schedule, dated 3/12/23, revealed the facility had 1 LVN, 1 CMA, and 1 CNA on 3/12/23. A second CNA was seen noted for the locked unit, but the second CNA's name scratched out and moved to another unit.<BR/>Record review of the facility's current staff roster, provided on 3/15/23, revealed the facility had 17 CNAs, 11 Nurse Aides, 4 CMAs, 9 LVNs, and 1 RN. Including the non-clinical staff, the facility had 65 total employees.<BR/>Record review of the facility's uploaded files from TULIP for Intake #411419 (which was the incident involving Resident #1 and Resident #2 on 3/9/23), revealed the following in-services conducted on the following dates:<BR/>-On 3/9/23, the facility educated 14 staff members on Falls and Unmanageable Residents. <BR/>-On 3/9/23, the facility also educated 22 staff members on Prevention of Abuse and Neglect. However, of the 22 staff members, 2 staff members signed their names twice for a total of 20 staff members. Of these now 20 staff members, 14 were the same staff members educated on Falls and Unmanageable residents. Only 6 new staff members received this education. <BR/>-On 3/13/23, the facility also educated 13 staff members on Abuse Reporting. <BR/>-On 3/13/23, the facility also educated 13 staff members on Managing Fall Risk. The 13 staff members on this in-service were the same 13 staff members who were educated on Abuse Reporting.<BR/>During an observation and interview on 3/15/23 at 1:11 p.m., Resident #1 was seen in bed, awake, alert, and fully-dressed. CO H was at Resident #1's bedside and CO H stated Resident #1 may not be able to answer questions due to his diagnosis of dementia. An interview was attempted with Resident #1. When asked if he had any issues with other residents, Resident #1 answered, yes, but he did not elaborate on his answer when this surveyor prompted Resident #1 to elaborate. CO H stated Resident #1 was attacked 3 times last week and stated Resident #1's last attack was on Sunday, 3/12/23. CO H stated she received a call from CO J and they both went to a local emergency department. CO H stated, the story they told [CO J] is that the nurse was out on the patio and she heard someone yell 'get out of here.' She [the nurse] went to investigate and [Resident #1] was on the floor. And that's when the hip was broken . They [the facility] promised me they were going to keep [Resident #1 and Resident #2] separate and keep [Resident #1] safe.<BR/>During an interview on 3/15/23 at 3:11 p.m., NA G stated if [Resident #3] sees anyone walking by, he'll try to pick a fight. Usually Resident #5 is afraid of Resident #3.<BR/>In a follow-up interview on 3/15/23 at 3:20 p.m., NA G stated she had heard [Resident #2] had struck [Resident #1.] NA G stated Resident #2 was no longer in the facility. <BR/>During an interview on 3/17/23 at 9:21 a.m., Resident #5 stated he did not feel safe in the facility. Resident #5 stated the other residents make him feel unsafe and have hurt him before. Resident #5 did not provide the names of the other residents who had hurt him. <BR/>During an interview on 3/17/23 at 9:22 a.m., LVN C stated she ensured the safety of residents in the facility's locked unit by frequently monitoring the residents. LVN C stated she currently had 2 CNAs, but she was supposed to have a 3rd CNA that was supposed to come in later. When asked how they ensured Resident #1's safety, LVN C stated frequent re-direction all the time . to the best of our ability educate the residents that it's not intentional on his part to invade their space. LVN C stated [Resident #2] could go for a good amount of time [without being aggressive] and then slowly start to show the signs and then explode. When asked how they managed Resident #2's aggressive behavior, LVN C stated they spoke with [Resident #2] firmly. LVN C stated after Resident #2 struck Resident #1 they had temporarily moved Resident #1 to the women's side until lunch the next day, 3/10/23, after Resident #2 was discharged . LVN C stated only new interventions she was aware of for [Resident #1] was to consider alternative placement but it was difficult to find alternative placement for Resident #1 due to his wandering. <BR/>Continuing the interview on 3/17/23 at 9:22 a.m., LVN C stated Resident #3's aggressive behavior was new for Resident #3. LVN C stated she believed Resident #3 may be mimicking Resident #2's aggressive behavior. LVN C stated, [Resident #3] somehow got attached to him and he was always calling out for [Resident #2.] And I found that extremely odd because [Resident #3] was becoming dependent on [Resident #2.] [Resident #3] felt safe around him. LVN C stated prior to 3/12/23, Resident #3 was approaching other residents with the intent to push them over, but when [Resident #3] was aware he was being watched by the facility staff, he would leave the other residents alone. LVN C confirmed she was working on 3/12/23, the day Resident #3 pushed Resident #1. LVN C stated, We were short [a staff member] that day. I remember because I had to take them out to smoke because usually a CNA would do it. So to keep the [other residents] calm I went and initiated the smoke [smoke break.] So I let them [the residents] out and then it happened. LVN C stated after Resident #3 pushed over Resident #1 and caused Resident #1 to break his hip they made sure [Resident #3] stayed away from the others.<BR/>During an interview on 3/17/23 at 10:48 a.m., LVN I stated he was currently the primary nurse for Resident #1. LVN I stated Resident #1 was currently on physical therapy and occupational therapy, which was new for Resident #1. LVN I stated Resident #1 could previously walk independently and currently cannot bear weight on his broken hip.<BR/>During an interview on 3/17/23 at 12:28 p.m., the DOR stated Resident #1 was currently on physical therapy and occupational therapy for his broken right hip. The DOR stated Resident #1 never required therapy before because he was ambulatory [able to walk] without any device and was independent with ADLs prior to his broken hip. The DOR stated Resident #1 was currently bed-bound at this point. He was independent, but now he's dependent. <BR/>During an interview on 3/17/23 at 1:34 p.m., the Director of Marketing LVN stated his current role at the facility was a Nurse Manager due to the fact the facility did not have a DON and ADON. The Director of Marketing LVN stated the facility ensured the safety of residents in the locked unit by frequent monitoring. The Director of Marketing LVN stated if 2 residents had a physical altercation the staff would ensure the altercation doesn't happen again by monitoring continuously. When asked about the incident involving Resident #1 and Resident #2 on 2/15/23, the Director of Marketing stated he could not recall much about the incident as that was around the time he began to become more involved in nurse management. The Director of Marketing LVN stated after the incident we did our frequent monitoring and then our redirection and then provided activities on the unit. <BR/>Continuing the interview on 3/17/23 at 1:34 p.m., the Director of Marketing LVN stated a resident was considered unmanageable when medication management failed to manage a resident's behavior and once that was identified the facility would find alternative placement. The Director of Marketing LVN stated Resident #2 was very nice . but he would have his spurts where if an individual invaded his space too closely, he might get a little aggressive . He was more of a verbal yelling and screaming. Just whenever his personal space was invaded. The Director of Marketing LVN stated to manage Resident #2's aggression they provided activities for him. We have an activity assistant back there [in the unit] to encourage to do activities throughout the day. The Director of Marketing LVN stated the facility had attempted to discharge Resident #2 to other nursing homes but was denied. The Director of Marketing LVN stated he was unsure if the facility ever issued a 30 day discharge notice to Resident #2. When asked about what happened between Resident #1 and Resident #2 on 3/9/23, the Director of Marketing LVN stated the facility sent out Resident #2 to the hospital for medical clearance but Resident #2 was sent back. The facility then scheduled Resident #2 to be sent out to another local hospital and when transportation arrived Resident #2 became combative, law enforcement was involved, Resident #2 was arrested and was currently not in the facility. The Director of Marketing LVN stated afterwards the facility initiated in-services on abuse, neglect, and resident-to-resident altercation. The Director of Marketing LVN stated the facility continued their current interventions from 2/15/23 for Resident #1 which included redirection, music therapy, providing more staff in the locked unit, and posting an identification marker on his Resident #1's room to help Resident #1 find where his room is.<BR/>Continuing the interview on 3/17/23 at 1:34 p.m., the Director of Marketing LVN stated Resident #3 had a diagnosis of dementia, anxiety, unspecified psychosis, and persistent mood disorder. The Director of Marketing LVN stated from admission until these recent events he's been very pleasant and after Resident #3 pushed Resident #1 the facility provided redirection, a calming environment, and scheduled a psychiatric evaluation for Resident #3 after he returned to the facility on 3/12/23. The Director of Marketing LVN stated the ideal staffing in the locked unit was 1 nurse and 2 CNAs, but on 3/12/23, the locked unit was short 1 CNA. The Director of Marketing LVN stated he did not feel the short-staffing contributed to Resident #1's incident on 3/12/23. When asked about the incident on 3/12/23, the Director of Marketing LVN stated the initial report was not made to him but to the facility's former MDS Nurse who was no longer employed at the facility. The Director of Marketing LVN stated, the only thing I remember is that the resident stated he didn't do it. I know [the former MDS Nurse] set up for [Resident #3] to be sent to [a local hospital] to be evaluated for psychiatric treatment and he came back. When asked if the facility implemented new interventions for Resident #3, the Director of Marketing LVN stated, just our general intervention. Just to provide a calm environment, redirection, and continuous monitoring. When asked if they implemented anything new for the staff, the Director of Marketing LVN stated, I know they did some in-services on abuse and neglect. The Director of Marketing LVN stated Resident #1 was independent before his incident on 3/12/23. When asked if they implemented anything new for Resident #1, the Director of Marketing LVN stated, we did incorporate a lot of activities that were off the unit to change his environment for him. The Director of Marketing LVN stated, I think they did everything they could have done to ensure the safety of all residents in this facility. They followed the procedures meant to be implemented in these situations.<BR/>During an interview on 3/17/23 at 3:05 p.m., the Administrator stated he had been the Administrator at the facility since early February 2023 and was currently the abuse coordinator. The Administrator stated they ensured the safety of residents in their locked unit by supervision and increased activities. The Administrator stated he did not recall if the facility had implemented any interventions for the locked unit after the incident involving Resident #1 and Resident #2 on 2/15/23. The Administrator stated he was not too familiar with Resident #2 beyond the incident between Resident #1 and Resident #2 on 3/9/23. The Administrator stated he was not aware of any new interventions for Resident #2 prior to 3/9/23. The Administrator stated he was aware the facility had attempted to discharge Resident #2 before 3/9/23 but with no success. The Administrator stated aside from in-servicing, the facility did not make any major changes after the incident between Resident #1 and Resident #2 on 3/9/23. <BR/>Continuing the interview on 3/17/23 at 3:05 p.m., the Administrator stated he heard Resident #3 became aggressive towards Resident #5 prior to Resident #3 pushing over Resident #1 on 3/12/23. The Administrator stated on 3/12/23 he was notified of the incident between Resident #3 and Resident #1 and he came on-site the same day to conduct safe surveys with other residents. When asked if there were any interventions in place to ensure Resident #1's safety, the Administrator stated, just the 15-minute check thing that we've done. I'll tell you what the problem is, it's the size of the hall . Most everyone has dementia and some of those guys get into people's personal space and some people don't like it. And [Resident #1] does that. He'll enter people's personal space and these guys-they have dementia too and I assume they don't like it. The Administrator stated he was unsure if there were any considerations to place Resident #1 in another facility. When asked if he felt the facility had done everything they could to ensure Resident #1's safety, the Administrator stated, I don't think I could have done anything to make that not happen. An updated education for the facility's incident report on 3/12/23 was requested at this time. <BR/>In a follow-up interview on 3/17/23 at 5:47 p.m., the Marketing Director LVN stated the facility's education on 3/9/23 carried over to the incident on 3/12/23. <BR/>During an interview on 3/18/23 at 10:45 a.m. with the Administrator, this surveyor requested for a copy of a 30-day discharge for Resident #2, if one was available.<BR/>In a follow-up interview on 3/18/23 at 11:03 a.m., LVN C stated she was aware Resident #3 attempted to push Resident #5 before and heard Resident #3 raised a fist at Resident #5. LVN C stated Resident #5 felt unsafe around Resident #3 and wanted to change rooms.<BR/>In a follow-up interview on 3/18/23 at 11:15 a.m. with CO H, CO H stated, [Resident #1] walks and always has. That honestly is my biggest concern . He used to sit up by himself and stand and now he can't do that . Something that he's never done before that's really concerned me is that I went to move his hair out of his eyes and he flinched. And that broke my heart. He knows I'd never lay a hand on him . He sleeps a lot more. He never used to sleep during the day. He was always up and walking.<BR/>During an interview on 3/18/23 at 11:59 a.m., the Assistant Activities Director stated she conducted activities for the locked unit. The Assistant Activities Director stated she was told to do more activities with the men's locked unit, but added, I'm still making it work because she was trying to balance doing activities for the men and women's locked unit. When asked about any new changes to their activities schedule, the Assistant Activities Director stated the facility started having weekly outings on Thursdays since 3/2/23. The Assistant Activities Director stated off-unit activities had been implemented since October 2022. The Assistant Activities Director state the facility's off-unit activities included coffee socials on Tuesday, and bingo on Tuesdays and Thursdays. When asked about Resident #1, the Assistant Activities Director stated the resident liked to go for walks and she would take him to walk through the dining hall and outside at least 2 or 3 times per week for 30 minutes. <BR/>During an interview and record review on 3/18/23 at 12:28 p.m., the Assistant Activities Director stated she was asked to pass to this surveyor a print-out of Resident #2'nursing and physician progress notes with highlighted portions indicating the facility's unsuccessful attempts to discharge Resident #2. No 30-day discharge notice was provided with this print-out and there was no documentation in the progress notes that indicated a 30-day discharge notice was provided.<BR/>Record review of a facility policy titled, Preventing Resident Abuse, dated February 2014, revealed the following, Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse . The facility's goal is to achieve and maintain an abuse-free environment. <BR/>Record review of Resident #1's signed admission agreement, dated 10/19/23, revealed the following: Each Resident has the right to be free from verbal, sexual, mental and physical abuse, corporal punishment, and involuntary seclusion.<BR/>The Administrator was notified of an IJ on 3/17/23 at 5:48 p.m. and was given a copy of the IJ Tem[TRUNCATED]

Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 halls (100 hall) in that:<BR/>1. Men's unit (hot zone)- CNA K and LVN L not wearing eye protection in the hot zone hall.<BR/>a. CNA K walked from the hot zone to the cold zone to use the bathroom, without taking off her N95 mask. <BR/>b. LVN L pushed the lunch cart from the hot zone to the cold zone, a door was separating the zones. Observation of lunch cart had 10 trays and 10 plate tops that were not sanitized. <BR/>c. LVN L pushed the hydration cart with 3 tall plastic coffee pitchers, 3 1-gallon clear containers on 1st shelf, the 2nd shelf had a container with sugar, and the 3rd shelf had a metal wide container with ice and 3 resident plastic pitchers were not sanitized. This hydration cart was pushed from the hot zone to the cold zone.<BR/>2. Women's unit-LVN I was not wearing a N96 mask or eye protection when administering Resident #48's medications (hot zone room). <BR/>3. The 100-hall was not treated as a presumed COVID-19 hall after a COVID-19 exposure. Resident #81 resided on the 100-hall and was discovered COVID-19 positive and transferred to the COVID-10 unit. <BR/>4. The laundry department did not treat COVID-19 laundry per the CDC's guidelines for COVID-19. <BR/>These deficient practices could affect residents, visitors and staff and result in cross contamination and infections.<BR/>The findings were: <BR/>Interview on 1/23/22 at 10:52 a.m. with the Administrator stated the secure unit, 100 hall had a women's unit, (cold zone) on the left side of 100 hall and the right side of the 100 hall was the men's unit (hot zone) of the 100 hall-memory care unit. <BR/>1. Observation on 1/24/2022 at 11 a.m. revealed CNA K was in the hot zone, she took off her gown and gloves, opened the door to the cold zone to use the bathroom without taking off her N95 mask. <BR/>Observation on 1/24/2022 at 11:10 a.m. in the hot zone (right side of 100 hall) revealed CNA K and LVN L were not wearing eye protection and walked up and down the hall. (-no residents were observed near the door)<BR/>Interview on 1/24/2022 at 11:11 a.m. with CNA K, she stated she was told her prescription glasses were enough for the COVID-19 unit. CNA K stated she was told by the ADON she could use the bathroom in the women's cold zone. CNA K stated she was positive for COVID-19 and had no symptoms.<BR/>Interview on 1/24/2022 at 11:12 a.m. with LVN L, she stated the ADON (administrative staff) told her no eye protection was required in the hot zone, when aske by surveyor why she did not have her eye protection on in the hot zone.<BR/>Interview on 1/24/2022 at 12:37 p.m. with LVN I, she stated the lunch cart and hydration cart came to the women's unit (cold zone), staff opened the doors separating the two zones, to the hot zone (100 hall-men's unit), then came back to cold zone (women's unit) after being sanitized by staff. <BR/>Observation on 1/24/2022 at 1:21 p.m. in front of cold zone door that separated the hot zone and cold zone revealed the lunch cart (10 trays and plate tops) and hydration cart in the hot zone, then LVN L open the door and pushed the lunch cart and hydration tray cart ( 3 tall plastic coffee pitchers, 3 1-gallon clear containers on 1st shelf, the 2nd shelf had a container with sugar, and the 3rd shelf had a metal wide container with ice and 3 resident plastic pitchers) to the cold zone to CNA M. Staff LVN L sanitized the food tray and hydration cart frame but did not sanitize the items on the carts. Observed in the hot zone LVN L and CNA K in the hot zone and were not wearing eye protection. <BR/>Interview on 1/24/2022 at 1:30 p.m. LVN L stated she sanitized the frame of the carts. State Surveyor asked if she sanitized the items in lunch/hydration carts, she stated she did not know she had too. <BR/>Interview on 1/24/22 at 3:31 p.m. to 3:37 p.m. CNA M stated the staff in the hot zone sanitized the carts, then the lunch/hydration carts were rolled from the hot zone to the cold zone, by opening the doors, then CNA M got the lunch trays/plate guards and placed them in the lunch cart,from the women's side, then she rolled the carts down the opposite end of the hall, to the outside patio where the kitchen staff picked up the lunch/hydration cart. <BR/>Interview on 1/26/2022 at 10 a.m. with the ADON, she stated she never told staff in the hot zone that their prescription glasses counted as eye protection. ADON stated the staff in hot zone should wear full PPE, including eye protection (googles/face shield). (ADON left before I could ask more questions).<BR/>Record review of CNA K's positive COVID-19 test was on 1/20/202 and LVN L's positve COVID -19 test was on <BR/>2. Observation on 1/24/22 at 12:45 p.m. LVN I went into Resident #48's room (hot zone room), who tested positive for COVID-19 today and administered her medications without wearing a N95 mask or eye protection. LVN I was wearing a surgical mask, gown, and gloves. <BR/>Interview on 1/24/22 at 12:46 p.m. LVN I confirmed she entered Resident #48's room, who was positive for COVID-19, without a wearing N95 mask or face sheld/goggles. LVN I stated she had her prescription glasses on for her eye protection. Interview with LVN I stated she tested Resident #48 for COVID -19 that morning and LVN I stated she was positive. LVN I stated Resident #48 was quarantined to her room until the staff could move her to the hot zone. <BR/>Observation on 1/24/22 at 12:47 p.m. at the nurse's station, cold zone, women's hall, left side of 100 hall, a PPE posting on doffing/donning, staff wear gown, gloves, N95 mask and eye protection (goggles/face shield).<BR/>Interview on 1/24/22 at 1:16 p.m. LVN I stated she tested all residents in the women's secure unit, today. LVN I stated Resident #48 was the only resident who tested positive for COVID-19 this day. LVN I stated Resident #48 was in a quarantined room until they could move her to hot zone.<BR/>Interview on 1/25/22 at 2:56 p.m. the Regional Nurse, she stated she worked at the facility 1-2 days a week and from home on electronic records. She stated once staff worked in the hot zone, staff should not go to cold zone. The Regional Nurse stated staff in the hot zone should be wearing full PPE, to include N95 masks and eye protection (goggles/face shield) when working/caring for residents in the hot zone. The Regional Nurse stated the lunch and hydration cart should not go from hot zone to cold zone, staff should take it outside of the hot zone and take it to the kitchen for them to sanitize the carts. <BR/>Record review of Resident #48 and LVN I were vaccinated or not? <BR/>3.<BR/>Observation on 1/23/2022 at 10:00 am of the facility's memory care, 100 hall, revealed the hall separated from the facility by closed double doors, the doors presented with no signage to designate any quarantine or isolation precautions. The 100-hall memory care unit was further separated by a set of closed double smoke barrier doors, at the end of the hall. The women residents ambulated in the hallway, some residents wore masks and others did not, Resident #11 ambulated throughout the unit in her wheelchair and wore a surgical mask on her chin. LVN I attended to residents, LVN I wore a KN95 FFR as her only PPE. <BR/>During an interview on 1/23/2022 at 10:05 am LVN I stated the 100-hall memory care unit is separated by women and men. The women were in the part of the hall where she was, and the men resided behind the closed double barrier door. LVN I stated the men were COVID-19 positive and had dedicated staff, specifically, ADON O and COVID-19 positive CNA P. LVN I stated the women's area was not considered a COVID-19 area. LVN I stated the facility routinely tested residents for COVID-19 and on 1/17/2022 Resident #81 was COVID-19 positive and was transferred to the 200 hall COVID-19 unit. LVN I stated Resident #81 had a roommate Resident #11, and Resident #11 was attempted to be quarantined but due to her diagnosed dementia with wandering behavior she continued to ambulate throughout the unit. LVN I stated routine testing on 1/19/2022 revealed Resident #19 was COVID-19 positive. When asked if the 100-hall women's area was considered under any isolation / quarantine precautions, LVN I stated the women residents don't have COVID-19, therefore, there were no special isolation / quarantine precautions other than the facility had imposed all staff to wear KN95 FFR's. <BR/>During an interview on 1/24/2022 at 3:00 pm the Administrator stated the root cause analysis of the current COVID-19 outbreak revealed the outbreak started the week before Christmas 2021 and has spread throughout the facility into January 2022. The Administrator stated the outbreak triggered the facility's COVID-19 emergency testing protocols and the facility tested all staff and residents twice weekly on Mondays and Thursdays, the Administrator stated the testing initially revealed only staff were discovered COVID-19 positive and on January 17th, 2022, 7 residents who resided on the 100-hall were discovered COVID-19 positive; Of the 7, 6 were men and the men's area was developed into a COVID-19 unit. The female Resident (Resident #81) was transferred to the facility's newly developed COVID-19 unit at the end of 200 hall. The Administrator stated Resident #81 had a roommate Resident #11 and she was not successfully quarantined due to her diagnosed dementia and wandering behaviors and continued to ambulate throughout the unit. The Administrator stated the facility developed a COVID-19 unit at the end of 200 hall, specifically rooms 201 through 208. The Administrator stated continued daily testing revealed 100-hall memory care female Resident #19 tested COVID-19 positive on 1/19/2021 and she was transferred to the 200 hall COVID-19 unit.<BR/>4.<BR/>Observation on 1/25/2022 at 12:10 pm of Resident #77 room revealed a red sign which read, STOP Special Droplet / contact Precautions-in addition to standardized precautions only essential personnel should enter this room. When doing aerosolizing procedures fit tested N-95 with eye protection or higher required. Further observation revealed CNA Q wore full COVID-19 PPE N95, eye protection, gown gloves and exited Resident #77's room with 2 bags of soiled COVID-19 laundry and placed the soiled laundry bags into a 55-gallon trash can with a lid. CNA Q wheeled the can down the hall to the laundry department, CNA Q alerted Laundry Aide R to the 2 bags of COVID-19 soiled laundry stored in the soiled laundry room. CNA Q doffed her gown and gloves and provided hand hygiene, CNA Q exited to the cold zone and doffed the contaminated N95 FFR and donned a new fresh N95 FFR, CNA Q disinfected her face shield, and resumed CNA duties on 300 halls. <BR/>Observation on 1/25/2022 at 12:20 pm of Laundry Aide R revealed she wore a N95 FFR, eye goggles, gloves, and a gown, and wore a black neoprene apron over her gown, and black neoprene gloves over her gloves, Laundry Aide R picked up the 2 COVID-19 soiled laundry bags and placed the soiled COVID-19 laundry into the washing machine. Laundry Aide R doffed the black neoprene apron and disinfected the apron, doffed the black neoprene gloves, and disinfected the gloves, doffed the gown and gloves and provided hand hygiene, Laundry Aide R doffed the face shield and disinfected the face shield and then proceeded to handle clean laundry in the clean laundry area, while continuing to wear the same COVID-19 contaminated N95 FFR . <BR/>During an interview on 1/25/2022 at 12:33 pm with Laundry Aide R stated she was trained today by the Regional DON to don full COVID-19 PPE and to doff the gown and gloves after care with COVID-19 residents and their soiled laundry, and to then proceed to the facility's designated cold zone to doff the COVID-19 contaminated N95 FFR. Laundry Aide R stated she did not doff her COVID-19 contaminated N95 FFR because she was confused as to where the cold zone was. <BR/>During an interview on 1/25/2022 at 5:01 pm ADON H stated she was involved in the COVID-19 emergency outbreak planning on 1/17/2022 when 2 staff, and 11 residents were discovered COVID-19 positive. ADON O stated the Administrator, the regional Administrator, the Regional DON, and the ADON H were all participants in the meeting. The conclusion of the meeting resulted in the recognition of the difficulty to quarantine residents in the women's memory care 100 hall. The plan was developed and implemented to have the 100-hall women to be designated a presumed COVID-19 unit. ADON H stated the 100-hall presumed COVID-19 and COVID-19 units and the COVID 200-hall unit were in place prior to 1/23/2022 when surveyors entered the facility.<BR/>During an interview on 1/26/2022 at 9:00 am the Administrator and the Regional DON stated the the facility followed the Centers For Disease Prevention and Control concerning COVI-19. The Regional DON stated the facility's policy, training, and expectations were for staff to work soley in the covid-19 unit and not enter the facility, to wear PPE as per CDC guidelines in the COVID-19 unit (specifically a N95 FFR, eye protection, gown, and gloves) and to doff all the PPE when exiting the covid-19 unit. The Regional DON stated the facility's policy, training, and expectations were for staff who enter presumed (warm) COVID-19 rooms, was to wear PPE as per CDC guidelines in the COVID-19 unit (specifically a N95 FFR, eye protection, gown, and gloves) and to doff all the PPE when exiting the presumed (warm) COVID-19 room. The Regional DON stated the infection control breakdowns were the responsibility of each individual staff member to be held accountable for their individual adherance to the facility training and infection control policy. The Regional DON and the administrator stated the 1/2 of the 100-hall (the womens side) was deemed a presumed (warm) Covid-19 unit after the resident #81 was discovered COVID-19 positive and the other half of the 100-hall (the mens side was seperated by closed double doors and designated the Covid-19 (hot) unit with deicated staff (staff who solely work the covid unit). The Administrator and the Regional DON stated staff who are assigned to the Presumed (warm) unit are to utilize PPE and infection control measures as set by the CDC, (specifically a N95 FFR, eye protection, gown, and gloves) and to doff all the PPE when exiting the presumed covid-19 unit. The Regional DON and the administrator stated no PPE, equipment, or materials from the covid-19 units are to cross into the non- COVID-19 facility; if such durable equipment needs to cross the material is to be disinfected, such as meal delivery carts, and soiled laundry barrels. The training is provided by multi-leveled staff begining with the Regional DON, the ADON's, and the charge nurses; after which the responsibility is individualized. The Regional DON and the Administrator stated as of 1/25/2022 the whole facility is deemed presumed (warm) COVID-19 with individual COVID-19 rooms, and 2 seperate COVID units (100-hall and 200-hall) due to the continued COVID-19 outbreaks and staff infection control breakdowns.<BR/>Record review of the facility's, undated, PPE for facility 3 policy revealed Contact isolation rooms are identified with a red contact isolation sheet on the door. These rooms are considered hot zone. Upon exiting the room, you will doff (take Off) your gown, gloves, step through the door and put a new gown on, sanitize your hands and walk to the cold zone and replace your mask and disinfect your face shield. Examples of non-direct contact: b. Passing medications that are not crushed or administered through a g-tube.<BR/>A record review of the Centers for Disease Prevention and Control website titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 10, 2021 revealed, Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection, Personal Protective Equipment, HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).<BR/>A record review of the Centers for Disease Prevention and Control website titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 10, 2021 revealed, Source control options for HCP include: A NIOSH-approved N95 or equivalent or higher-level respirator . When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions), they should be removed and discarded after the patient care encounter and a new one should be donned.<BR/>Record review of the CDC website, accessed 1/26/2022, regarding face shields revealed the following:<BR/> https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html#anchor_1605043382236:<BR/>Conventional Capacity Strategies<BR/>Use eye protection according to product labeling and local, state, and federal requirements.<BR/>In healthcare settings, eye protection is used by HCP to protect their eyes from exposure to splashes, sprays, splatter, and respiratory secretions (e.g., for patients on Droplet Precautions and for all patient encounters when there is moderate to substantial community transmission of SARS-CoV-2). Disposable eye protection should be removed and discarded. Reusable eye protection should cleaned and disinfected after each patient encounter.<BR/>Record review of CDC website, accessed 1/26/2022, revealed the following instructions for cleaning and disinfection of face shields:<BR/> https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html#anchor_1605043382236:<BR/>Selected Options for Reprocessing Eye Protection<BR/>Adhere to recommended manufacturer instructions for cleaning and disinfection.<BR/>When manufacturer instructions for cleaning and disinfection are unavailable, such as for single use disposable face shields or goggles, consider:<BR/>1. While wearing a clean pair of gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe.<BR/>2. Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution.<BR/>3. Wipe the outside of face shield or goggles with clean water or alcohol to remove residue.<BR/>4. Fully dry (air dry or use clean absorbent towels).<BR/>5. Remove gloves and perform hand hygiene.<BR/>6. Cleaned and disinfected eye protection can be stored onsite, in a designated clean area within the facility.<BR/>A facility policy was requested on 1/26/2022 at 9:00 am, and the Administrator stated the facility followed CDC's COVID-19 guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 7 of 7 residents (Resident #'s 1-7) reviewed for neglect, in that:<BR/>Resident #'s 1-7 were occupying rooms in 100 Hall (Male Secured Unit) and 200 Hall without functioning HVAC/Heating Systems which resulted in these residents being subjected to enduring cold temperatures during cold winter weather. The facility did not report this to the state agency.<BR/>This deficiency placed residents at risk for harm by a diminished quality of life, specifically, sleep deprivation and cold-related injuries (hypothermia) for residents.<BR/>The findings included:<BR/>Observation on 01/17/24 at 2:15 PM, when entering the facility, revealed it was noticeably cold and residents/staff were still wearing winter clothing (jackets/gloves/scarfs/ski caps) while in the building. <BR/>Record review of website: Past Weather in [city] Texas, USA - Yesterday or Further Back (timeanddate.com) of the air temperatures for [city], Texas revealed the following air temperatures and corresponding dates for the city this facility was located:<BR/>Date: Low High<BR/>1/12/2024 29 F 59 F<BR/>1/13/2024 24 F 61 F<BR/>1/14/2024 16 F 28 F<BR/>1/15/2024 14 F 30 F <BR/>1/16/2024 15 F 34 F<BR/>1/17/2024 13 F 52 F<BR/>Interview on 1/16/2024 at 2:34 PM, the administrator stated the facility's heating units for 100 Hall (Male Secured Unit) and 200 Hall were not functioning and pending replacement. The administrator stated 2 portable heating units had been placed at both ends of the 100 Hall (Male Secured Unit) and one large space heater was placed at the end of 200 Hall until the facility's permanent heating units could be replaced. The Administrator also said portable heaters were purchased and offered to residents who wanted one in their room in response to staff and residents complaining of cold temperatures within the building on the night of 1/13/2024.<BR/>Observation on 1/16/2024 at 3:06 PM of 100 Hall (Secured Men's) revealed 2 temporary heating units (THU) located at both ends of the hall. Further observation revealed the THU at the beginning of 100 Hall was running at a setting of 80 F and indicated room temperature (Hallway) of 69 F. Observation of the THU at the end of 100 Hall revealed the THU was not running. <BR/>Observation and interview on 1/16/2024 at 3:09 PM, Resident #1 was observed walking 100 Hall (Secured Men's) and lead this investigator his room. Resident #1 indicated his room was cold and would get colder at night. Resident #1 proceeded to show this investigator 4 blankets on his bed he was utilizing in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. <BR/>Observation and interview on 1/16/2024 at 3:14 PM, Resident #2 (100 Hall Secured Men's) was observed lying in his bed. Resident #2 was observed wearing gloves and when asked why, Resident #2 responded, because I like them! When asked if the resident was cold at night, he responded, Yes! When asked how the resident was doing in an attempt to stay warm, he responded, The blankets. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation and interview on 1/16/2024 at 3:16 PM, Resident #3 (100 Hall Secured Men's) was observed sitting in the secured dining area in his wheelchair. During the interview, Resident #3 said that this week had been, really cold. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation on 1/16/2024 at 3:38 PM revealed a space heater at the end of Hall 200.The space heater was on and glowing. The room temperature in this hall felt uncomfortably cold while wearing a jacket. <BR/>Observation and interview on 1/16/2024 at 3:40 PM, Resident #4 (200 Hall). Resident #4 was asked about the temperature of her room and indicated she had been, Very cold, and said she had been using multiple blankets in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation and interview on 1/17/2024 at 7:38 AM, facility staff were observed wearing winter-clothing in the building which consisted of extra layers and ski hats. At this time, an unknown staff shouted, It's cold in there, 50 degrees.<BR/>Observation and interview on 1/17/2024 at 7:44 AM, Resident, Resident #1 was observed lying in his bed with a blanket over his head. A reading of the room's temperature revealed a temperature of 56 F. During an interview that this time, Resident #1 was asked if he was cold and responded, Yes The resident stated he did not sleep well because his room was cold. <BR/>Observation and interview on 1/17/2024 at 7:57 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #1's bed which revealed a temperature reading of 56 F. LVN B confirmed the temperature in Resident #1's room was 56 F and responded, Oh wow, that's cold.<BR/>Observation and interview on 1/17/2024 at 7:44 AM, Resident #5 was observed lying in bed with a navy blue blanket over his head (photo taken). A reading of the room's temperature revealed a temperature of 51 F. During an interview at this time, Resident #5 was asked how he was doing and responded, Cold. When asked if the Resident #5 felt tired, he responded, Yeah, I can't sleep. <BR/>Observation and interview on 1/17/2024 at 7:58 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #5's bed which revealed a temperature reading of 51 F. During an interview at this time, LVN B was asked what the temperature should be to be considered comfortable to which she responded, Around 70 F.<BR/>Observation and interview on 1/17/2024 at 8:07 AM with Staff C, this investigator pointed a thermal thermometer laser at the wall closest to Resident #4's bed which revealed a temperature reading of 51 F. Staff C confirmed the temperature for Resident #4's room was 51 F. <BR/>During an interview at this time, Staff C said Resident #4 had requested to be moved to a new location due to feeling cold in her room. Staff C mentioned another Resident, Resident #7 (Hall 200) had also requested to be moved because she was cold in her room. <BR/>Interview and observation on 1/17/2024 at 9:50 PM, the Maintenance Supervisor and this investigator compared thermal temperature guns and confirmed their readings matched within +/-.3 degrees F. The Maintenance Supervisor's thermal temperature gun was orange and black ([NAME] Tools IR1 Infrared Thermometer), The Maintenance Director was asked what the room temperatures should be and responded, Around 75 F in the winter and around 70 F in the summer.<BR/>Interview and observation on 1/17/2024 at 10:00 AM, the Maintenance Supervisor measured Resident #1's room (100 Hall - Secured Men's Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 61 F. During an interview at this time, the Maintenance Supervisor said, It feels chili in here, I would need more blankets and double socks.<BR/>Interview and observation on 1/17/2024 at 10:04 AM, the Maintenance Supervisor measured Resident #5's room (100 Hall - Secured Men's Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #5's which revealed a temperature of 61 F. Resident #5 was observed still lying in bed with blankets over his head. A space heater was observed in this resident's room and was emitting heat but the room still felt cold. During an interview at this time, Resident #5 was asked if he was still cold to which he responded, Ya. At this time, the Maintenance Director said, Even with a space heater the room still feels cold. I don't see why the main heating unit (for 100 Hall) wasn't fixed before the cold weather.<BR/>Interview on 1/17/2024 at 10:15 AM, the administrator stated she had moved all but 1 resident on 200 Hall from the second half of 200 Hall to other locations including the first half of 200 Hall. The Administrator also stated she had closed the smoke barrier doors located in the middle of 200 Hall in an effort to prevent cold air coming down the first half of the 200 hall. Additionally, the Administrator said all residents on the 100 Hall (Male Secured unit) were moved to the 100 Hall (Female Secured unit) and indicated that section of 100 Hall had a HVAC. <BR/>Interview and observation on 1/17/2024 at 10:29 AM, the Maintenance Supervisor measured Resident #7's room (200 Hall) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 57.7 F. Resident #6 was observed lying in her bed under layers of blankets. During an interview at this time, Resident #6 was asked how she was doing to which she responded, I'm cold. The Maintenance Director then said, Ya, it's cold, I wouldn't want to be in there. The Maintenance Director then confirmed Resident #7's room was on the first half of 200 Hall that was supposed to be the side residents were moved to because it was warmer than the second half of 200 Hall. The Maintenance Supervisor agreed it felt much colder in the resident's room than in the hall. <BR/>A record review of the facility's Abuse/Neglect - Clinical Protocol revised 12/2016, stated, Assessment and Recognition - 2. Neglect is defined as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional destress . 4. If there is concern related to possible abuse and/or neglect of a resident, a nurse will assess the individual and document findings. Further review stated, The facility management and staff will comply with applicable laws and regulations pertaining to the documentation and management of abuse and neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 1 Resident (Resident #38) reviewed for coordination with the State Agency, in that;<BR/>The facility did not submit the Nursing Facility Specialized Services (NFSS) form to the State Agency.<BR/>This deficient practice placed the resident at risk for not receiving specialized services provided by the State Agency.<BR/>The findings include:<BR/>A record review of Resident #38's face sheet, dated 1/24/2022, revealed an admission date of 4/14/2021, with diagnoses which included moderate intellectual disabilities, cognitive communication deficit, and major depressive disorder. <BR/>A record review of Resident #38's Brief interview for Mental Status (BIMS) score, dated 1/24/2022, revealed 03, severe intellectual disability.<BR/>A record review of Resident #38's Pre-admission Screening and Resident Review (PASRR) dated June 8th, 2021, revealed a positive finding her intellectual disabilities.<BR/>A record review of Resident #38's Care Plan , dated 3/3/2022, revealed goals, Will have behavior identified so that staff may intervene quickly with listed interventions daily through next review date; will have decreased behavioral episodes and feel safe within the facility environment with dignity intact; will have knowledge of potential for harm related to refusal to participate in recommended treatments / specialized services through the next quarter; resident self-inflicted scratches will heal without complication.<BR/>A record review of Resident #38's care plan conference meeting note, dated 6/8/2021, documented by ADON O, revealed IDT meeting for PASRR resident meeting held in conference room resident is doing well at the facility he states I'm happy here and I want to stay here discuss services related to PASRR that he is eligible for at the facility. [Resident #38's family] provided with information on community living at group homes if he chooses in the future, discussed that he would like to have job training and would like to attend day hab services once the facilities reopen .will be evaluated by all three services physical therapy, occupational therapy, speech therapy.<BR/>During an interview on 1/25/2021 at 9:22 am the Minimum Data Set (MDS) Nurse stated she was responsible for uploading the Nursing Facility Specialized Services form in the Texas Mental Health Partnership website portal, however, she was not employed in this position until November 2021. MDS Nurse stated she had access to the facilities PASRR records and Resident #38 had an Interdisciplinary Team (IDT) Meeting, on June 8th, 2021, which included the occupational therapist, regarding a positive finding for level II PASRR. MDS Nurse stated the facility's MDS nurse would be the person responsible for taking the therapist's information and completing the NFSS form in the TMHP website to alert the state the need for services for a PASRR positive Resident. MDS Nurse stated the facility has 20 days after the PASRR IDT meeting to complete the NFSS form in the TMHP website portal. MDS Nurse stated she could not find any evidence the form was completed and submitted.<BR/>During an interview on 1/26/2022 at 9:50 am ADON O stated she attended the PASRR care plan meeting for Resident #38 on 6/8/2021 where the IDT in collaboration with Resident #38 and family agreed Resident #38 did not want / need specialized services from the state agency. ADON O stated the MDS nurse would have submitted the NFSS form to the state agency, however the portal did not allow submission for an entry of no services and / or refusal of services. ADON O stated she had no knowledge if the state agency for PASRR services was contacted for assistance with the NFSS form submission. <BR/>During an interview on 1/26/2022 at 11:10 am the Regional DON stated the facility did not submit the NFSS form in the TMHP portal due to the Resident refused / did not need specialized services from the state agency. The Regional DON stated the facility could not submit the NFSS form in the TMHP website portal due to the form did not provide for the option of no services needed. The Regional DON stated she had no knowledge if the state agency for PASRR services was contacted for assistance with the NFSS form submission. The Regional DON stated the MDS Nurse would be responsible to enter the information into the NFSS form in the TMHP portal website in coordination with the therapist's evaluation. The MDS nurse would also be the person responsible for reviewing alerts regarding the lack of NFSS submissions. <BR/>During an interview on 1/26/2022 at 11:47 am with the state agency's PASRR Unit- Program Specialist stated, regarding the facility's statements, the Resident did not need any services or the resident's family refused services, There is no documentation [in the TMHP] that the services were refused. They are continuing to be out of compliance today. They still haven't had an update meeting to document changes (including changes for refusals or services not needed) and/or submitted NFSS requests. I am able to verify this in the portal. Nothing is in there.<BR/>During an interview on 1/26/2022 at 11:10 am a facility policy for submission of PASRR positive residents, regarding the NFSS form was requested from the Regional DON. A policy wasnot provided. The Regional DON stated the facility follows all HHSC guidelines.<BR/>A record review of the Texas Health and Human Services document titled Detailed Item by Item Guide for Completing the Authorization Request for PASRR Nursing Facility Specialized Services (NFSS) form April 2021, revealed, Initiating PASRR nursing facility specialized services the nursing facility has 20 business days from the date of the initial ID T or a specialized services review meeting to initiate all PASRR nursing facility specialized services for those with a positive PE for ID / DD recommended and agreed to at the meeting. And NFSS form assistance call TMHP at [PHONE NUMBER] option 1 for general inquiries.

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access, for 1 of 1 Resident (#72) reviewed for medication storage, in that:<BR/>RN H left Resident #72's medication unattended and unsecured at Resident #72's bedside.<BR/>This deficient practice placed residents at risk for not receiving therapeutic effects of the medications as prescribed. <BR/>The findings are:<BR/>A record review of Resident #72's face sheet revealed an admission date of 9/15/2021 with diagnoses which included seizures, anxiety disorder, and paranoid schizophrenia [severe type, and a form of psychosis, paranoid schizophrenia is characterized by delusions and sometimes hallucinations].<BR/>A record review of Resident #72's Brief Interview for Mental Status score revealed 06 severe cognitive impairment.<BR/>A record review of Resident #72's care plan, dated 1/26/2022, revealed, revealed, Death and dying issues related to terminal condition, as evidenced by: Hospice services .administer medications and treatments as ordered monitor side effects and effectiveness.<BR/>A record review of Resident #72's physician's orders, dated 1/26/2022, revealed :<BR/>Aspirin, low dose tablet, delayed release, 81 milligrams, one tab oral, once a day at 8:00 AM.<BR/>Lorazepam, schedule IV [controlled narcotic] tablet, 0.5mg, one tab oral at 8:00 AM.<BR/>Oxcarbazepine, tablet 300 milligrams, one tab, oral, at 8:00 AM.<BR/>Phenobarbital, schedule IV [controlled narcotic] tablet, 16.2 milligrams, two tabs, oral at 8:00 AM.<BR/>Valproic acid capsule, 250 milligrams, two capsules, oral at 8:00 am.<BR/>Hyoscyamine tablet, 0.125mg, 1 tab, as needed for secretions. <BR/>During an observation on 1/23/22 at 9:09 am revealed Resident #72 was lying in bed, awake, with a bedside table next to the bed. Seven multicolored medication pills in a small plastic cup. There was not a nurse or Medication aid in the room. The medications were unattended and unsecured. <BR/>During an interview on 1/23/2022 at 9:11 am with Resident #72 stated, those are my pills, the nurse left them there .get the [expletive] out!<BR/>During an observation on 1/23/2022 at 9:14 AM ADON RN H was at the nurse's station, at the end of the hallway, away from Resident #72's room.<BR/>During an interview on 1/23/2022 at 9:15 am ADON RN H stated she prepared resident #72's medications at 9:00 am and left them at the bedside. ADON RN H stated Resident #72 is a difficult person to get medication compliance, so she left them there so he could take them at his leisure. ADON RN H stated her training and professional practice prohibit leaving medications at the bedside. <BR/>During an interview on 1/23/2022 at 4:11 pm the Regional DON stated the facility policy and training is for medication aides, and licensed nurses to administer medications to residents, on time as the physician ordered and to observe and verify the resident swallowed the oral medications without difficulty, and then document the administration.<BR/>The facility policy titled storage of Medications dated April 2007, stated, compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, boxes.) containing drugs and biologicals shall be locked when not in use; and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observations, interviews, and record reviews the facility failed to provide quality laboratory services to meet the needs of its residents, for 1 of 1 glucometer reviewed for calibration, in that:<BR/>The facility did not record the serial number of the glucometer being calibrated, the calibration solutions were not labeled with the opened date, and the glucometer was not calibrated daily.<BR/>These deficient practices placed residents at risk for their blood sugar levels not being accurately assessed. <BR/>The findings included<BR/>An observation on 1/26/2022 at 4:22 pm of the facility's 100-hall glucometer [a device for measuring the concentration of glucose in the blood, typically using a small drop of blood placed on a disposable test strip, where a chemical reaction with glucose alters the electrical conductivity of the strip] revealed the facility utilized the [brand name] glucometer with the serial number (21)K008119H2721. <BR/>A record review of the facility's Glucose Monitoring Quality Control Record for January 2022, revealed no serial number recorded for the glucometer being calibrated. Further review revealed the glucometer was not being tested daily, the document presented with blank data spaces for the dates January 8, 9, 13, 14, 15, 18, 19, 21, 22, 23, 24, 25 and 26. <BR/>An observation on 1/26/2022 at 4:32 pm of the facility's glucometer calibration testing solutions [2 bottles low/ high] utilized for the 100-hall glucometer were in use without an open date labeled on the bottles.<BR/>During an interview, observation, and record review on 1/26/2022 at 4 :35 pm with LVN I stated she used the glucometer today [1/26/2022] and is 1 of 2 glucometers on the unit. LVN I stated the other was new and not in current use on 100-hall. LVN I stated she believed there were other glucometers in use at the facility for other residents not on 100-hall. LVN I confirmed the serial number for the glucometer was not documented on the Glucose Monitoring Quality Control Record for January 2022. When asked how LVN I could identify if the glucometer in use was the same as the glucometer calibrated, LVN I stated, I can't [since] the number is not recorded. LVN I confirmed the glucometer should be calibrated daily and stated the task fell to the 10pm to 6 am nursing shift. LVN I confirmed the observation of blank data spaces for 13 dates in January 2022. LVN I confirmed the 2 bottles of calibrating solution which were in use, were not labeled with an open date. LVN I stated the date would alert the nurse if the solutions were within expiration dates. LVN gave, to this surveyor, the manufactures user's manual for the [brand name] glucometer in use. <BR/>During an interview on 1/26/2022 at 4:50 PM the Regional DON stated the glucometers are calibrated daily by the 10:00 PM to 6:00 AM nursing shift and the glucometer serial number should be recorded on the document the regional [NAME] stated the calibration solutions should be labeled with an open date and discarded after three months or the bottles expiration date whichever comes first. The Regional DON stated the calibration is to ensure accurate measurements of residents blood sugars and resulting nursing interventions. <BR/>During an interview on 1/26/2022 at 4:50 PM a policy for a glucose meter calibration was requested from the Regional DON and not provided.<BR/>Record review of the manufactures user's manual, undated, for the[brand name] glucometer revealed, Check the expiration dates printed on the bottle when you first open a control solution bottle. Record the discard date (date opened plus three months) in the space provided on the label. You should do a controlled solution test when you want to practice the test procedure using the control solution instead of blood, Checking the system you should check your meter and test strips using [brand name] control solutions (level one and two) [brand name] control solutions contain known amounts of glucose and are used to check that the meter and the test strips are working properly.

.<BR/>Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:<BR/>1. Employee A did not have a beard guard on to cover his facial hair during food preparation.<BR/>2. The handles of measuring utensils stored in the sugar, flour and rice bins touched the products stored in the bins instead of in an upright position.<BR/>3. Two and &frac12; cases of canned food (peaches, mashed potatoes, and sliced carrots) were stored on the floor in the dry storage room instead of 6 off the floor.<BR/>These deficient practices could place all residents who received meals/snacks from the kitchen at risk for food borne illness.<BR/>The findings were:<BR/>1. Observation on 1/23/22 at 9:08 a.m. revealed Employee A was standing by the 3-compartment sink washing pots and pans. Employee A had a beard about &frac14;-3/8 long and did not have a beard guard/restraint on. Employee A stated he was assisting in the kitchen because the dietary manager and several other dietary employees were out sick.<BR/>Observation on 1/23/22 at 9:27 a.m. revealed Employee A poured cake mix into a bowl and added milk to it while not wearing a beard guard/restraint to cover his facial hair. The surveyor asked Employee A if the kitchen had any beard guards/restraints, he responded hairnets were available and then asked the surveyor Why should I wear one?. Employee A then went to the dietary manager's office and placed a hair net over his beard.<BR/>Record review of the policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised December 2008, revealed 12. Hair nets or caps and/or beard restraints ust be worn to keep hair from contacting exposed food, clean equipment, utensils and linens.<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. <BR/>2. Observation on 1/23/22 at 9:26 a.m. of 3 large white storage bins revealed one was labeled flour, the second was labeled sugar and the third was labeled rice. Inside each storage bin was a plastic 2-cup measuring pitcher that was laying on the flour, rice, and sugar with the handle of each pitcher touching the flour, sugar, and rice. <BR/>Observation on 1/25/22 at 10:52 a.m. with the Dietary Manager of the 3 large white storage bins labeled flour, sugar, and rice revealed inside each storage bin was a plastic 2-cup measuring pitcher that was laying on the flour, rice, and sugar with the handle of each pitcher touching the flour, sugar, and rice. Interview with the Dietary Manager at this time confirmed the handles of the measuring pitchers should not touch the sugar, flour, and rice.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-304.12 In-Use Utensils, Between-Use Storage revealed During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .(B) In food that is not time/temperature control for safety food with their handles above the top of the food withing containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon;<BR/>3. Observation on 1/23/22 at 9:12 a.m. of the dry good storeroom revealed on the floor was a full case (6 #10-cans) of mashed potatoes, a full case of sliced carrots and an open case with 3 #10-cans of peaches.<BR/>In an interview on 1/25/22 at 10:55 a.m. the Dietary Manager reported cases of food should be put on the shelves as soon as possible and not left on the floor.<BR/>Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-305.11 Food Storage revealed (A) .Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.<BR/>Record review of the policy titled Food Receiving and Storage, revised December 2008, revealed Food shall be received and stored in a manner that complies with safe food handling practices. Under Policy Interpretation and Implementation was 5. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents.<BR/>Record review of the CMS 672 Resident Census and Conditions of Residents, completed by the facility on 1/26/22, revealed all residents in the facility received meals and snacks prepared and served from the kitchen.<BR/>.

Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 halls (100 hall) in that:<BR/>1. Men's unit (hot zone)- CNA K and LVN L not wearing eye protection in the hot zone hall.<BR/>a. CNA K walked from the hot zone to the cold zone to use the bathroom, without taking off her N95 mask. <BR/>b. LVN L pushed the lunch cart from the hot zone to the cold zone, a door was separating the zones. Observation of lunch cart had 10 trays and 10 plate tops that were not sanitized. <BR/>c. LVN L pushed the hydration cart with 3 tall plastic coffee pitchers, 3 1-gallon clear containers on 1st shelf, the 2nd shelf had a container with sugar, and the 3rd shelf had a metal wide container with ice and 3 resident plastic pitchers were not sanitized. This hydration cart was pushed from the hot zone to the cold zone.<BR/>2. Women's unit-LVN I was not wearing a N96 mask or eye protection when administering Resident #48's medications (hot zone room). <BR/>3. The 100-hall was not treated as a presumed COVID-19 hall after a COVID-19 exposure. Resident #81 resided on the 100-hall and was discovered COVID-19 positive and transferred to the COVID-10 unit. <BR/>4. The laundry department did not treat COVID-19 laundry per the CDC's guidelines for COVID-19. <BR/>These deficient practices could affect residents, visitors and staff and result in cross contamination and infections.<BR/>The findings were: <BR/>Interview on 1/23/22 at 10:52 a.m. with the Administrator stated the secure unit, 100 hall had a women's unit, (cold zone) on the left side of 100 hall and the right side of the 100 hall was the men's unit (hot zone) of the 100 hall-memory care unit. <BR/>1. Observation on 1/24/2022 at 11 a.m. revealed CNA K was in the hot zone, she took off her gown and gloves, opened the door to the cold zone to use the bathroom without taking off her N95 mask. <BR/>Observation on 1/24/2022 at 11:10 a.m. in the hot zone (right side of 100 hall) revealed CNA K and LVN L were not wearing eye protection and walked up and down the hall. (-no residents were observed near the door)<BR/>Interview on 1/24/2022 at 11:11 a.m. with CNA K, she stated she was told her prescription glasses were enough for the COVID-19 unit. CNA K stated she was told by the ADON she could use the bathroom in the women's cold zone. CNA K stated she was positive for COVID-19 and had no symptoms.<BR/>Interview on 1/24/2022 at 11:12 a.m. with LVN L, she stated the ADON (administrative staff) told her no eye protection was required in the hot zone, when aske by surveyor why she did not have her eye protection on in the hot zone.<BR/>Interview on 1/24/2022 at 12:37 p.m. with LVN I, she stated the lunch cart and hydration cart came to the women's unit (cold zone), staff opened the doors separating the two zones, to the hot zone (100 hall-men's unit), then came back to cold zone (women's unit) after being sanitized by staff. <BR/>Observation on 1/24/2022 at 1:21 p.m. in front of cold zone door that separated the hot zone and cold zone revealed the lunch cart (10 trays and plate tops) and hydration cart in the hot zone, then LVN L open the door and pushed the lunch cart and hydration tray cart ( 3 tall plastic coffee pitchers, 3 1-gallon clear containers on 1st shelf, the 2nd shelf had a container with sugar, and the 3rd shelf had a metal wide container with ice and 3 resident plastic pitchers) to the cold zone to CNA M. Staff LVN L sanitized the food tray and hydration cart frame but did not sanitize the items on the carts. Observed in the hot zone LVN L and CNA K in the hot zone and were not wearing eye protection. <BR/>Interview on 1/24/2022 at 1:30 p.m. LVN L stated she sanitized the frame of the carts. State Surveyor asked if she sanitized the items in lunch/hydration carts, she stated she did not know she had too. <BR/>Interview on 1/24/22 at 3:31 p.m. to 3:37 p.m. CNA M stated the staff in the hot zone sanitized the carts, then the lunch/hydration carts were rolled from the hot zone to the cold zone, by opening the doors, then CNA M got the lunch trays/plate guards and placed them in the lunch cart,from the women's side, then she rolled the carts down the opposite end of the hall, to the outside patio where the kitchen staff picked up the lunch/hydration cart. <BR/>Interview on 1/26/2022 at 10 a.m. with the ADON, she stated she never told staff in the hot zone that their prescription glasses counted as eye protection. ADON stated the staff in hot zone should wear full PPE, including eye protection (googles/face shield). (ADON left before I could ask more questions).<BR/>Record review of CNA K's positive COVID-19 test was on 1/20/202 and LVN L's positve COVID -19 test was on <BR/>2. Observation on 1/24/22 at 12:45 p.m. LVN I went into Resident #48's room (hot zone room), who tested positive for COVID-19 today and administered her medications without wearing a N95 mask or eye protection. LVN I was wearing a surgical mask, gown, and gloves. <BR/>Interview on 1/24/22 at 12:46 p.m. LVN I confirmed she entered Resident #48's room, who was positive for COVID-19, without a wearing N95 mask or face sheld/goggles. LVN I stated she had her prescription glasses on for her eye protection. Interview with LVN I stated she tested Resident #48 for COVID -19 that morning and LVN I stated she was positive. LVN I stated Resident #48 was quarantined to her room until the staff could move her to the hot zone. <BR/>Observation on 1/24/22 at 12:47 p.m. at the nurse's station, cold zone, women's hall, left side of 100 hall, a PPE posting on doffing/donning, staff wear gown, gloves, N95 mask and eye protection (goggles/face shield).<BR/>Interview on 1/24/22 at 1:16 p.m. LVN I stated she tested all residents in the women's secure unit, today. LVN I stated Resident #48 was the only resident who tested positive for COVID-19 this day. LVN I stated Resident #48 was in a quarantined room until they could move her to hot zone.<BR/>Interview on 1/25/22 at 2:56 p.m. the Regional Nurse, she stated she worked at the facility 1-2 days a week and from home on electronic records. She stated once staff worked in the hot zone, staff should not go to cold zone. The Regional Nurse stated staff in the hot zone should be wearing full PPE, to include N95 masks and eye protection (goggles/face shield) when working/caring for residents in the hot zone. The Regional Nurse stated the lunch and hydration cart should not go from hot zone to cold zone, staff should take it outside of the hot zone and take it to the kitchen for them to sanitize the carts. <BR/>Record review of Resident #48 and LVN I were vaccinated or not? <BR/>3.<BR/>Observation on 1/23/2022 at 10:00 am of the facility's memory care, 100 hall, revealed the hall separated from the facility by closed double doors, the doors presented with no signage to designate any quarantine or isolation precautions. The 100-hall memory care unit was further separated by a set of closed double smoke barrier doors, at the end of the hall. The women residents ambulated in the hallway, some residents wore masks and others did not, Resident #11 ambulated throughout the unit in her wheelchair and wore a surgical mask on her chin. LVN I attended to residents, LVN I wore a KN95 FFR as her only PPE. <BR/>During an interview on 1/23/2022 at 10:05 am LVN I stated the 100-hall memory care unit is separated by women and men. The women were in the part of the hall where she was, and the men resided behind the closed double barrier door. LVN I stated the men were COVID-19 positive and had dedicated staff, specifically, ADON O and COVID-19 positive CNA P. LVN I stated the women's area was not considered a COVID-19 area. LVN I stated the facility routinely tested residents for COVID-19 and on 1/17/2022 Resident #81 was COVID-19 positive and was transferred to the 200 hall COVID-19 unit. LVN I stated Resident #81 had a roommate Resident #11, and Resident #11 was attempted to be quarantined but due to her diagnosed dementia with wandering behavior she continued to ambulate throughout the unit. LVN I stated routine testing on 1/19/2022 revealed Resident #19 was COVID-19 positive. When asked if the 100-hall women's area was considered under any isolation / quarantine precautions, LVN I stated the women residents don't have COVID-19, therefore, there were no special isolation / quarantine precautions other than the facility had imposed all staff to wear KN95 FFR's. <BR/>During an interview on 1/24/2022 at 3:00 pm the Administrator stated the root cause analysis of the current COVID-19 outbreak revealed the outbreak started the week before Christmas 2021 and has spread throughout the facility into January 2022. The Administrator stated the outbreak triggered the facility's COVID-19 emergency testing protocols and the facility tested all staff and residents twice weekly on Mondays and Thursdays, the Administrator stated the testing initially revealed only staff were discovered COVID-19 positive and on January 17th, 2022, 7 residents who resided on the 100-hall were discovered COVID-19 positive; Of the 7, 6 were men and the men's area was developed into a COVID-19 unit. The female Resident (Resident #81) was transferred to the facility's newly developed COVID-19 unit at the end of 200 hall. The Administrator stated Resident #81 had a roommate Resident #11 and she was not successfully quarantined due to her diagnosed dementia and wandering behaviors and continued to ambulate throughout the unit. The Administrator stated the facility developed a COVID-19 unit at the end of 200 hall, specifically rooms 201 through 208. The Administrator stated continued daily testing revealed 100-hall memory care female Resident #19 tested COVID-19 positive on 1/19/2021 and she was transferred to the 200 hall COVID-19 unit.<BR/>4.<BR/>Observation on 1/25/2022 at 12:10 pm of Resident #77 room revealed a red sign which read, STOP Special Droplet / contact Precautions-in addition to standardized precautions only essential personnel should enter this room. When doing aerosolizing procedures fit tested N-95 with eye protection or higher required. Further observation revealed CNA Q wore full COVID-19 PPE N95, eye protection, gown gloves and exited Resident #77's room with 2 bags of soiled COVID-19 laundry and placed the soiled laundry bags into a 55-gallon trash can with a lid. CNA Q wheeled the can down the hall to the laundry department, CNA Q alerted Laundry Aide R to the 2 bags of COVID-19 soiled laundry stored in the soiled laundry room. CNA Q doffed her gown and gloves and provided hand hygiene, CNA Q exited to the cold zone and doffed the contaminated N95 FFR and donned a new fresh N95 FFR, CNA Q disinfected her face shield, and resumed CNA duties on 300 halls. <BR/>Observation on 1/25/2022 at 12:20 pm of Laundry Aide R revealed she wore a N95 FFR, eye goggles, gloves, and a gown, and wore a black neoprene apron over her gown, and black neoprene gloves over her gloves, Laundry Aide R picked up the 2 COVID-19 soiled laundry bags and placed the soiled COVID-19 laundry into the washing machine. Laundry Aide R doffed the black neoprene apron and disinfected the apron, doffed the black neoprene gloves, and disinfected the gloves, doffed the gown and gloves and provided hand hygiene, Laundry Aide R doffed the face shield and disinfected the face shield and then proceeded to handle clean laundry in the clean laundry area, while continuing to wear the same COVID-19 contaminated N95 FFR . <BR/>During an interview on 1/25/2022 at 12:33 pm with Laundry Aide R stated she was trained today by the Regional DON to don full COVID-19 PPE and to doff the gown and gloves after care with COVID-19 residents and their soiled laundry, and to then proceed to the facility's designated cold zone to doff the COVID-19 contaminated N95 FFR. Laundry Aide R stated she did not doff her COVID-19 contaminated N95 FFR because she was confused as to where the cold zone was. <BR/>During an interview on 1/25/2022 at 5:01 pm ADON H stated she was involved in the COVID-19 emergency outbreak planning on 1/17/2022 when 2 staff, and 11 residents were discovered COVID-19 positive. ADON O stated the Administrator, the regional Administrator, the Regional DON, and the ADON H were all participants in the meeting. The conclusion of the meeting resulted in the recognition of the difficulty to quarantine residents in the women's memory care 100 hall. The plan was developed and implemented to have the 100-hall women to be designated a presumed COVID-19 unit. ADON H stated the 100-hall presumed COVID-19 and COVID-19 units and the COVID 200-hall unit were in place prior to 1/23/2022 when surveyors entered the facility.<BR/>During an interview on 1/26/2022 at 9:00 am the Administrator and the Regional DON stated the the facility followed the Centers For Disease Prevention and Control concerning COVI-19. The Regional DON stated the facility's policy, training, and expectations were for staff to work soley in the covid-19 unit and not enter the facility, to wear PPE as per CDC guidelines in the COVID-19 unit (specifically a N95 FFR, eye protection, gown, and gloves) and to doff all the PPE when exiting the covid-19 unit. The Regional DON stated the facility's policy, training, and expectations were for staff who enter presumed (warm) COVID-19 rooms, was to wear PPE as per CDC guidelines in the COVID-19 unit (specifically a N95 FFR, eye protection, gown, and gloves) and to doff all the PPE when exiting the presumed (warm) COVID-19 room. The Regional DON stated the infection control breakdowns were the responsibility of each individual staff member to be held accountable for their individual adherance to the facility training and infection control policy. The Regional DON and the administrator stated the 1/2 of the 100-hall (the womens side) was deemed a presumed (warm) Covid-19 unit after the resident #81 was discovered COVID-19 positive and the other half of the 100-hall (the mens side was seperated by closed double doors and designated the Covid-19 (hot) unit with deicated staff (staff who solely work the covid unit). The Administrator and the Regional DON stated staff who are assigned to the Presumed (warm) unit are to utilize PPE and infection control measures as set by the CDC, (specifically a N95 FFR, eye protection, gown, and gloves) and to doff all the PPE when exiting the presumed covid-19 unit. The Regional DON and the administrator stated no PPE, equipment, or materials from the covid-19 units are to cross into the non- COVID-19 facility; if such durable equipment needs to cross the material is to be disinfected, such as meal delivery carts, and soiled laundry barrels. The training is provided by multi-leveled staff begining with the Regional DON, the ADON's, and the charge nurses; after which the responsibility is individualized. The Regional DON and the Administrator stated as of 1/25/2022 the whole facility is deemed presumed (warm) COVID-19 with individual COVID-19 rooms, and 2 seperate COVID units (100-hall and 200-hall) due to the continued COVID-19 outbreaks and staff infection control breakdowns.<BR/>Record review of the facility's, undated, PPE for facility 3 policy revealed Contact isolation rooms are identified with a red contact isolation sheet on the door. These rooms are considered hot zone. Upon exiting the room, you will doff (take Off) your gown, gloves, step through the door and put a new gown on, sanitize your hands and walk to the cold zone and replace your mask and disinfect your face shield. Examples of non-direct contact: b. Passing medications that are not crushed or administered through a g-tube.<BR/>A record review of the Centers for Disease Prevention and Control website titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 10, 2021 revealed, Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection, Personal Protective Equipment, HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).<BR/>A record review of the Centers for Disease Prevention and Control website titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated Sept. 10, 2021 revealed, Source control options for HCP include: A NIOSH-approved N95 or equivalent or higher-level respirator . When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions), they should be removed and discarded after the patient care encounter and a new one should be donned.<BR/>Record review of the CDC website, accessed 1/26/2022, regarding face shields revealed the following:<BR/> https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html#anchor_1605043382236:<BR/>Conventional Capacity Strategies<BR/>Use eye protection according to product labeling and local, state, and federal requirements.<BR/>In healthcare settings, eye protection is used by HCP to protect their eyes from exposure to splashes, sprays, splatter, and respiratory secretions (e.g., for patients on Droplet Precautions and for all patient encounters when there is moderate to substantial community transmission of SARS-CoV-2). Disposable eye protection should be removed and discarded. Reusable eye protection should cleaned and disinfected after each patient encounter.<BR/>Record review of CDC website, accessed 1/26/2022, revealed the following instructions for cleaning and disinfection of face shields:<BR/> https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html#anchor_1605043382236:<BR/>Selected Options for Reprocessing Eye Protection<BR/>Adhere to recommended manufacturer instructions for cleaning and disinfection.<BR/>When manufacturer instructions for cleaning and disinfection are unavailable, such as for single use disposable face shields or goggles, consider:<BR/>1. While wearing a clean pair of gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe.<BR/>2. Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution.<BR/>3. Wipe the outside of face shield or goggles with clean water or alcohol to remove residue.<BR/>4. Fully dry (air dry or use clean absorbent towels).<BR/>5. Remove gloves and perform hand hygiene.<BR/>6. Cleaned and disinfected eye protection can be stored onsite, in a designated clean area within the facility.<BR/>A facility policy was requested on 1/26/2022 at 9:00 am, and the Administrator stated the facility followed CDC's COVID-19 guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to maintain essential equipment in safe operating condition for 2 of 2 HVAC Heating Units reviewed for safe operating equipment:<BR/>1. The HVAC Heating Unit for Hall 100 (Male Secured Unit) was not functioning during cold winter weather<BR/>2. The HVAC Heating Unit for Hall 200 was not functioning during cold winter weather<BR/>This failure placed residents at risk for harm by a diminished quality of life, specifically, sleep deprivation and cold-related injuries (hypothermia).<BR/>The findings included:<BR/>Observation on 01/17/24 at 2:15 PM, when entering the facility, revealed it was noticeably cold and residents/staff were still wearing winter clothing (jackets/gloves/scarfs/ski caps) while in the building. <BR/>Record review of website: Past Weather in [city] Texas, USA - Yesterday or Further Back (timeanddate.com) of the air temperatures for [city], Texas revealed the following air temperatures and corresponding dates for the city this facility was located:<BR/>Date: Low High<BR/>1/12/2024 29 F 59 F<BR/>1/13/2024 24 F 61 F<BR/>1/14/2024 16 F 28 F<BR/>1/15/2024 14 F 30 F <BR/>1/16/2024 15 F 34 F<BR/>1/17/2024 13 F 52 F<BR/>Interview on 1/16/2024 at 2:34 PM, the administrator stated the facility's heating units for 100 Hall (Male Secured Unit) and 200 Hall were not functioning and pending replacement. The administrator stated 2 portable heating units had been placed at both ends of the 100 Hall (Male Secured Unit) and one large space heater was placed at the end of 200 Hall until the facility's permanent heating units could be replaced. The Administrator also said portable heaters were purchased and offered to residents who wanted one in their room in response to staff and residents complaining of cold temperatures within the building on the night of 1/13/2024.<BR/>Observation on 1/16/2024 at 3:06 PM of 100 Hall (Secured Men's) revealed 2 temporary heating units (THU) located at both ends of the hall. Further observation revealed the THU at the beginning of 100 Hall was running at a setting of 80 F and indicated room temperature (Hallway) of 69 F. Observation of the THU at the end of 100 Hall revealed the THU was not running. <BR/>Observation and interview on 1/16/2024 at 3:09 PM, Resident #1 was observed walking 100 Hall (Secured Men's) and lead this investigator his room. Resident #1 indicated his room was cold and would get colder at night. Resident #1 proceeded to show this investigator 4 blankets on his bed he was utilizing in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. <BR/>Observation and interview on 1/16/2024 at 3:14 PM, Resident #2 (100 Hall Secured Men's) was observed lying in his bed. Resident #2 was observed wearing gloves and when asked why, Resident #2 responded, because I like them! When asked if the resident was cold at night, he responded, Yes! When asked how the resident was doing in an attempt to stay warm, he responded, The blankets. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation and interview on 1/16/2024 at 3:16 PM, Resident #3 (100 Hall Secured Men's) was observed sitting in the secured dining area in his wheelchair. During the interview, Resident #3 said that this week had been, really cold. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation on 1/16/2024 at 3:38 PM revealed a space heater at the end of Hall 200.The space heater was on and glowing. The room temperature in this hall felt uncomfortably cold while wearing a jacket. <BR/>Observation and interview on 1/16/2024 at 3:40 PM, Resident #4 (200 Hall). Resident #4 was asked about the temperature of her room and indicated she had been, Very cold, and said she had been using multiple blankets in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation and interview on 1/17/2024 at 7:38 AM, facility staff were observed wearing winter-clothing in the building which consisted of extra layers and ski hats. At this time, an unknown staff shouted, It's cold in there, 50 degrees.<BR/>Observation and interview on 1/17/2024 at 7:44 AM, Resident, Resident #1 was observed lying in his bed with a blanket over his head. A reading of the room's temperature revealed a temperature of 56 F. During an interview that this time, Resident #1 was asked if he was cold and responded, Yes The resident stated he did not sleep well because his room was cold. <BR/>Observation and interview on 1/17/2024 at 7:57 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #1's bed which revealed a temperature reading of 56 F. LVN B confirmed the temperature in Resident #1's room was 56 F and responded, Oh wow, that's cold.<BR/>Observation and interview on 1/17/2024 at 7:44 AM, Resident #5 was observed lying in bed with a navy blue blanket over his head (photo taken). A reading of the room's temperature revealed a temperature of 51 F. During an interview at this time, Resident #5 was asked how he was doing and responded, Cold. When asked if the Resident #5 felt tired, he responded, Yeah, I can't sleep. <BR/>Observation and interview on 1/17/2024 at 7:58 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #5's bed which revealed a temperature reading of 51 F. During an interview at this time, LVN B was asked what the temperature should be to be considered comfortable to which she responded, Around 70 F.<BR/>Observation and interview on 1/17/2024 at 8:07 AM with Staff C, this investigator pointed a thermal thermometer laser at the wall closest to Resident #4's bed which revealed a temperature reading of 51 F. Staff C confirmed the temperature for Resident #4's room was 51 F. <BR/>During an interview at this time, Staff C said Resident #4 had requested to be moved to a new location due to feeling cold in her room. Staff C mentioned another Resident, Resident #7 (Hall 200) had also requested to be moved because she was cold in her room. <BR/>Interview and observation on 1/17/2024 at 9:50 PM, the Maintenance Supervisor and this investigator compared thermal temperature guns and confirmed their readings matched within +/-.3 degrees F. The Maintenance Supervisor's thermal temperature gun was orange and black ([NAME] Tools IR1 Infrared Thermometer), The Maintenance Director was asked what the room temperatures should be and responded, Around 75 F in the winter and around 70 F in the summer.<BR/>Interview and observation on 1/17/2024 at 10:00 AM, the Maintenance Supervisor measured Resident #1's room (100 Hall - Secured Men's Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 61 F. During an interview at this time, the Maintenance Supervisor said, It feels chili in here, I would need more blankets and double socks.<BR/>Interview and observation on 1/17/2024 at 10:04 AM, the Maintenance Supervisor measured Resident #5's room (100 Hall - Secured Men's Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #5's which revealed a temperature of 61 F. Resident #5 was observed still lying in bed with blankets over his head. A space heater was observed in this resident's room and was emitting heat but the room still felt cold. During an interview at this time, Resident #5 was asked if he was still cold to which he responded, Ya. At this time, the Maintenance Director said, Even with a space heater the room still feels cold. I don't see why the main heating unit (for 100 Hall) wasn't fixed before the cold weather.<BR/>Interview on 1/17/2024 at 10:15 AM, the administrator stated she had moved all but 1 resident on 200 Hall from the second half of 200 Hall to other locations including the first half of 200 Hall. The Administrator also stated she had closed the smoke barrier doors located in the middle of 200 Hall in an effort to prevent cold air coming down the first half of the 200 hall. Additionally, the Administrator said all residents on the 100 Hall (Male Secured unit) were moved to the 100 Hall (Female Secured unit) and indicated that section of 100 Hall had a HVAC. <BR/>Interview and observation on 1/17/2024 at 10:29 AM, the Maintenance Supervisor measured Resident #7's room (200 Hall) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 57.7 F. Resident #6 was observed lying in her bed under layers of blankets. During an interview at this time, Resident #6 was asked how she was doing to which she responded, I'm cold. The Maintenance Director then said, Ya, it's cold, I wouldn't want to be in there. The Maintenance Director then confirmed Resident #7's room was on the first half of 200 Hall that was supposed to be the side residents were moved to because it was warmer than the second half of 200 Hall. The Maintenance Supervisor agreed it felt much colder in the resident's room than in the hall. <BR/>Record review of website, https://www.nia.nih.gov/health/safety/cold-weather-safety-older-adults , dated, 1/3/2024 , stated: Older adults have a higher chance of being affected by cold weather. Changes that come with aging can make it harder for older adults to be aware of their body becoming too cold, which can turn into a dangerous health issue quickly. Hazards of cold weather include falls on wintry surfaces; injury caused by freezing (frostbite); and hypothermia, a medical emergency that occurs when your body temperature gets too low. Being informed and taking certain actions can help lessen risks during the colder months . Staying warm indoors. About 20% of injuries related to exposure to cold occur in the home. Here are some tips to help keep warm: Even mildly cool homes with temperatures from 60 to 65&deg;F can lead to hypothermia in older adults.

.<BR/>Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing data was posted in a prominent place readily accessible to residents and visitors for 1 of 1 facility reviewed for staff posting for 2 of 4 days, in that:<BR/>The facility failed to post the nursing staffing information daily at the start of the shift. <BR/>This failure could place residents at risk of not having access to information regarding staffing data and facility census.<BR/>The findings were:<BR/>Observation on 1/23/22 at 8:51 a.m. of the Daily Nurse Staffing posting in a clear acrylic holder across from the 300/400 Hall nurse's station revealed it was dated 1/21/22.<BR/>In an interview on 1/23/22 at 11:46 a.m. with LVN B, after she looked at the Daily Nurse Staffing posting, confirmed the posting was dated 1/21/22 and was for all the shifts.<BR/>Observation on 1/25/22 at 8:25 a.m. of the Daily Nurse Staffing posting in a clear acrylic holder across from the 300/400 Hall nurse's station revealed it was dated 1/24/22.<BR/>In an interview on 1/25/22 at 9:57 a.m. with the Administrator revealed she was responsible for updating the daily staff posting. The Administrator stated she would update the posting as her first task of the day which was not at the start of the shift, confirmed she did not update the posting on 1/25/22 at the start of the shift and stated she was not able to update it immediately because she was dealing with things requested from the surveyors and facility staff. The Administrator stated when she is not in the facility and on the weekends, the ADONs would be responsible for updating the Daily Nurse Staff Posting. <BR/>In an interview on 1/25/22 at 4:49 p.m. with the Regional Nurse revealed the facility did not have a policy on the Daily Nurse Staff Posting and the facility would follow the state and federal regulations.<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility to provide a safe and comfortable environment for residents, staff in 1 of 2 (women's unit) shower rooms in the 100 hall in that: <BR/>In the Women's unit shower room, in the 100 hall, there was a tall plastic 3 shelf storage bin which contained 7.5 fluid ounces of peri-fresh spray, tray of razors 15 count, 3 24 fluid ounce body wash bottles, and a 16 ounce zinc oxide ointment container. Resident #58 was observed walking back and forth on the hall, but not in the shower room. <BR/>The Findings were:<BR/>Record review of Resident #58's face sheet dated 1/26/2022 revealed she was admitted on [DATE] with diagnoses of anxiety disorder, vascular dementia with behavioral disturbance, cognitive communication deficit, major depressive disorder and weakness. <BR/>Record review of Resident #58's Quarterly MDS dated [DATE] in Section C-Cognitive Patterns revealed she had a BIMs of 5/15, severely cognitively impaired.<BR/>Observation on 1/23/22 at 9:46 a.m. with CAN J, in the women's unit, the shower room door was unlocked. Observed a razor on the bathroom plastic cart near shower, a tall plastic 3 shelf storage bin, included 7.5 fl. oz peri-fresh spray, tray of razors 15 count, 3 24 fl. oz body wash bottles and 16 oz zinc oxide ointment container. <BR/>Interview on 1/24/20211 at 9:46 a.m. with CNA J confirmed the women's shower room was unlocked. CNA J confirmed the women's shower room had a razor on a plastic cart near shower and the tall plastic 3 shelf storage bin, included peri-fresh spray 7.5 fl. oz, tray of razors 15 count, 3 body wash bottles 24 fl. oz and zinc oxide ointment container 16 oz. <BR/>Interview and observation on 1/24/22 at 9:47 a.m. LVN I entered the women's shower room with CNA J and confirmed the bathroom lock was not working. LVN I stated she was not aware that the lock did not work. LVN I stated all the containers in the shower room had warning to keep out of reach of children and the razors should not be accessible to residents. <BR/>Observation on 1/24/22 at 9:51 a.m. revealed Resident #58 was walking/wandering up and down the hall, not opening doors or going into rooms. <BR/>Observation on 1/24/22 at 12:35 p.m. in the secure unit-women's unit, Resident #58 was walking up and down the hallway and trying to open doors. <BR/>Observation on 1/24/22 at 1 p.m. revealed Resident #58 walked to the end of the women's hall and tore hot zone posting off the door. Resident #58 was observed walking down the hall trying to open doors but were all locked. <BR/>Interview on 1/25/22 at 10:30 a.m. CNA D stated Resident #58 will go into other resident rooms and gets close to another residents' space. <BR/>Interview on 1/26/22 at 11:13 AM with Administrator stated she was not aware the shower room lock was not working. This surveyor requested environment policy. An environment/maintenance policy was not provided before exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility to provide a safe and comfortable environment for residents, staff in 1 of 2 (women's unit) shower rooms in the 100 hall in that: <BR/>In the Women's unit shower room, in the 100 hall, there was a tall plastic 3 shelf storage bin which contained 7.5 fluid ounces of peri-fresh spray, tray of razors 15 count, 3 24 fluid ounce body wash bottles, and a 16 ounce zinc oxide ointment container. Resident #58 was observed walking back and forth on the hall, but not in the shower room. <BR/>The Findings were:<BR/>Record review of Resident #58's face sheet dated 1/26/2022 revealed she was admitted on [DATE] with diagnoses of anxiety disorder, vascular dementia with behavioral disturbance, cognitive communication deficit, major depressive disorder and weakness. <BR/>Record review of Resident #58's Quarterly MDS dated [DATE] in Section C-Cognitive Patterns revealed she had a BIMs of 5/15, severely cognitively impaired.<BR/>Observation on 1/23/22 at 9:46 a.m. with CAN J, in the women's unit, the shower room door was unlocked. Observed a razor on the bathroom plastic cart near shower, a tall plastic 3 shelf storage bin, included 7.5 fl. oz peri-fresh spray, tray of razors 15 count, 3 24 fl. oz body wash bottles and 16 oz zinc oxide ointment container. <BR/>Interview on 1/24/20211 at 9:46 a.m. with CNA J confirmed the women's shower room was unlocked. CNA J confirmed the women's shower room had a razor on a plastic cart near shower and the tall plastic 3 shelf storage bin, included peri-fresh spray 7.5 fl. oz, tray of razors 15 count, 3 body wash bottles 24 fl. oz and zinc oxide ointment container 16 oz. <BR/>Interview and observation on 1/24/22 at 9:47 a.m. LVN I entered the women's shower room with CNA J and confirmed the bathroom lock was not working. LVN I stated she was not aware that the lock did not work. LVN I stated all the containers in the shower room had warning to keep out of reach of children and the razors should not be accessible to residents. <BR/>Observation on 1/24/22 at 9:51 a.m. revealed Resident #58 was walking/wandering up and down the hall, not opening doors or going into rooms. <BR/>Observation on 1/24/22 at 12:35 p.m. in the secure unit-women's unit, Resident #58 was walking up and down the hallway and trying to open doors. <BR/>Observation on 1/24/22 at 1 p.m. revealed Resident #58 walked to the end of the women's hall and tore hot zone posting off the door. Resident #58 was observed walking down the hall trying to open doors but were all locked. <BR/>Interview on 1/25/22 at 10:30 a.m. CNA D stated Resident #58 will go into other resident rooms and gets close to another residents' space. <BR/>Interview on 1/26/22 at 11:13 AM with Administrator stated she was not aware the shower room lock was not working. This surveyor requested environment policy. An environment/maintenance policy was not provided before exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility to provide a safe and comfortable environment for residents, staff in 1 of 2 (women's unit) shower rooms in the 100 hall in that: <BR/>In the Women's unit shower room, in the 100 hall, there was a tall plastic 3 shelf storage bin which contained 7.5 fluid ounces of peri-fresh spray, tray of razors 15 count, 3 24 fluid ounce body wash bottles, and a 16 ounce zinc oxide ointment container. Resident #58 was observed walking back and forth on the hall, but not in the shower room. <BR/>The Findings were:<BR/>Record review of Resident #58's face sheet dated 1/26/2022 revealed she was admitted on [DATE] with diagnoses of anxiety disorder, vascular dementia with behavioral disturbance, cognitive communication deficit, major depressive disorder and weakness. <BR/>Record review of Resident #58's Quarterly MDS dated [DATE] in Section C-Cognitive Patterns revealed she had a BIMs of 5/15, severely cognitively impaired.<BR/>Observation on 1/23/22 at 9:46 a.m. with CAN J, in the women's unit, the shower room door was unlocked. Observed a razor on the bathroom plastic cart near shower, a tall plastic 3 shelf storage bin, included 7.5 fl. oz peri-fresh spray, tray of razors 15 count, 3 24 fl. oz body wash bottles and 16 oz zinc oxide ointment container. <BR/>Interview on 1/24/20211 at 9:46 a.m. with CNA J confirmed the women's shower room was unlocked. CNA J confirmed the women's shower room had a razor on a plastic cart near shower and the tall plastic 3 shelf storage bin, included peri-fresh spray 7.5 fl. oz, tray of razors 15 count, 3 body wash bottles 24 fl. oz and zinc oxide ointment container 16 oz. <BR/>Interview and observation on 1/24/22 at 9:47 a.m. LVN I entered the women's shower room with CNA J and confirmed the bathroom lock was not working. LVN I stated she was not aware that the lock did not work. LVN I stated all the containers in the shower room had warning to keep out of reach of children and the razors should not be accessible to residents. <BR/>Observation on 1/24/22 at 9:51 a.m. revealed Resident #58 was walking/wandering up and down the hall, not opening doors or going into rooms. <BR/>Observation on 1/24/22 at 12:35 p.m. in the secure unit-women's unit, Resident #58 was walking up and down the hallway and trying to open doors. <BR/>Observation on 1/24/22 at 1 p.m. revealed Resident #58 walked to the end of the women's hall and tore hot zone posting off the door. Resident #58 was observed walking down the hall trying to open doors but were all locked. <BR/>Interview on 1/25/22 at 10:30 a.m. CNA D stated Resident #58 will go into other resident rooms and gets close to another residents' space. <BR/>Interview on 1/26/22 at 11:13 AM with Administrator stated she was not aware the shower room lock was not working. This surveyor requested environment policy. An environment/maintenance policy was not provided before exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide comfortable and safe temperature levels maintained within a range of 71 to 81 degrees Fahrenheit for 7 of 7 residents (Resident #s 1, 2, 3, 5 on Hall 100 Male Secured Unit) and (Resident #s 4, 6, 7 - Hall 200) reviewed for environment. <BR/>The facility presented with 2 non-functioning Heating Ventilation and Air Conditioning [HVAC] systems, which resulted in cold resident room interior temperatures (low 50s - 60s Fahrenheit) for residents living in 100 Hall (Male Secured Unit) and 200 Hall. Facility leadership was aware the HVAC systems were not adequately functioning since October 2023. <BR/>An Immediate Jeopardy (IJ) situation was identified on 01/17/24. While the IJ was removed on 01/22/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure placed residents at risk for harm by a diminished quality of life, specifically, sleep deprivation and cold-related injuries (hypothermia).<BR/>The findings were:<BR/>Observation on 01/17/24 at 2:15 PM, when entering the facility, revealed it was noticeably cold and residents/staff were still wearing winter clothing (jackets/gloves/scarfs/ski caps) while in the building. <BR/>Record review of website: Past Weather in [city] Texas, USA - Yesterday or Further Back (timeanddate.com) of the air temperatures for [city], Texas revealed the following air temperatures and corresponding dates for the city this facility was located:<BR/>Date: Low High<BR/>1/12/2024 29 F 59 F<BR/>1/13/2024 24 F 61 F<BR/>1/14/2024 16 F 28 F<BR/>1/15/2024 14 F 30 F <BR/>1/16/2024 15 F 34 F<BR/>1/17/2024 13 F 52 F<BR/>Interview on 01/16/2024 at 2:34 PM, the administrator stated the facility's heating units for 100 Hall (Male Secured Unit) and 200 Hall were not functioning and pending replacement. The administrator stated 2 portable heating units had been placed at both ends of the 100 Hall (Male Secured Unit) and one large space heater was placed at the end of 200 Hall until the facility's permanent heating units could be replaced. The administrator also said portable heaters were purchased and offered to residents who wanted one in their room in response to staff and residents complaining of cold temperatures within the building on the night of 1/13/2024.<BR/>Observation on 01/16/2024 at 3:06 PM of 100 Hall (Secured Men's) revealed 2 temporary heating units (THU) located at both ends of the hall. Further observation revealed the THU at the beginning of 100 Hall was running at a setting of 80 F and indicated room temperature (Hallway) of 69 F. Observation of the THU at the end of 100 Hall revealed the THU was not running. <BR/>Observation and interview on 01/16/2024 at 3:09 PM, Resident #1 was observed walking 100 Hall (Male Secured Unit) and lead this investigator his room. Resident #1 indicated his room was cold and would get colder at night. Resident #1 proceeded to show this investigator 4 blankets on his bed he was utilizing in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket. <BR/>Observation and interview on 01/16/2024 at 3:14 PM, Resident #2 (100 Hall - Male Secured Unit) was observed lying in his bed. Resident #2 was observed wearing gloves and when asked why, Resident #2 responded, because I like them! When asked if the resident was cold at night, he responded, Yes! When asked how the resident was doing in an attempt to stay warm, he responded, The blankets. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation and interview on 01/16/2024 at 3:16 PM, Resident #3 (100 Hall - Male Secured Unit) was observed sitting in the secured dining area in his wheelchair. During the interview, Resident #3 said that this week had been, really cold. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation on 01/16/2024 at 3:38 PM revealed a space heater at the end of Hall 200.The space heater was on and glowing. The room temperature in this hall felt uncomfortably cold while wearing a jacket. <BR/>Observation and interview on 01/16/2024 at 3:40 PM, Resident #4 (200 Hall) was asked about the temperature of her room and indicated she had been, Very cold, and said she had been using multiple blankets in an attempt to stay warm. The room temperature in this location felt uncomfortably cold while wearing a jacket.<BR/>Observation and interview on 01/17/2024 at 7:38 AM, facility staff were observed wearing winter-clothing in the building which consisted of extra layers and ski hats. At this time, an unknown staff shouted, It's cold in there, 50 degrees.<BR/>Observation and interview on 01/17/2024 at 7:44 AM, Resident #1 was observed lying in his bed with a blanket over his head. A reading of the room's temperature revealed a temperature of 56 F. During an interview at this time, Resident #1 was asked if he was cold and responded, Yes The resident stated he did not sleep well because his room was cold. <BR/>Observation and interview on 01/17/2024 at 7:57 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #1's bed which revealed a temperature reading of 56 F. LVN B confirmed the temperature in Resident #1's room was 56 F and responded, Oh wow, that's cold.<BR/>Observation and interview on 01/17/2024 at 7:44 AM, Resident #5 was observed lying in bed with a navy blue blanket over his head (photo taken). A reading of the room's temperature revealed a temperature of 51 F. During an interview at this time, Resident #5 was asked how he was doing and responded, Cold. When asked if the Resident #5 felt tired, he responded, Yeah, I can't sleep. <BR/>Observation and interview on 01/17/2024 at 7:58 AM with LVN B, this investigator pointed a thermal thermometer laser at the wall closest to Resident #5's bed which revealed a temperature reading of 51 F. During an interview at this time, LVN B was asked what the temperature should be to be considered comfortable to which she responded, Around 70 F.<BR/>Observation and interview on 01/17/2024 at 8:07 AM with Staff C, this investigator pointed a thermal thermometer laser at the wall closest to Resident #4's bed which revealed a temperature reading of 51 F. Staff C confirmed the temperature for Resident #4's room was 51 F. During an interview at this time, Staff C said Resident #4 had requested to be moved to a new location due to feeling cold in her room. Staff C mentioned another resident, Resident #7 - Hall 200, had also requested to be moved because she was cold in her room. <BR/>Interview and observation on 01/17/2024 at 9:50 PM, the Maintenance Supervisor and this investigator compared thermal temperature guns and confirmed their readings matched within +/-.3 degrees F. The Maintenance Supervisor's thermal temperature gun was orange and black (IR1 Infrared Thermometer), The Maintenance Director was asked what the room temperatures should be and responded, Around 75 F in the winter and around 70 F in the summer.<BR/>Interview and observation on 01/17/2024 at 10:00 AM, the Maintenance Supervisor measured Resident #1's room (100 Hall - Male Secured Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 61 F. During an interview at this time, the Maintenance Supervisor said, It feels chili in here, I would need more blankets and double socks.<BR/>Interview and observation on 01/17/2024 at 10:04 AM, the Maintenance Supervisor measured Resident #5's room (100 Hall - Male Secured Unit) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #5's which revealed a temperature of 61 F. Resident #5 was observed still lying in bed with blankets over his head. A space heater was observed in this resident's room and was emitting heat but the room still felt cold. During an interview at this time, Resident #5 was asked if he was still cold to which he responded, Ya. At this time, the Maintenance Director said, Even with a space heater the room still feels cold. I don't see why the main heating unit (for 100 Hall) wasn't fixed before the cold weather.<BR/>Interview on 01/17/2024 at 10:15 AM, the administrator stated she had moved all but 1 resident on 200 Hall from the second half of 200 Hall to other locations including the first half of 200 Hall. The Administrator also stated she had closed the smoke barrier doors located in the middle of 200 Hall in an effort to prevent cold air coming down the first half of the 200 hall. Additionally, the Administrator said all residents on the 100 Hall (Male Secured Unit) were moved to the 100 Hall (Female Secured Unit) and indicated that section of 100 Hall had a HVAC. <BR/>Interview and observation on 01/17/2024 at 10:29 AM, the Maintenance Supervisor measured Resident #7's room (200 Hall) with his infrared temperature gun by pointing the laser at the wall closest to the Resident #1's which revealed a temperature of 57.7 F. Resident #6 was observed lying in her bed under layers of blankets. During an interview at this time, Resident #6 was asked how she was doing to which she responded, I'm cold. The Maintenance Director then said, Ya, it's cold, I wouldn't want to be in there. The Maintenance Director then confirmed Resident #7's room was on the first half of 200 Hall that was supposed to be the side residents were moved to because it was warmer than the second half of 200 Hall. The Maintenance Supervisor agreed it felt much colder in the resident's room than in the hall. <BR/>Interview on 01/17/2024 at 4:45 pm with the Chief Operations Officer (COO) and the administrator revealed the facility discovered in October 2023 the HVAC for 100 Hall Male Secured Unit and 200 Hall were not adequately functioning. The administrator indicated the facility had been in the process of replacing the units since then but there had been delays. The administrator further stated she anticipated the heating units for 200 Hall and 100 Hall (Male Secured Unit) would be replaced by 01/19/2024.<BR/>Record review of facility policy, Quality of Life - Homelike Environment, (Revised May 2017), stated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . 2. The facility and staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .h. Comfortable and safe temperatures (71 F - 81 F) .<BR/>Record review of website, https://www.nia.nih.gov/health/safety/cold-weather-safety-older-adults , dated, 01/03/2024 , stated: Older adults have a higher chance of being affected by cold weather. Changes that come with aging can make it harder for older adults to be aware of their body becoming too cold, which can turn into a dangerous health issue quickly. Hazards of cold weather include falls on wintry surfaces; injury caused by freezing (frostbite); and hypothermia, a medical emergency that occurs when your body temperature gets too low. Being informed and taking certain actions can help lessen risks during the colder months . Staying warm indoors. About 20% of injuries related to exposure to cold occur in the home. Here are some tips to help keep warm: Even mildly cool homes with temperatures from 60 to 65&deg;F can lead to hypothermia in older adults.<BR/>This was determined to be an Immediate Jeopardy on 01/17/24 at 5:50 PM. The administrator and COO were notified. The administrator was provided the Immediate Jeopardy template on 01/17/24 at 6:00 PM .<BR/>The following Plan of Removal submitted by the facility was accepted on 01/19/24 at 2:00 PM:<BR/>Plan for REMOVAL<BR/>The facility failed to provide a safe, clean, comfortable, and homelike environment, to<BR/>include maintenance services necessary to maintain comfortable and safe temperature<BR/>levels, for 1 of 1 facility reviewed for a safe, clean, comfortable, and homelike<BR/>environment.<BR/>F584<BR/>1- On 1/17/2024 Residents on 100 unit (men's secure unit) were moved to warm secure<BR/>unit. Residents on 200 hallway cold areas were moved to warm side of the unit by IDT.<BR/>Units that are not holding temperature of 71 degrees Fahrenheit were temporarily closed by Maintenance Director. <BR/>2- On 1/17/2024 Maintenance Director ordered and paid for heating units repairs which are scheduled for 1/22/204 to be installed due to a delay<BR/>in the crane delivery. Per the contractor all work on the HVAC units will be repaired on<BR/>the same day as arrival.<BR/>3- On 1/17/2024 Social Worker/Designee notified RPs of the room changes.<BR/>4- On 1/17/2024 Director of Nursing/Designee assessed residents for s/s of hypothermia or sleep deprivation due to feeling cold - no negative findings noted. The Medical Director updated on findings by Administrator on 1/17/2024.<BR/>5- On 1/17/2024 COO (Chief Operating Officer) completed 1:1 in-service with<BR/>Administrator and Maintenance Director on emergency readiness, inclement weather<BR/>preparedness, and s/s of hypothermia.<BR/>6- On 1/17/2024 Director of Nursing/Designee initiated in-services with staff of identifying s/s of hypothermia, timely notification of Administrator/Supervisor when noting patients room/residents' areas feel cold or residents/staff/visitors complaints of feeling cold, residents' sleep deprivation, and cold-related injuries (hypothermia) due to cold temperatures in the facility. Staff will not be allowed to work until they receive training, including agency staff and PRN. Anyone who is not able to receive training will not be allowed to work until the in servicing is completed.<BR/>7- Ad-Hoc QAPI meeting was held on 1/17/2024, with the Medical Director, NHA (Nursing Home Administrator), DON, and Maintenance Director to review the alleged<BR/>deficiencies, policy and procedure, and the plan for removal of immediacy.<BR/>The policies pertaining to Emergency readiness were reviewed on 1/17/2024 by the<BR/>NHA (Nursing Home Administrator), DON, and Medical Director.<BR/>8- Starting on 1/17/2024, IDT (Interdisciplinary team), including Administrator, Activity<BR/>Director, DON, Social Worker, admission manager, MDS, and Maintenance Director will<BR/>meet with residents daily to identify if any residents have sleep deprivation and s/s of<BR/>hypothermia due to cold temperatures Monday through Friday, and Manager on Duty<BR/>on Saturday, Sunday, until heating units are repaired. Any issues or concerns will be<BR/>brought up to the Administrator immediately and IDT team members for any follow-up<BR/>needed. Residents' room temps will be taken daily to ensure compliance by<BR/>Maintenance Director or designee until HVAC units are installed. If any room<BR/>temperatures are below 71 degrees; the Administrator will be contacted and the<BR/>resident will be offered another room that is above 71 degrees. Temperatures of the<BR/>rooms will be taken 2xs a day and temps recorded in the temperature spreadsheet in<BR/>maintenance book until HVAC units are installed. Residents' temperature will be taken<BR/>daily to ensure no signs or symptoms of hypothermia.<BR/>9-The Administrator/designee will monitor compliance by completing an audit of five (5)<BR/>residents per week for four (4) weeks until heating units are repaired. This was initiated<BR/>on 1/17/2024. Any identified concern will be addressed immediately and if trends and<BR/>patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if<BR/>additional interventions are needed to ensure compliance.<BR/>10- The COO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed.[sic]<BR/>The facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by:<BR/>-Observations on 01/19/2024 of 200 Hall, between 3:15 PM and 3:17 PM revealed room temperatures between 71.4 F to 74.4 F. Further observation reviewed smoke barrier doors were closed in the middle of 200 Hall to prevent the escape of warm air. <BR/>Observations on 01/19/2024 of 100 Hall, between 3:18 PM and 3:19 PM revealed room temperatures between 71.4 F to 74.4 F. <BR/>Observations on 01/19/2024 at 3:20 PM revealed 100 Hall (Male Secured Unit) had been completely vacated by all residents.<BR/>Interview on 01/19/2024 at 4:08 PM, the Maintenance Director stated 3 HVAC three units had been ordered and paid for and had heard they would be installed on Monday 01/22/2024. Record review at this time supported the information provided specific to this interview.<BR/>Observation on 01/22/2024 at 2:00 PM, HVAC staff were observed over 200 Hall working on the HVAC Unit on the roof. <BR/>Interview on 01/22/2024 at 2:05 PM, the administrator stated the new HVAC unit was being in-stalled over 200 Hall and said HVAC installers were in the process of custom fitting the plenum and anticipated both units would be completely installed by cob. <BR/>Record review of the facility's Electronic Resident Database under section, Progress Notes. Revealed documentation inputted by the facility's social worker indicating RP and/or attempted RP notifications for residents that had been moved to a different room. <BR/>Interview and record review on 01/19/2024 at 3:42 PM, the DON stated she assessed all residents impacted by the cold weather to ensure they did not have s/s of hypothermia. Record review of facility documentation supported this statement. <BR/>Interview on 01/19/2024 at 3:53 PM, the administrator stated the emergency preparedness in-service covered inclement weather and other items specific to disasters. This included checking the generator, making sure an evacuation plan was in place, extra blankets were available, and a phone roster for staff in-case of an emergency. Regarding hypothermia, the administrator said this can be determined by body temperature, vital signs, and alert/oriented status. <BR/>Interview on 01/19/2024 at 4:00 PM, the Maintenance Director stated he would look for drowsiness, confusion, shivering, memory loss et specific to hypothermia. Regarding emergency preparedness, the Maintenance Director said he was instructed to make sure there were adequate blankets, an addendum to have heaters, check room temps periodically throughout the day. He said he was also in-serviced regarding inclement weather, specifically ensuring thermostats were set properly, windows were to be shut, the generator was adequately working, et. He further stated the generator was tested on [DATE] and added a solution to prevent gelling of the gasoline.<BR/>Interview with the administrator on 01/22/2024 at 5:44 PM, the administrator said that if conditions were extreme, heaters would be used as needed. The Administrator stated they would be placed in the hallways within the line of sight of nurses/aides). The administrator said this was indicated in her emergency preparedness manual. <BR/>Record review of sign in sheets on 01/22/2024 provided by the administrator revealed information that supported this interview. <BR/>Interview on 01/19/2024, the Corporate Nurse stated staff that have been in-serviced by person or via telephone were documented on a list and said that staff who have not yet received the in servicing will not be able to work. <BR/>Record review of a 3 page document titled, Employee Roster, generated on 01/17/2024, revealed a list of all facility staff. Further review of this document revealed signatures next to staff who had completed the trainings. This list also showed attempts to contact 6 staff but had been unsuccessful. <BR/>Observations and interviews on 01/18/2024 thru 01/22/2024 of resident rooms where residents were temporarily transferred 100 Hall (Women's Secured Unit) and the first half of 200 Hall (before smoke barrier doors) measured above 71 degrees F and it was noticeably a comfortable temperature in those resident rooms. <BR/>Interviews with a sample of staff (CNAs, LVNs, RNs, DON - from all 3 facility shifts), the Maintenance Director, and administrative staff 01/19/2024 thru 01/22/2024 revealed staff had been in-serviced specific to the Plan of Removal and knew to immediately notify the administrator if they noticed an unusual occurrence, which included if the heat went out in the building. Staff were also able to explain their familiarity with signs and symptoms of hypothermia and indicated they would provide blankets, warm liquids, and ensure all doors and windows were closed to keep the heat inside. <BR/>Record review of sign in sheets on 01/22/2024 provided by the administrator revealed information that supported this interview. <BR/>Interview on 01/19/2024 at 4:06 PM, the Maintenance Director stated he had been checking room temps 4 times daily to ensure compliance and said the nurses were also checking room temps in the evening utilizing his thermal temperature gun (the same thermal temperature gun utilized during previous temperature observations with this investigator). <BR/>Record review facility documentation revealed monitoring was occurring in accordance to this plan. <BR/>Interview on 01/18/2024 at 4:42 PM, the administrator said she would be monitoring 5 residents a week for 4 weeks and would be monitoring residents daily to ensure there were not signs or symptoms of hypothermia or other potential adverse reactions related to cold weather or new interventions. She said they would be utilizing a resident roster daily to document this information. <BR/>Record review of documentation on 01/22/2024 provided by the administrator revealed information that supported this interview. <BR/>Interview on 01/18/2024 at 4:29 PM, the COO stated she would be frequenting the facility once per month to provide oversite to the Administrator to ensure items on the plan of removal are reviewed and completed. <BR/>The administrator was informed the Immediate Jeopardy was removed on 01/22/2024. The facility remained out of compliance at a severity of potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place .

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access, for 1 of 1 Resident (#72) reviewed for medication storage, in that:<BR/>RN H left Resident #72's medication unattended and unsecured at Resident #72's bedside.<BR/>This deficient practice placed residents at risk for not receiving therapeutic effects of the medications as prescribed. <BR/>The findings are:<BR/>A record review of Resident #72's face sheet revealed an admission date of 9/15/2021 with diagnoses which included seizures, anxiety disorder, and paranoid schizophrenia [severe type, and a form of psychosis, paranoid schizophrenia is characterized by delusions and sometimes hallucinations].<BR/>A record review of Resident #72's Brief Interview for Mental Status score revealed 06 severe cognitive impairment.<BR/>A record review of Resident #72's care plan, dated 1/26/2022, revealed, revealed, Death and dying issues related to terminal condition, as evidenced by: Hospice services .administer medications and treatments as ordered monitor side effects and effectiveness.<BR/>A record review of Resident #72's physician's orders, dated 1/26/2022, revealed :<BR/>Aspirin, low dose tablet, delayed release, 81 milligrams, one tab oral, once a day at 8:00 AM.<BR/>Lorazepam, schedule IV [controlled narcotic] tablet, 0.5mg, one tab oral at 8:00 AM.<BR/>Oxcarbazepine, tablet 300 milligrams, one tab, oral, at 8:00 AM.<BR/>Phenobarbital, schedule IV [controlled narcotic] tablet, 16.2 milligrams, two tabs, oral at 8:00 AM.<BR/>Valproic acid capsule, 250 milligrams, two capsules, oral at 8:00 am.<BR/>Hyoscyamine tablet, 0.125mg, 1 tab, as needed for secretions. <BR/>During an observation on 1/23/22 at 9:09 am revealed Resident #72 was lying in bed, awake, with a bedside table next to the bed. Seven multicolored medication pills in a small plastic cup. There was not a nurse or Medication aid in the room. The medications were unattended and unsecured. <BR/>During an interview on 1/23/2022 at 9:11 am with Resident #72 stated, those are my pills, the nurse left them there .get the [expletive] out!<BR/>During an observation on 1/23/2022 at 9:14 AM ADON RN H was at the nurse's station, at the end of the hallway, away from Resident #72's room.<BR/>During an interview on 1/23/2022 at 9:15 am ADON RN H stated she prepared resident #72's medications at 9:00 am and left them at the bedside. ADON RN H stated Resident #72 is a difficult person to get medication compliance, so she left them there so he could take them at his leisure. ADON RN H stated her training and professional practice prohibit leaving medications at the bedside. <BR/>During an interview on 1/23/2022 at 4:11 pm the Regional DON stated the facility policy and training is for medication aides, and licensed nurses to administer medications to residents, on time as the physician ordered and to observe and verify the resident swallowed the oral medications without difficulty, and then document the administration.<BR/>The facility policy titled storage of Medications dated April 2007, stated, compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, boxes.) containing drugs and biologicals shall be locked when not in use; and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

.<BR/>Based on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 3 of 3 dumpsters for 3 of 4 days, in that: <BR/>All 3 dumpsters (Dumpster #1, #2 and #3) did not have drain plugs for 3 of 3 days; and Dumpster #3 had lids ajar with trash bags bulging out for 2 of 3 days. <BR/>This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents.<BR/>The finding included:<BR/>Interview on 1/23/22 at 9:28 a.m. with the Maintenance Director revealed the facility had a problem with racoons getting into the dumpsters, leaving the lids open, removing the drain plugs with their paws and pulling the plastic bags out through the drain plug. The Maintenance Director reported he replaced the dumpster drain plugs numerous times because of the racoons removing them.<BR/>Observation on 1/23/22 at 9:31 a.m. of the three dumpsters used for the disposal of trash revealed Dumpster #1 (the dumpster closest to the wooden shed) had the drain plug missing with plastic pulled through the drain hole sticking out about six inches; Dumpster #2 (the middle dumpster) was missing a drain plug; and Dumpster #3 (the dumpster closest to the metal shed) did not have a drain plug and both lids on top were open with bags of trash sticking above the top of the dumpster. <BR/>Observation on 1/24/22 at 6:23 p.m. revealed all three dumpsters had the lids closed but did not have drain plugs.<BR/>Observation of the 3 dumpsters and interview with the Dietary Manager on 1/25/22 at 11:00 a.m. revealed Dumpster #1 had the drain plug missing with plastic pulled through the drain hole sticking out about six inches; Dumpster #2 was missing a drain plug; and Dumpster #3 did not have a drain plug and both lids on top were open with bags of trash sticking above the top of the dumpster. The Dietary Manager lifted the lid to Dumpster #3 and pushed the bag of trash down so the lid would close. Interview with the Dietary Manager at this time confirmed the lid was open on Dumpster #3 and all three dumpsters did not have drain plugs. <BR/>In an interview on 1/24/22 at 2:57 p.m. the Administrator revealed the facility had very large racoons that would come from the wooded area behind the dumpsters, open the lids and remove the drain plugs.<BR/>Record review of the undated policy titled Waste Disposal Outside Dumpster Container revealed 3. The Outside Dumpster Container doors or lids will remain closed, there will be no outside trash on the ground, and the Outside Dumpster Container will have a plug in the drain hole.<BR/>.

.<BR/>Based on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 3 of 3 dumpsters for 3 of 4 days, in that: <BR/>All 3 dumpsters (Dumpster #1, #2 and #3) did not have drain plugs for 3 of 3 days; and Dumpster #3 had lids ajar with trash bags bulging out for 2 of 3 days. <BR/>This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents.<BR/>The finding included:<BR/>Interview on 1/23/22 at 9:28 a.m. with the Maintenance Director revealed the facility had a problem with racoons getting into the dumpsters, leaving the lids open, removing the drain plugs with their paws and pulling the plastic bags out through the drain plug. The Maintenance Director reported he replaced the dumpster drain plugs numerous times because of the racoons removing them.<BR/>Observation on 1/23/22 at 9:31 a.m. of the three dumpsters used for the disposal of trash revealed Dumpster #1 (the dumpster closest to the wooden shed) had the drain plug missing with plastic pulled through the drain hole sticking out about six inches; Dumpster #2 (the middle dumpster) was missing a drain plug; and Dumpster #3 (the dumpster closest to the metal shed) did not have a drain plug and both lids on top were open with bags of trash sticking above the top of the dumpster. <BR/>Observation on 1/24/22 at 6:23 p.m. revealed all three dumpsters had the lids closed but did not have drain plugs.<BR/>Observation of the 3 dumpsters and interview with the Dietary Manager on 1/25/22 at 11:00 a.m. revealed Dumpster #1 had the drain plug missing with plastic pulled through the drain hole sticking out about six inches; Dumpster #2 was missing a drain plug; and Dumpster #3 did not have a drain plug and both lids on top were open with bags of trash sticking above the top of the dumpster. The Dietary Manager lifted the lid to Dumpster #3 and pushed the bag of trash down so the lid would close. Interview with the Dietary Manager at this time confirmed the lid was open on Dumpster #3 and all three dumpsters did not have drain plugs. <BR/>In an interview on 1/24/22 at 2:57 p.m. the Administrator revealed the facility had very large racoons that would come from the wooded area behind the dumpsters, open the lids and remove the drain plugs.<BR/>Record review of the undated policy titled Waste Disposal Outside Dumpster Container revealed 3. The Outside Dumpster Container doors or lids will remain closed, there will be no outside trash on the ground, and the Outside Dumpster Container will have a plug in the drain hole.<BR/>.

.<BR/>Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. <BR/>The facility failed to employ a certified dietary manager as required. <BR/>This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition.<BR/>Findings included:<BR/>Record review of the policy titled Food Services Manager, revised 12/2008, revealed The Food Services Manager is a qualified supervisor licensed by this state and is knowledgeable and trained in food procurement, storage, handling, preparation, and delivery.<BR/>Record Review of an undated list of employees revealed Employee F was the Dietary Manager.<BR/>Record review of the Dietary Manager's employee file revealed he was hired on 1/10/2022 as the Dietary Manager. <BR/>Record review of the Dietary Manager's undated Employment Application revealed he did not have any certification or degrees.<BR/>In an interview on 1/25/22 at 10:42 a.m. the Dietary Manager revealed he was hired on 1/10/22, stated he did not have any certification or degrees, and stated he was previously an assistant manager position at a local fast-food restaurant and a specialized cook at a local hospital.<BR/>In an interview on 1/25/22 at 2:47 p.m., the Administrator stated Employee F was not a Certified Dietary Manager and the Administrator had not yet enrolled him in a dietary manager training course. The Administrator stated the facility had a consultant dietitian who was not in the facility full time and was in the facility one or two days a month.<BR/>Record review of the CMS 672 Resident Census and Conditions of Residents, completed by the facility on 1/26/22, revealed all residents in the facility received meals and snacks served from the kitchen.<BR/>.

.<BR/>Based on observations, interviews, and record reviews the facility failed to ensure the menu was followed for 1 of 1 kitchen reviewed for menus in that:<BR/>The facility failed to ensure protion sizes were served according to the menu and recipe:<BR/>1. Residents who received a pureed diet were served &frac12; cup portion of Pureed Spaghetti with Pureed Meat Sauce instead of a 1 cup portion at the noon meal; and<BR/>2. Residents who received a regular diet were served one &frac12; cup portion of Caesar Salad instead of two &frac12; cup portions at the noon meal.<BR/>These deficient practices could place residents at risk of dissatisfaction, poor meal intake, and/or unwanted weight loss.<BR/>The findings were:<BR/>Record review of the Diet Spreadsheet for Fall Winter 2021-2022 Extensions for Day 10 Tuesday revealed at the noon meal: <BR/>1. Residents who received a pureed diet were to receive two #8 scoops (two &frac12; cup portions to equal 1 cup) of Pureed Spaghetti with Pureed Italian Meat Sauce, and<BR/> 2. Residents who received a regular diet were to receive two 4-ounce measuring utensil to equal 1 cup serving of Caesar Salad.<BR/>The findings were:<BR/>Record review of the Diet Spreadsheet (extended menu) Fall Winter 2021 for Day 10 Tuesday revealed residents who received a pureed diet were to be served two #8 scoops (1 cup portion), and residents who received a regular diet were to receive two 4-ounce portions (1 cup portion) of Caesar salad.<BR/>Record review of the recipe titled Pureed Spaghetti with Pureed Italian Meat Sauce for Day 10 Lunch revealed the portion sized to be served after the product was pureed was two #8 scoops (1 cup portion).<BR/>Record review of the recipe titled Caesar Salad for Day 10 Lunch revealed the portion size to be served was two 4-ounce serving utensils.<BR/>Observation on 1/25/22 from 12:16 p.m. to 12:55 p.m. revealed Employee A served 1 #8 scoop (a &frac12; cup portion) of Pureed Spaghetti with Pureed Italian Meat Sauce to residents who received a pureed diet; and Dietary Aide G served 1 tong full of Caesar Salad to residents who received a regular diet instead of a measuring the amount of salad served.<BR/>Observation on 1/25/22 at 12:56 p.m. revealed when Employee A placed a tong full of Caesar Salad into a 4-ounce measuring utensil revealed 1 tong full of Cesar Salad filled up a &frac12; cup measuring utensil which was only half the portion residents were to receive. <BR/>In an interview on 1/25/22 at 12:58 p.m., Employee A revealed he would look at the recipes to determine what scoop sized to use to serve the food to residents. Employee A looked at the recipe for Pureed Spaghetti with Pureed Italian Meat Sauce and stated the recipe indicated two #8 scoops (1/2 cup portions) were to be served to equal 1 cup. He then looked at the recipe for Caesar Salad and confirmed the recipe indicated two 4-ounce measuring utensils should had been used to serve the salad. <BR/>In an interview on 1/25/22 at 2:29 p.m., the Dietary Manager revealed employees should look at the menu [extended menu] and recipe before serving to determine what portion is to be served. After the Dietary Manager reviewed the recipes for Pureed Spaghetti with Pureed Italian Meat Sauce and the recipe for Caesar Salad, he confirmed 1 cup portion should had been served of both items.<BR/>Record review of the policy titled Menus, revised December 2008, revealed Menus shall . c) be followed. <BR/>.

.<BR/>Based on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 3 of 3 dumpsters for 3 of 4 days, in that: <BR/>All 3 dumpsters (Dumpster #1, #2 and #3) did not have drain plugs for 3 of 3 days; and Dumpster #3 had lids ajar with trash bags bulging out for 2 of 3 days. <BR/>This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents.<BR/>The finding included:<BR/>Interview on 1/23/22 at 9:28 a.m. with the Maintenance Director revealed the facility had a problem with racoons getting into the dumpsters, leaving the lids open, removing the drain plugs with their paws and pulling the plastic bags out through the drain plug. The Maintenance Director reported he replaced the dumpster drain plugs numerous times because of the racoons removing them.<BR/>Observation on 1/23/22 at 9:31 a.m. of the three dumpsters used for the disposal of trash revealed Dumpster #1 (the dumpster closest to the wooden shed) had the drain plug missing with plastic pulled through the drain hole sticking out about six inches; Dumpster #2 (the middle dumpster) was missing a drain plug; and Dumpster #3 (the dumpster closest to the metal shed) did not have a drain plug and both lids on top were open with bags of trash sticking above the top of the dumpster. <BR/>Observation on 1/24/22 at 6:23 p.m. revealed all three dumpsters had the lids closed but did not have drain plugs.<BR/>Observation of the 3 dumpsters and interview with the Dietary Manager on 1/25/22 at 11:00 a.m. revealed Dumpster #1 had the drain plug missing with plastic pulled through the drain hole sticking out about six inches; Dumpster #2 was missing a drain plug; and Dumpster #3 did not have a drain plug and both lids on top were open with bags of trash sticking above the top of the dumpster. The Dietary Manager lifted the lid to Dumpster #3 and pushed the bag of trash down so the lid would close. Interview with the Dietary Manager at this time confirmed the lid was open on Dumpster #3 and all three dumpsters did not have drain plugs. <BR/>In an interview on 1/24/22 at 2:57 p.m. the Administrator revealed the facility had very large racoons that would come from the wooded area behind the dumpsters, open the lids and remove the drain plugs.<BR/>Record review of the undated policy titled Waste Disposal Outside Dumpster Container revealed 3. The Outside Dumpster Container doors or lids will remain closed, there will be no outside trash on the ground, and the Outside Dumpster Container will have a plug in the drain hole.<BR/>.

Based on interviews and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed for qualifications of Social Worker. The facility, licensed for 179 beds, did not employ a full-time social worker. This failure could place residents at risk of social service and psychosocial needs not being met.The findings included: Record review of the facility's Daily Census Report, dated 07/22/2025, noted the facility had a total licensed bed capacity of 179. Record review of the Facility Summary Report from the Texas Unified Licensure Information Portal (TULIP) noted the facility had a total licensed capacity of 179 beds. During an interview on 07/23/2025 at 1:47 PM, the Administrator stated he believed the need for a social worker was based on census, not licensed beds. The Administrator stated there was a remote, as needed social worker, who did not work for the facility on a full-time basis. The Administrator stated he terminated the last social worker and the position had not been filled. The Administrator stated the last day of work for the previously employed social worker was 05/20/2025. Record review of facility policy titled, Social Services dated 06/10/2025, reflected, in part, A facility with more than 120 beds will employ a qualified social worker on a full-time basis.

**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 2 (Resident #1 and Resident #2) of 20 residents reviewed for clinical records, in that: <BR/>1. Resident #1's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident. <BR/>2. Resident #2's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident.<BR/>These deficient practices could result in in errors in care and treatment. <BR/>The findings were: <BR/>1. Record review of Resident #1's facesheet, dated 02/27/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, Cerebral Infarction and Vascular Dementia Unspecified Severity Without Behavioral Disturbance. <BR/>Record review of Resident #1's annual MDS, dated [DATE], revealed a BIMS score of 07 which indicated severe cognitive impairment. <BR/>Record review of Resident #1's care plan, dated 02/27/2025, revealed, [Resident #1] has a behavioral problem where she has delusions [related to] dementia and a cerebral infarction. She says statements that after investigation have been found to be not true . The resident is/has potential to be physically aggressive to staff and others. <BR/>Record review of Resident #1's psychiatric provider after visit note, dated 02/11/2025, revealed, Active Medical Problems .delusions . neuropathy .Assessment and Plan: Dementia with Behaviors.<BR/>Further review of Resident #1's facesheet, dated 02/27/2025, revealed the diagnoses of delusions, neuropathy, and dementia with behaviors were not noted. <BR/>2. Record review of Resident #2's facesheet, dated 02/27/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Other Specified Interstitial Pulmonary Diseases, Anemia, and Insomnia. <BR/>Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 0 which indicated severe cognitive impairment. <BR/>Record review of Resident #2's care plan, dated 02/27/2025, revealed, [Resident #2] has little or no activity involvement [related to] disinterest, resident wishes not to participate .<BR/>Record review of Resident #2's psychiatric provider after visit note, dated 02/11/2025, revealed, Active Medical Problems .Major Depressive Disorder .<BR/>Record review of Resident #2's Order Summary Report, dated 02/27/2025, revealed, Amitriptyline HCl Oral Tablet 25 [milligrams] (Amitriptyline HCl) Give 1 tablet by mouth at bedtime every 2 day(s) for Depression. <BR/>Further review of Resident #2's facesheet, dated 02/27/2025, revealed the diagnosis of Major Depressive Disorder was not noted. <BR/>During an interview with the DON on 02/28/2025 at 9:30 a.m., the DON confirmed Resident #1's diagnoses of delusions, neuropathy, and dementia with behaviors were not noted on the resident's face sheet and should have been. The DON additionally confirmed that Resident #2's diagnosis of Major Depressive Disorder was not noted on the resident's face sheet and should have been. The DON stated the facility had recently changed from one electronic health record provider to another and that the oversight was likely due to the change. The DON stated nursing staff were responsible to ensure accuracy of records, and nurse management were responsible for oversight of nursing staff. The DON confirmed that inaccuracy of the residents' clinical records could result in errors in care and treatment. <BR/>Record review of the facility policy, Electronic Medical Records, dated 2001, revealed, Electronic medical records may be used in lieu of paper records when approved by the administrator.

.<BR/>Based on interview and record review, the facility failed to maintain the required minimum of 12 hours annual in-service records for 2 of 2 CNAs (CNA C and CNA D) records reviewed for staff training.<BR/>The facility failed to provide CNAs C and D with 12 hours in-service training per year.<BR/>This failure could affect the residents by allowing them to be care for by untrained staff. <BR/>Findings included:<BR/>Record review of the following CNA's Individual Education Record (annual log of in-service hours) revealed the following:<BR/>CNA C had a hire date of 7/18/2018 and had only completed 2 hours of annual training.<BR/>CNA D had a hire date of 7/10/2020 and had only completed 2 hours of annual training. <BR/>In an interview on 1/26/22 at 3:35 p.m., the Administrator revealed in-service training was conducted monthly. The Administrator stated the previous Human Resource employee would log employees in-service training on the Individual Education Record, but her employment ended in June 2021 and the Administrator has not had a chance to train the new Human Resource employee to record the in-services. The Administrator was asked at this time to provide surveyors any further documentation of in-service training that could be found for CNAs C and D, but as printing of this document none was provided.<BR/>In an interview on 1/26/22 at 3:35 p.m., the Regional Nurse revealed the facility did not have a policy on 12-hours annual in-services for CNAs and stated the facility would follow the state and federal regulations.<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes or maintains their quality of life for 1 of 7 residents (Resident #289) reviewed for dignity in that:<BR/>Resident #289 was observed in their resident room wearing nothing but a disposable brief. The door to the resident's room was open, and the privacy curtain in front of the resident's bed was open. <BR/>These failures could affect residents by contributing to poor self-esteem and decreased self-worth. <BR/>The findings included:<BR/>Record Review of Resident #289's Face Sheet reflected the resident was a [AGE] year-old male on hospice admitted to the facility on [DATE] with diagnosis that include alcoholic cirrhosis of the liver (chronic liver damage that causes liver failure), Hepatic encephalopathy (loss of brain function due to the liver not removing toxins from the blood), and osteoporosis (condition in which bones become weak and brittle). <BR/>Observation on 4/23/2023 at 10:05 AM, Resident #289 was observed in bed with the door to the resident's room open, the privacy curtain pulled back to expose the resident who was laying on the bed in the resident room wearing only a disposable brief. <BR/>Observation and attempted interview on 4/23/2023 at 11:20 AM, Resident #289 was observed wearing only a brief with their blanket covering their lower legs. The curtain in the resident's room was pulled 2/3 of the way closed, and the resident was visible from the hallway. Attempt to interview resident was unsuccessful. <BR/>Interview on 4/24/2023 at 9:13 AM, CMA F stated that Resident #289 was on hospice and had only been at the facility for a few days. CMA F stated she does not leave residents in briefs only, and if she ever sees residents in only briefs, she helps them get dressed. CMA F stated that leaving a resident in briefs, especially if others can see them in only briefs, is not respectful to a resident's dignity. CMA F stated residents' privacy was not respected by allowing him to be seen by others in his brief with the curtain and door open.<BR/>Interview on 4/25/2023 at 1:54 PM, ADON stated that residents are provided privacy and that Resident #289 has been provided a private room for his family to visit. The ADON stated that her goal for staff is to encourage residents to dress in their clothing, but to provide privacy when necessary. <BR/>Record review of facility's policy on dignity, revised August 2009, reflected Staff shall promote, maintain and protect resident privacy .staff shall treat cognitively impaired residents with dignity and sensitivity.

**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 2 (Resident #1 and Resident #2) of 20 residents reviewed for clinical records, in that: <BR/>1. Resident #1's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident. <BR/>2. Resident #2's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident.<BR/>These deficient practices could result in in errors in care and treatment. <BR/>The findings were: <BR/>1. Record review of Resident #1's facesheet, dated 02/27/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, Cerebral Infarction and Vascular Dementia Unspecified Severity Without Behavioral Disturbance. <BR/>Record review of Resident #1's annual MDS, dated [DATE], revealed a BIMS score of 07 which indicated severe cognitive impairment. <BR/>Record review of Resident #1's care plan, dated 02/27/2025, revealed, [Resident #1] has a behavioral problem where she has delusions [related to] dementia and a cerebral infarction. She says statements that after investigation have been found to be not true . The resident is/has potential to be physically aggressive to staff and others. <BR/>Record review of Resident #1's psychiatric provider after visit note, dated 02/11/2025, revealed, Active Medical Problems .delusions . neuropathy .Assessment and Plan: Dementia with Behaviors.<BR/>Further review of Resident #1's facesheet, dated 02/27/2025, revealed the diagnoses of delusions, neuropathy, and dementia with behaviors were not noted. <BR/>2. Record review of Resident #2's facesheet, dated 02/27/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Other Specified Interstitial Pulmonary Diseases, Anemia, and Insomnia. <BR/>Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 0 which indicated severe cognitive impairment. <BR/>Record review of Resident #2's care plan, dated 02/27/2025, revealed, [Resident #2] has little or no activity involvement [related to] disinterest, resident wishes not to participate .<BR/>Record review of Resident #2's psychiatric provider after visit note, dated 02/11/2025, revealed, Active Medical Problems .Major Depressive Disorder .<BR/>Record review of Resident #2's Order Summary Report, dated 02/27/2025, revealed, Amitriptyline HCl Oral Tablet 25 [milligrams] (Amitriptyline HCl) Give 1 tablet by mouth at bedtime every 2 day(s) for Depression. <BR/>Further review of Resident #2's facesheet, dated 02/27/2025, revealed the diagnosis of Major Depressive Disorder was not noted. <BR/>During an interview with the DON on 02/28/2025 at 9:30 a.m., the DON confirmed Resident #1's diagnoses of delusions, neuropathy, and dementia with behaviors were not noted on the resident's face sheet and should have been. The DON additionally confirmed that Resident #2's diagnosis of Major Depressive Disorder was not noted on the resident's face sheet and should have been. The DON stated the facility had recently changed from one electronic health record provider to another and that the oversight was likely due to the change. The DON stated nursing staff were responsible to ensure accuracy of records, and nurse management were responsible for oversight of nursing staff. The DON confirmed that inaccuracy of the residents' clinical records could result in errors in care and treatment. <BR/>Record review of the facility policy, Electronic Medical Records, dated 2001, revealed, Electronic medical records may be used in lieu of paper records when approved by the administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents received proper treatment and assistive devices to maintain hearing abilities for that 1 of 7 residents (Resident #14) reviewed for hearing in that:<BR/>The facility failed to ensure Resident #14 received appropriate services to assess for maintaining or improving hearing abilities. <BR/>This failure could affect residents by placing them at risk for unmet needs and diminished quality of life. <BR/>The findings included: <BR/>Record review of Resident #14's face sheet dated 4/26/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included Type 2 diabetes (chronic condition that affects the way the body processes sugar), post-traumatic stress disorder, and dementia (thinking and social symptoms that interfere with daily functioning). <BR/>Record review of Resident #14 MDS dated [DATE] states Resident #14 can hear with minimal difficulty. <BR/>Record review of Resident #14's Care Plan with a problem start date of 8/12/2022 indicated the resident was hard of hearing, and that nurses were instructed to observe, document, and report any changes to hearing status to Resident #14's doctor. <BR/>Interview on 4/23/2023 at 10:52 AM, Resident #14 stated she was very hard of hearing, and asked interviewer to speak loudly or yell so that she can hear. Resident #14 stated she does not have a hearing aid and has not had her hearing checked. The resident stated she is frustrated that she has not been able to hear anyone. The resident indicated that she would like her hearing check and to talk to someone about possibly getting hearing aids. She stated she had told staff previously that she wanted hearing aids but could not remember who.<BR/>Interview on 4/23/2023 at 11:00 AM, CMA F stated Resident #14's hearing has been bad for a long time, and she can hardly hear. CMA F stated Resident #14 had requested to be seen for her hearing and had told the charge nurse.<BR/>Interview on 4/23/2023 at 11:05 AM, LVN D stated Resident #14 does not have hearing aids. LVN D stated he doctor may have written an order for Resident #14's hearing, but was not sure when or any further information on the order.<BR/>Interview on 4/27/2023 at 10:18 AM, the administrator stated he does not believe Resident #14 had any information in her medical record of seeing an audiologist or being assessed for hearing services.<BR/>Record review of the facility's policy on social assessments dated April 2012 indicated physical factors that impact function and quality of life including hearing should be obtained to help staff develop a care plan that will meet the individual's needs.

Based on interviews and record reviews the facility failed to establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 facility reviewed for antibiotic stewardship program, in that:<BR/>The facility did not perform antibiotic stewardship for 4 consecutive months (October, November, December 2022, and January 2023. <BR/>This deficient practice placed residents at risk for infections and ineffective antibiotic therapies.<BR/>The findings:<BR/>During an interview on 4/24/2023 at 1:33 p.m., ADON stated she was the facility's Infection preventionist starting February 2023. <BR/>During an interview on 4/24/2023 at 1:45 p.m. with ADON stated she could not produce any documentation for the infection control or antibiotic stewardship surveillance and tracking for October, November, December 2022, and January 2023. ADON only provided antibiotic stewartship survelance for Febuary , March and April 2023 . <BR/>During an interview on 4/24/2021 at 4:20 p.m., the Clinical nurse consultant confirmed the previous DON was the infection preventionist up until early January 2023 and did not perform any infection surveillance or antibiotic stewardship monitoring and tracking for the last 4 months [October , November, December 2022 and January 2023]. <BR/>Record review of the facility's antibiotic stewardship records was not possible because the records could not be produced.<BR/>Record review of the facility's policy could not be reviewed as ADON could not provide a policy , because they did not have one .

Based on interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 1 of 10 kitchen staff (Dietary Aide E) reviewed for qualified dietary staff. <BR/>The facility failed to ensure the Dietary Aide E met the requirements for food handling by obtaining a current and valid Food Handler's Certificate. <BR/>This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food born illnesses.<BR/>The findings included:<BR/>During an interview on 6/11/25 at 6:33 p.m., Dietary Aide E stated he had worked in the facility for the past 6 months and initially worked as a housekeeper. Dietary Aide E stated he currently worked as the cook in the facility kitchen and did not have his Texas Food Handler's certification because he had not had time to complete the course. Dietary Aide E stated, they (the facility) were just looking for staff to work the kitchen. Dietary Aide E stated he had worked in commercial kitchens before but not like this.<BR/>During an observation and interview on 6/11/25 at 6:48 p.m., the Administrator stated he had informed Dietary Aide E that he needed to complete the Texas Food Handler's course to obtain a food handler's certificate three times and was not aware Dietary Aide E did not have it. The Administrator provided a copy of Dietary Aide E's Texas Food Handler's certificate dated 6/11/25.

Based on record reviews and interviews the facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 1 of 1 facility's reviewed for nursing staffing. 1.The facility failed to have the services of an RN on 02/22/2025, 02/23/2025, 03/09/2025, 06/01/2025, and 06/14/2025. 2.The facility failed to have at least 8 consecutive hours of RN coverage on 03/22/2025, 03/23/2025, 04/19/2025, 04/20/2025, 05/02/2025, 05/03/2025, 05/04/2025, 05/12/2025, 05/13/2025, 05/17/2025, 05/31/2025, and 06/15/2025. These failures could have placed residents at risk of not having the critical skills of a RN. The findings were: Record review of the facility's census report for the date of 07/22/2025 revealed a census of 76 residents daily. 1.Record review of the facility's RN staff payroll hours for the period from 1/1/2025 through 6/27/2025 revealed no RN Services on the following dates: 02/22/2025 02/23/2025 03/09/2025 06/01/2025 06/14/2025 2.Further review reflected less than 8 hours of RN Services on the following dates: On 03/22/2025, there were 7.75 hours of RN coverage. On 03/23/2025, there were 6.5 hours of RN coverage. On 04/19/2025, there were 4 hours of RN coverage. On 04/20/2025, there were 6 hours of RN coverage. On 05/02/2025, there were 2 hours of RN coverage. On 05/03/2025, there were 5 hours of RN coverage. On 05/04/2025, there were 6 hours of RN coverage. On 05/12/2025, there were 4 hours of RN coverage. On 05/13/2025, there were 4 hours of RN coverage. On 05/17/2025, there were 7 hours of RN coverage. On 05/31/2025, there were 5 hours of RN coverage. On 06/15/2025, there were 6 hours of RN coverage. Interview on 07/26/2025 at 2:43 PM, the Administrator stated there were 3 days in the last 6 months that there was no RN coverage. The Administrator stated he did not know why there was not an RN working on these days. The Administrator stated he did not have any other record to show an RN worked the dates that did not have RN coverage, and that all of the dates occurred before he was an administrator. The Administrator stated it was important to have an RN working each day for, assessments. Record review of Facility Policy titled, Nursing Services-Registered Nurse (RN), dated 05/30/2025, reflected, The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes or maintains their quality of life for 1 of 7 residents (Resident #289) reviewed for dignity in that:<BR/>Resident #289 was observed in their resident room wearing nothing but a disposable brief. The door to the resident's room was open, and the privacy curtain in front of the resident's bed was open. <BR/>These failures could affect residents by contributing to poor self-esteem and decreased self-worth. <BR/>The findings included:<BR/>Record Review of Resident #289's Face Sheet reflected the resident was a [AGE] year-old male on hospice admitted to the facility on [DATE] with diagnosis that include alcoholic cirrhosis of the liver (chronic liver damage that causes liver failure), Hepatic encephalopathy (loss of brain function due to the liver not removing toxins from the blood), and osteoporosis (condition in which bones become weak and brittle). <BR/>Observation on 4/23/2023 at 10:05 AM, Resident #289 was observed in bed with the door to the resident's room open, the privacy curtain pulled back to expose the resident who was laying on the bed in the resident room wearing only a disposable brief. <BR/>Observation and attempted interview on 4/23/2023 at 11:20 AM, Resident #289 was observed wearing only a brief with their blanket covering their lower legs. The curtain in the resident's room was pulled 2/3 of the way closed, and the resident was visible from the hallway. Attempt to interview resident was unsuccessful. <BR/>Interview on 4/24/2023 at 9:13 AM, CMA F stated that Resident #289 was on hospice and had only been at the facility for a few days. CMA F stated she does not leave residents in briefs only, and if she ever sees residents in only briefs, she helps them get dressed. CMA F stated that leaving a resident in briefs, especially if others can see them in only briefs, is not respectful to a resident's dignity. CMA F stated residents' privacy was not respected by allowing him to be seen by others in his brief with the curtain and door open.<BR/>Interview on 4/25/2023 at 1:54 PM, ADON stated that residents are provided privacy and that Resident #289 has been provided a private room for his family to visit. The ADON stated that her goal for staff is to encourage residents to dress in their clothing, but to provide privacy when necessary. <BR/>Record review of facility's policy on dignity, revised August 2009, reflected Staff shall promote, maintain and protect resident privacy .staff shall treat cognitively impaired residents with dignity and sensitivity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs without adequate indications for its use for 1 of 3 Resident (Resident #46) whose records were reviewed for unnecessary medications. Resident #46 had an order for a psychotropic medication (Buspirone HCl) without adequate indications for its use. This failure could place residents at risk for adverse drug consequences and receiving unnecessary medications. The findings included: Record review of Resident #46's admission Record, dated 07/25/2025, reflected a [AGE] year-old resident initially admitted on [DATE] with diagnoses which included alcoholic cirrhosis of liver with ascites (advanced scarring of the liver caused by excessive alcohol use) and hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation). Record review of Resident #46's Quarterly MDS, dated [DATE], reflected Resident #46 had a BIMS score of 7, indicating severe cognitive impairment. Further review of Section I - Active Diagnoses did not reflect a diagnosis of any psychiatric mood disorder. Record review of Resident #46's Comprehensive Person-Centered Care Plan, undated, reflected, [Resident #46] uses anti-anxiety medications Ativan, Buspar r/t anxiety disorder with a date initiated of 07/15/2025. Further review reflected, [Resident #46] uses antidepressant medication Citalopram r/t Depression with a date initiated of 07/15/2025. Record review of Resident #46's Order Summary Report, dated 07/25/2025, reflected the order, LORazepam Oral Tablet 1 MG (LORazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety,; busPIRone HCl Oral Tablet 10 MG (Buspirone HCl Give 2 tablet by mouth three times a day for Mood; and Citalopram Hydrobromide Oral Tablet 10 MG (Citalopram Hydrobromide) Give 1 tablet by mouth one time a day for depression. Record review of Resident #46's Order Audit Report, dated 07/25/2025, reflected an order for, busPIRone HCl Oral Tablet 10 MG (Buspirone HCl) Give 2 tablet by mouth three times a day for Mood with an order date of 06/19/2025. Interview on 07/25/2025 at 3:39 PM, the DON stated that an order for buspirone is typically for anxiety. The DON stated that an order for a psychotropic medication should have a diagnosis attached to it. Record review of facility policy titled, Use of Psychotropic Medication(s) dated 05/07/2025, reflected, Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication.

Based on record reviews and interviews the facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 1 of 1 facility's reviewed for nursing staffing. 1.The facility failed to have the services of an RN on 02/22/2025, 02/23/2025, 03/09/2025, 06/01/2025, and 06/14/2025. 2.The facility failed to have at least 8 consecutive hours of RN coverage on 03/22/2025, 03/23/2025, 04/19/2025, 04/20/2025, 05/02/2025, 05/03/2025, 05/04/2025, 05/12/2025, 05/13/2025, 05/17/2025, 05/31/2025, and 06/15/2025. These failures could have placed residents at risk of not having the critical skills of a RN. The findings were: Record review of the facility's census report for the date of 07/22/2025 revealed a census of 76 residents daily. 1.Record review of the facility's RN staff payroll hours for the period from 1/1/2025 through 6/27/2025 revealed no RN Services on the following dates: 02/22/2025 02/23/2025 03/09/2025 06/01/2025 06/14/2025 2.Further review reflected less than 8 hours of RN Services on the following dates: On 03/22/2025, there were 7.75 hours of RN coverage. On 03/23/2025, there were 6.5 hours of RN coverage. On 04/19/2025, there were 4 hours of RN coverage. On 04/20/2025, there were 6 hours of RN coverage. On 05/02/2025, there were 2 hours of RN coverage. On 05/03/2025, there were 5 hours of RN coverage. On 05/04/2025, there were 6 hours of RN coverage. On 05/12/2025, there were 4 hours of RN coverage. On 05/13/2025, there were 4 hours of RN coverage. On 05/17/2025, there were 7 hours of RN coverage. On 05/31/2025, there were 5 hours of RN coverage. On 06/15/2025, there were 6 hours of RN coverage. Interview on 07/26/2025 at 2:43 PM, the Administrator stated there were 3 days in the last 6 months that there was no RN coverage. The Administrator stated he did not know why there was not an RN working on these days. The Administrator stated he did not have any other record to show an RN worked the dates that did not have RN coverage, and that all of the dates occurred before he was an administrator. The Administrator stated it was important to have an RN working each day for, assessments. Record review of Facility Policy titled, Nursing Services-Registered Nurse (RN), dated 05/30/2025, reflected, The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility to provide a safe and comfortable environment for residents, staff in 1 of 2 (women's unit) shower rooms in the 100 hall in that: <BR/>In the Women's unit shower room, in the 100 hall, there was a tall plastic 3 shelf storage bin which contained 7.5 fluid ounces of peri-fresh spray, tray of razors 15 count, 3 24 fluid ounce body wash bottles, and a 16 ounce zinc oxide ointment container. Resident #58 was observed walking back and forth on the hall, but not in the shower room. <BR/>The Findings were:<BR/>Record review of Resident #58's face sheet dated 1/26/2022 revealed she was admitted on [DATE] with diagnoses of anxiety disorder, vascular dementia with behavioral disturbance, cognitive communication deficit, major depressive disorder and weakness. <BR/>Record review of Resident #58's Quarterly MDS dated [DATE] in Section C-Cognitive Patterns revealed she had a BIMs of 5/15, severely cognitively impaired.<BR/>Observation on 1/23/22 at 9:46 a.m. with CAN J, in the women's unit, the shower room door was unlocked. Observed a razor on the bathroom plastic cart near shower, a tall plastic 3 shelf storage bin, included 7.5 fl. oz peri-fresh spray, tray of razors 15 count, 3 24 fl. oz body wash bottles and 16 oz zinc oxide ointment container. <BR/>Interview on 1/24/20211 at 9:46 a.m. with CNA J confirmed the women's shower room was unlocked. CNA J confirmed the women's shower room had a razor on a plastic cart near shower and the tall plastic 3 shelf storage bin, included peri-fresh spray 7.5 fl. oz, tray of razors 15 count, 3 body wash bottles 24 fl. oz and zinc oxide ointment container 16 oz. <BR/>Interview and observation on 1/24/22 at 9:47 a.m. LVN I entered the women's shower room with CNA J and confirmed the bathroom lock was not working. LVN I stated she was not aware that the lock did not work. LVN I stated all the containers in the shower room had warning to keep out of reach of children and the razors should not be accessible to residents. <BR/>Observation on 1/24/22 at 9:51 a.m. revealed Resident #58 was walking/wandering up and down the hall, not opening doors or going into rooms. <BR/>Observation on 1/24/22 at 12:35 p.m. in the secure unit-women's unit, Resident #58 was walking up and down the hallway and trying to open doors. <BR/>Observation on 1/24/22 at 1 p.m. revealed Resident #58 walked to the end of the women's hall and tore hot zone posting off the door. Resident #58 was observed walking down the hall trying to open doors but were all locked. <BR/>Interview on 1/25/22 at 10:30 a.m. CNA D stated Resident #58 will go into other resident rooms and gets close to another residents' space. <BR/>Interview on 1/26/22 at 11:13 AM with Administrator stated she was not aware the shower room lock was not working. This surveyor requested environment policy. An environment/maintenance policy was not provided before exit.

.<BR/>Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. <BR/>The facility failed to employ a certified dietary manager as required. <BR/>This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition.<BR/>Findings included:<BR/>Record review of the policy titled Food Services Manager, revised 12/2008, revealed The Food Services Manager is a qualified supervisor licensed by this state and is knowledgeable and trained in food procurement, storage, handling, preparation, and delivery.<BR/>Record Review of an undated list of employees revealed Employee F was the Dietary Manager.<BR/>Record review of the Dietary Manager's employee file revealed he was hired on 1/10/2022 as the Dietary Manager. <BR/>Record review of the Dietary Manager's undated Employment Application revealed he did not have any certification or degrees.<BR/>In an interview on 1/25/22 at 10:42 a.m. the Dietary Manager revealed he was hired on 1/10/22, stated he did not have any certification or degrees, and stated he was previously an assistant manager position at a local fast-food restaurant and a specialized cook at a local hospital.<BR/>In an interview on 1/25/22 at 2:47 p.m., the Administrator stated Employee F was not a Certified Dietary Manager and the Administrator had not yet enrolled him in a dietary manager training course. The Administrator stated the facility had a consultant dietitian who was not in the facility full time and was in the facility one or two days a month.<BR/>Record review of the CMS 672 Resident Census and Conditions of Residents, completed by the facility on 1/26/22, revealed all residents in the facility received meals and snacks served from the kitchen.<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility to provide a safe and comfortable environment for residents, staff in 1 of 2 (women's unit) shower rooms in the 100 hall in that: <BR/>In the Women's unit shower room, in the 100 hall, there was a tall plastic 3 shelf storage bin which contained 7.5 fluid ounces of peri-fresh spray, tray of razors 15 count, 3 24 fluid ounce body wash bottles, and a 16 ounce zinc oxide ointment container. Resident #58 was observed walking back and forth on the hall, but not in the shower room. <BR/>The Findings were:<BR/>Record review of Resident #58's face sheet dated 1/26/2022 revealed she was admitted on [DATE] with diagnoses of anxiety disorder, vascular dementia with behavioral disturbance, cognitive communication deficit, major depressive disorder and weakness. <BR/>Record review of Resident #58's Quarterly MDS dated [DATE] in Section C-Cognitive Patterns revealed she had a BIMs of 5/15, severely cognitively impaired.<BR/>Observation on 1/23/22 at 9:46 a.m. with CAN J, in the women's unit, the shower room door was unlocked. Observed a razor on the bathroom plastic cart near shower, a tall plastic 3 shelf storage bin, included 7.5 fl. oz peri-fresh spray, tray of razors 15 count, 3 24 fl. oz body wash bottles and 16 oz zinc oxide ointment container. <BR/>Interview on 1/24/20211 at 9:46 a.m. with CNA J confirmed the women's shower room was unlocked. CNA J confirmed the women's shower room had a razor on a plastic cart near shower and the tall plastic 3 shelf storage bin, included peri-fresh spray 7.5 fl. oz, tray of razors 15 count, 3 body wash bottles 24 fl. oz and zinc oxide ointment container 16 oz. <BR/>Interview and observation on 1/24/22 at 9:47 a.m. LVN I entered the women's shower room with CNA J and confirmed the bathroom lock was not working. LVN I stated she was not aware that the lock did not work. LVN I stated all the containers in the shower room had warning to keep out of reach of children and the razors should not be accessible to residents. <BR/>Observation on 1/24/22 at 9:51 a.m. revealed Resident #58 was walking/wandering up and down the hall, not opening doors or going into rooms. <BR/>Observation on 1/24/22 at 12:35 p.m. in the secure unit-women's unit, Resident #58 was walking up and down the hallway and trying to open doors. <BR/>Observation on 1/24/22 at 1 p.m. revealed Resident #58 walked to the end of the women's hall and tore hot zone posting off the door. Resident #58 was observed walking down the hall trying to open doors but were all locked. <BR/>Interview on 1/25/22 at 10:30 a.m. CNA D stated Resident #58 will go into other resident rooms and gets close to another residents' space. <BR/>Interview on 1/26/22 at 11:13 AM with Administrator stated she was not aware the shower room lock was not working. This surveyor requested environment policy. An environment/maintenance policy was not provided before exit.

**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 2 (Resident #1 and Resident #2) of 20 residents reviewed for clinical records, in that: <BR/>1. Resident #1's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident. <BR/>2. Resident #2's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident.<BR/>These deficient practices could result in in errors in care and treatment. <BR/>The findings were: <BR/>1. Record review of Resident #1's facesheet, dated 02/27/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, Cerebral Infarction and Vascular Dementia Unspecified Severity Without Behavioral Disturbance. <BR/>Record review of Resident #1's annual MDS, dated [DATE], revealed a BIMS score of 07 which indicated severe cognitive impairment. <BR/>Record review of Resident #1's care plan, dated 02/27/2025, revealed, [Resident #1] has a behavioral problem where she has delusions [related to] dementia and a cerebral infarction. She says statements that after investigation have been found to be not true . The resident is/has potential to be physically aggressive to staff and others. <BR/>Record review of Resident #1's psychiatric provider after visit note, dated 02/11/2025, revealed, Active Medical Problems .delusions . neuropathy .Assessment and Plan: Dementia with Behaviors.<BR/>Further review of Resident #1's facesheet, dated 02/27/2025, revealed the diagnoses of delusions, neuropathy, and dementia with behaviors were not noted. <BR/>2. Record review of Resident #2's facesheet, dated 02/27/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Other Specified Interstitial Pulmonary Diseases, Anemia, and Insomnia. <BR/>Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 0 which indicated severe cognitive impairment. <BR/>Record review of Resident #2's care plan, dated 02/27/2025, revealed, [Resident #2] has little or no activity involvement [related to] disinterest, resident wishes not to participate .<BR/>Record review of Resident #2's psychiatric provider after visit note, dated 02/11/2025, revealed, Active Medical Problems .Major Depressive Disorder .<BR/>Record review of Resident #2's Order Summary Report, dated 02/27/2025, revealed, Amitriptyline HCl Oral Tablet 25 [milligrams] (Amitriptyline HCl) Give 1 tablet by mouth at bedtime every 2 day(s) for Depression. <BR/>Further review of Resident #2's facesheet, dated 02/27/2025, revealed the diagnosis of Major Depressive Disorder was not noted. <BR/>During an interview with the DON on 02/28/2025 at 9:30 a.m., the DON confirmed Resident #1's diagnoses of delusions, neuropathy, and dementia with behaviors were not noted on the resident's face sheet and should have been. The DON additionally confirmed that Resident #2's diagnosis of Major Depressive Disorder was not noted on the resident's face sheet and should have been. The DON stated the facility had recently changed from one electronic health record provider to another and that the oversight was likely due to the change. The DON stated nursing staff were responsible to ensure accuracy of records, and nurse management were responsible for oversight of nursing staff. The DON confirmed that inaccuracy of the residents' clinical records could result in errors in care and treatment. <BR/>Record review of the facility policy, Electronic Medical Records, dated 2001, revealed, Electronic medical records may be used in lieu of paper records when approved by the administrator.

**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 2 (Resident #1 and Resident #2) of 20 residents reviewed for clinical records, in that: <BR/>1. Resident #1's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident. <BR/>2. Resident #2's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident.<BR/>These deficient practices could result in in errors in care and treatment. <BR/>The findings were: <BR/>1. Record review of Resident #1's facesheet, dated 02/27/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, Cerebral Infarction and Vascular Dementia Unspecified Severity Without Behavioral Disturbance. <BR/>Record review of Resident #1's annual MDS, dated [DATE], revealed a BIMS score of 07 which indicated severe cognitive impairment. <BR/>Record review of Resident #1's care plan, dated 02/27/2025, revealed, [Resident #1] has a behavioral problem where she has delusions [related to] dementia and a cerebral infarction. She says statements that after investigation have been found to be not true . The resident is/has potential to be physically aggressive to staff and others. <BR/>Record review of Resident #1's psychiatric provider after visit note, dated 02/11/2025, revealed, Active Medical Problems .delusions . neuropathy .Assessment and Plan: Dementia with Behaviors.<BR/>Further review of Resident #1's facesheet, dated 02/27/2025, revealed the diagnoses of delusions, neuropathy, and dementia with behaviors were not noted. <BR/>2. Record review of Resident #2's facesheet, dated 02/27/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Other Specified Interstitial Pulmonary Diseases, Anemia, and Insomnia. <BR/>Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 0 which indicated severe cognitive impairment. <BR/>Record review of Resident #2's care plan, dated 02/27/2025, revealed, [Resident #2] has little or no activity involvement [related to] disinterest, resident wishes not to participate .<BR/>Record review of Resident #2's psychiatric provider after visit note, dated 02/11/2025, revealed, Active Medical Problems .Major Depressive Disorder .<BR/>Record review of Resident #2's Order Summary Report, dated 02/27/2025, revealed, Amitriptyline HCl Oral Tablet 25 [milligrams] (Amitriptyline HCl) Give 1 tablet by mouth at bedtime every 2 day(s) for Depression. <BR/>Further review of Resident #2's facesheet, dated 02/27/2025, revealed the diagnosis of Major Depressive Disorder was not noted. <BR/>During an interview with the DON on 02/28/2025 at 9:30 a.m., the DON confirmed Resident #1's diagnoses of delusions, neuropathy, and dementia with behaviors were not noted on the resident's face sheet and should have been. The DON additionally confirmed that Resident #2's diagnosis of Major Depressive Disorder was not noted on the resident's face sheet and should have been. The DON stated the facility had recently changed from one electronic health record provider to another and that the oversight was likely due to the change. The DON stated nursing staff were responsible to ensure accuracy of records, and nurse management were responsible for oversight of nursing staff. The DON confirmed that inaccuracy of the residents' clinical records could result in errors in care and treatment. <BR/>Record review of the facility policy, Electronic Medical Records, dated 2001, revealed, Electronic medical records may be used in lieu of paper records when approved by the administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes or maintains their quality of life for 1 of 7 residents (Resident #289) reviewed for dignity in that:<BR/>Resident #289 was observed in their resident room wearing nothing but a disposable brief. The door to the resident's room was open, and the privacy curtain in front of the resident's bed was open. <BR/>These failures could affect residents by contributing to poor self-esteem and decreased self-worth. <BR/>The findings included:<BR/>Record Review of Resident #289's Face Sheet reflected the resident was a [AGE] year-old male on hospice admitted to the facility on [DATE] with diagnosis that include alcoholic cirrhosis of the liver (chronic liver damage that causes liver failure), Hepatic encephalopathy (loss of brain function due to the liver not removing toxins from the blood), and osteoporosis (condition in which bones become weak and brittle). <BR/>Observation on 4/23/2023 at 10:05 AM, Resident #289 was observed in bed with the door to the resident's room open, the privacy curtain pulled back to expose the resident who was laying on the bed in the resident room wearing only a disposable brief. <BR/>Observation and attempted interview on 4/23/2023 at 11:20 AM, Resident #289 was observed wearing only a brief with their blanket covering their lower legs. The curtain in the resident's room was pulled 2/3 of the way closed, and the resident was visible from the hallway. Attempt to interview resident was unsuccessful. <BR/>Interview on 4/24/2023 at 9:13 AM, CMA F stated that Resident #289 was on hospice and had only been at the facility for a few days. CMA F stated she does not leave residents in briefs only, and if she ever sees residents in only briefs, she helps them get dressed. CMA F stated that leaving a resident in briefs, especially if others can see them in only briefs, is not respectful to a resident's dignity. CMA F stated residents' privacy was not respected by allowing him to be seen by others in his brief with the curtain and door open.<BR/>Interview on 4/25/2023 at 1:54 PM, ADON stated that residents are provided privacy and that Resident #289 has been provided a private room for his family to visit. The ADON stated that her goal for staff is to encourage residents to dress in their clothing, but to provide privacy when necessary. <BR/>Record review of facility's policy on dignity, revised August 2009, reflected Staff shall promote, maintain and protect resident privacy .staff shall treat cognitively impaired residents with dignity and sensitivity.

**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 2 (Resident #1 and Resident #2) of 20 residents reviewed for clinical records, in that: <BR/>1. Resident #1's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident. <BR/>2. Resident #2's psychiatric provider notes included diagnoses not listed on the facility's list of diagnoses for the resident.<BR/>These deficient practices could result in in errors in care and treatment. <BR/>The findings were: <BR/>1. Record review of Resident #1's facesheet, dated 02/27/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, Cerebral Infarction and Vascular Dementia Unspecified Severity Without Behavioral Disturbance. <BR/>Record review of Resident #1's annual MDS, dated [DATE], revealed a BIMS score of 07 which indicated severe cognitive impairment. <BR/>Record review of Resident #1's care plan, dated 02/27/2025, revealed, [Resident #1] has a behavioral problem where she has delusions [related to] dementia and a cerebral infarction. She says statements that after investigation have been found to be not true . The resident is/has potential to be physically aggressive to staff and others. <BR/>Record review of Resident #1's psychiatric provider after visit note, dated 02/11/2025, revealed, Active Medical Problems .delusions . neuropathy .Assessment and Plan: Dementia with Behaviors.<BR/>Further review of Resident #1's facesheet, dated 02/27/2025, revealed the diagnoses of delusions, neuropathy, and dementia with behaviors were not noted. <BR/>2. Record review of Resident #2's facesheet, dated 02/27/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Other Specified Interstitial Pulmonary Diseases, Anemia, and Insomnia. <BR/>Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 0 which indicated severe cognitive impairment. <BR/>Record review of Resident #2's care plan, dated 02/27/2025, revealed, [Resident #2] has little or no activity involvement [related to] disinterest, resident wishes not to participate .<BR/>Record review of Resident #2's psychiatric provider after visit note, dated 02/11/2025, revealed, Active Medical Problems .Major Depressive Disorder .<BR/>Record review of Resident #2's Order Summary Report, dated 02/27/2025, revealed, Amitriptyline HCl Oral Tablet 25 [milligrams] (Amitriptyline HCl) Give 1 tablet by mouth at bedtime every 2 day(s) for Depression. <BR/>Further review of Resident #2's facesheet, dated 02/27/2025, revealed the diagnosis of Major Depressive Disorder was not noted. <BR/>During an interview with the DON on 02/28/2025 at 9:30 a.m., the DON confirmed Resident #1's diagnoses of delusions, neuropathy, and dementia with behaviors were not noted on the resident's face sheet and should have been. The DON additionally confirmed that Resident #2's diagnosis of Major Depressive Disorder was not noted on the resident's face sheet and should have been. The DON stated the facility had recently changed from one electronic health record provider to another and that the oversight was likely due to the change. The DON stated nursing staff were responsible to ensure accuracy of records, and nurse management were responsible for oversight of nursing staff. The DON confirmed that inaccuracy of the residents' clinical records could result in errors in care and treatment. <BR/>Record review of the facility policy, Electronic Medical Records, dated 2001, revealed, Electronic medical records may be used in lieu of paper records when approved by the administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to assist residents in obtaining routine dental care for 1 of 7 residents (Resident #14) reviewed for dental services in that:<BR/>The facility failed to assist Resident #14 in obtaining dental services after assessments indicated the resident had mouth or facial pain, discomfort, or difficulty with chewing.<BR/>These failures could lead to pain, and dental/gum problems.<BR/>The findings included: <BR/>Record review of Resident #14's face sheet dated 4/26/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included Type 2 diabetes (chronic condition that affects the way the body processes sugar), post-traumatic stress disorder, and dementia (thinking and social symptoms that interfere with daily functioning).<BR/>Record review of Resident #14's MDS assessment dated [DATE] indicated Resident #14 had mouth or facial pain, discomfort, or difficulty with chewing. <BR/>Record review of Resident #14's MDS assessment dated [DATE] indicated Resident #14 had mouth or facial pain, discomfort, or difficulty with chewing.<BR/>Record review of Resident #14's Care Plan dated 2/20/2023 does not indicate the resident has any problems with their oral status.<BR/>Interview on 4/23/2023 on 10:52 AM, Resident #14 stated she does not have teeth and that her mouth hurts at times and she was interested in dentures. She stated she had asked about dentures previously but was not sure who she had asked.<BR/>Interview on 4/27/2023 at 11:00 AM, the Marketing Director stated Resident #14 was on the list of future dental services and will see the dentist on 5/3/2023. He stated when reaching out to the dental provider, they were not able to provide any records of Resident #14's historical dental examinations or visits. <BR/>Interview on 4/27/2023 at 1:07 PM, the Marketing Director stated that residents are assessed for dental needs through any pain they report, including any pain reported in the MDS. <BR/>Record review of facility's policy on social assessments dated April 2012 indicates that physical factors that impact function and quality of life should be obtained to help staff develop a care plan that will meet the individual's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences involving the call light; in 1 of 81 residents reviewed for call light , Resident # 288 . <BR/>Resident #288 had no access to his call light, as he was lying in bed, and the call light was on the floor. <BR/>This deficient practice could affect 15 residents who used call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being. <BR/>Findings included:<BR/>Review of Resident # 288's electronic face sheet dated 4/23/23 revealed a [AGE] year-old male admitted on [DATE] with a diagnosis of [Acute Respiratory Distress] when fluid builds up in the tiny, elastic air sacs in the lungs. [Muscle Weakness] Lack of muscle strength. [ Essential Hypertension] abnormally high blood pressure that's not the result of a medical condition. <BR/>Review of Resident 288's admission MDS dated [DATE] revealed BIMS left blank, indicating resident # 288 could not complete the interview and suggesting severe impairment. <BR/>Review of the Residents admission MDS dated [DATE] revealed that under section G, functional status, B Option 3 was selected, indicating X 2-person physical assist. <BR/>Record review of Resident # 288 care plan dated 04/23/2023, updated 4/7/2023, revealed keep call bell within reach of resident. <BR/>Observation on 04/23/2023 at 10:51 AM of resident #288's room revealed that the call light was not visible. Further observation revealed that resident #288's call light was on the floor.<BR/>During an interview on 04/23/2023 at 10:51 AM with resident # 288, noted yelling and an inability to communicate. <BR/>During an interview on 04/23/2023 at 10:55 AM with LVN D, she confirmed that Resident #288's call light was on the floor; she stated it must have fallen to the floor when CNA made this bed this morning. She noted that the lack of accessibility of a call light could negatively affect any resident if they needed assistance. <BR/>During an interview on 04/23/2023 at 11:05 am with CNA E , confirmed that Resident #288's call light was out of reach of Resident #288 and that she was the assigned nursing assistant to the hall. CNA E stated that the absence of the call light could constitute potential harm if the resident needed assistance in an emergency.<BR/>During an interview on 03/19/22 at 11:49 AM with the Clinical nurse consultant, confirmed that the facility had a call light policy and staff has been in-service many times to keep call light within residents reach. <BR/>The clinical nurse consultant also confirmed that Resident # 288 's care plan addressed the need for a call light within reach. She does not know why it was not at resident # 288 's reach but would ensure all staff was in-service on this process again. <BR/>Record review of facility policy. Answering Call Light, dated 2001, revised October 2010, revealed, When a resident is in bed or a wheelchair, ensure call light is within easy reach.